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Fam Proc 1:15-29, 1962

Multiple Impact Psychotherapy with Families

ROBERT MACGREGOR, PH. D.a
aUniversity of Texas Medical Branch, Galveston, Texas.

This is a report of an investigation into the way in which self-rehabilitating family processes can be mobilized with brief psychotherapeutic intervention.1 The fact that families when threatened with evidence of mental illness in a child will travel relatively long distances to the University of Texas Medical Branch Hospitals at Galveston puts The Youth Development Project, an outpatient psychiatric clinic for adolescents, in a position to study families in crisis. The method employed requires devoting the entire time and facilities of an orthopsychiatric team to one family for half a week. Starting with a team-family conference, it proceeds through a series of different combinations of the people involved. It includes multiple therapist situations, individual interviews, and group therapy interspersed with brief staff conferences. Twelve families during 1957-1958 were seen by the team during the development of the procedures. In April, 1958 the development, demonstration, and study of the method was undertaken by a full-time team. Since that time fifty-five families with problem adolescents have been treated. The work has been particularly useful with families whose participation in usual child guidance procedures could not be gained. In forty-eight of the cases, exclusion of the child from the community had occurred or was imminent. In the remaining seven, the break-up of the home was imminent. Follow-up studies which are routine at six and eighteen months and include home visits to half the cases, indicate the method to have treatment results comparable to established intensive methods. Research results have contributed to the development of family diagnosis.

DEVELOPMENT OF THE METHOD

It is frequently felt in child guidance clinics that the decision to undertake treatment is "half the battle." It is a time when people are most accessible to the idea of giving up maladjusted patterns for more satisfying ones. Studies of psychotherapy have attributed results to theory, relationship, and technique, but have tended to regard the natural processes in the patient and family as seen in placebo control studies as extra-scientific (1). Ours is an attempt to utilize and assist these processes. The study of relationship aspects of this therapy includes not only the effect of the doctor's personality, but also of the family-like self-regulatory mechanisms within the team. In this research we have tried to identify and intensify therapeutically effective aspects of clinic intake procedures. "Multiple Impact Therapy" (MIT) is, in a sense, an expanded intake procedure involving the insinuation of our team into the family group in a manner that bespeaks our desire to participate in their problems. Gerald Caplan has made considerable study of the way in which a therapeutic response to a family crisis may yield enduring improvement in the mental health of the whole family. The same author shows a regard similar to our own for the corrective forces which can be mobilized within families and for the therapeutic value of natural situations. "... during the crisis period we keep our intervention down to the absolute minimum ... since we wish to modify as little as possible the impact of the hazardous life situation on the family, and also the family members' way of dealing with their problems both by their own efforts and through their mobilization of external sources of support and assistance. We are constantly being surprised by the strengths within and outside the family which are mobilized by the challenge of mounting tension...."2 Most of what we have included in our program has been tried separately by others. Harris Peck (3) has applied group therapy to the intake process. Whitaker (4) has used multiple therapists as a part of brief therapy and found that resolution of countertransference problems is facilitated. Dyrud and Rioch (5) found the multiple therapist situation improved communication between co-therapists. Considerable literature has been developed on interdisciplinary problems. While much of the literature is simply in favor of collaborative endeavors, many authors, Adelaide Johnson (6) among them, point to difficulties in communication between co-therapists. Our experience has been that communication problems among staff members may be of diagnostic value in understanding the way the family under study tends to involve others in their patterns of pathological inter-relationships. We differ with Starr (7) who feels the alternatives are between individual therapy by separate therapists working in isolation with each family member, and a single therapist working with the mother and child in that order. Both avoid the staff interaction problems which we find useful. Use of staff interaction was described by Stanton and Schwartz (8) in understanding acting out and other symptom-formation during hospitalization. Ackerman (9) in the introduction to his
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recent work on treatment of family relations speaks firmly against adherence to the traditional limitations on communication within the clinical team. There are also views in the literature as to whether the "child welfare focus" or focus on the adolescent-adult conflict (10) is more therapeutic. For example, Rosenthal (11) cites the difficulty arising in treatment where the parent's welfare is only of interest as it has bearing on the child. Otto Pollak (12) in retrospect observes that as their study of "family psychotherapy with a child welfare focus" progressed the matter of regarding the child or parent as the patient was less useful then the concept of treating "sick situations." The present project has committed itself from the outset to the interactional viewpoint in its treatment of such family situations.3

PSYCHOTHERAPEUTIC PROCEDURE
Planning: This work is typically carried on with families whose interest in psychotherapeutic work is not well developed. Considerable emphasis is given before the case is scheduled to promoting in each family an attitude that the two day opportunity must be exploited to the fullest. It involves a thorough orientation of the referring agency, and it involves most of the families in an intake visit to the clinic. Frequently we include a representative from the community, such as the responsible probation officer or the resident physician who has supervised the adolescent during a period of observation in the hospital, in our treatment procedures. Thus the referring agency is better able to perform these intake operations in advance of our seeing the family. We reserve the first two and a half days of the week for MIT. The family including parents, troubled adolescent, selected siblings when relevant, community representative, and occasionally a relative who has become involved in the problem, is scheduled to arrive at nine-thirty a.m. Monday. Briefing: The team assembles before the family arrives and speculates freely on the data at hand. From this we get an idea of each other's preconceptions and make some tentative plans as to what team member will see which family member individually after the initial team-family conference. The day then proceeds through a series of "impact" followed by "release" situations. Initial Team-Family Conference: "Impact" starts in a team-family conference, where as far as the family can see, everything is to be talked out. One of the team breaks into initial pleasantries by citing the urgency of the situation to get some kind of a statement of what the family is really here for. After their usually restrained remarks he may develop an interpretation that "breaks the ice" for subsequent thinking such as "Obviously this boy has to stay childish in that setting. Only by extending childhood could he help mother justify her excessive attentions to him." The observation that typically follows is that the mother has been driven to meet her tenderness needs through nagging, intimidating and infantilizing her child. When a child is thus able to short circuit his energies, school work and contact with age mates suffers. This brings questions that permit us to demonstrate how such a relationship thrives on defective communication. It is surprisingly easy for families to understand the underlying danger for the adolescent to show maturity under these circumstances and the taboos against permitting the matter to come into awareness. The team's acceptance of the exploitive aspects of family life has a calming influence. In many of our cases the initial work involves such a study of the threats to the child's individuality. When the family has difficulty expressing personal matters, the team members may debate the family or team-family problems in front of them. One may, in a protective gesture toward the mother, criticize the team member for his premature observation. Another may venture that the mother can speak for herself and if necessary he may guess aloud what her argument might be. Whether or not there are changes from the plans made in the briefing session as to which therapist is about to see whom, the plan is openly discussed by the team in the presence of the family, who usually show considerable relief to find that they are, in fact, to be individually heard at this point (release). Each team member then invites a family member to his office. It seems important that private conferences other than the scheduled ones not occur between therapists. This forces discussion of changes in evaluation and strategy out into the open in the presence of the family. Pressurized Ventilation: At this point each parent is under considerable pressure to have at least one person appreciate that whatever made him defensive in the group situation has an understandable history. His interviewer, meantime, gains a fair idea of what the person's mate has been up against through the years and may be very favorably disposed toward an interview with that spouse after lunch ("cross ventilation"). Initial Interview with the Teen-Ager: The interview with the teenager is briefer than that with the parents. In that interview a therapist tries to help the youth see his behavior as meaningfully related to family patterns. This may be a matter of revealing to the youngster that what appeared to be unreasonable behavior on his part may be the result of his having been unwittingly "taken in" to serve the poorly understood needs of others. We also acknowledge his influence in affecting present and future family patterns. The therapist may then express the concern: "Perhaps there's not enough of adult interest going on in your mother's life. Perhaps you have been making yourself too available for her instead of working on your own interests." This is a fairly brief interview, typically of a half an hour's length and the youngster may be sent off to the waiting room or may be asked to take some tests. His interviewer then telephones for permission to join in the session with either the mother or the father.

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Overlapping Session: In the overlapping session the therapist reviews to the entering therapist what has been learned in the past forty-five minutes. The parent has the opportunity to listen to a summary of how he has "gotten through" to a team member. The summary may include some tentative interpretation given in a way which invites a corrective comment, consensus, or new material.4 After the parent has indicated his attitude toward the summary, the overlapping therapist is usually moved to report that this makes some kind of sense in view of what he has been learning from their teen-ager. "You felt let down by his failure, but that's because you have been too dependent on him." At the end of the initial interviews the family members are informed that the team will talk about them at lunch. The family is encouraged to try to talk over their impressions of the morning's work and are asked to rejoin the team by one-thirty p.m. Noon Team Conference: At noon we become quite naturally aware of each other's attitudes toward different members of the family. The team members by their manner of presentation are apt to recapitulate typical patterns the family members use to manipulate each other. Attention to each other's attitudes is quite necessary in view of the fact that we have not taken the time to be neutral. Strategy is then mapped out for the afternoon. For instance, we may plan a series of overlapping sessions, where one team member seizes an apparent pattern and goes from office to office, conferring with each member on his part in it. Cross Ventilation: The afternoon starts with individual interviews. The interview with the father may now have the additional objective of discovering how he can be more of a resource for meeting his wife's needs. He already has gathered that there may be relief from the feelings of isolation in relation to the child who has alienated him. The interviewer, from his morning individual session with the wife, already has a grasp of the spouse's viewpoints and typically has a lot of curiosity about the mate's part in maintaining the unhealthy ones. During this period the youngster is tested. Simultaneous diagnostic work with siblings as well enables the parents to postpone their concern with the children and allows them to engage more fully in self study. Multiple Therapist Situations: From here on frequent use is made of overlapping sessions often with two therapists and two family members. Use may be made of the previously mentioned chain of overlapping sessions to validate a point. One therapist, facing the seemingly intractable resistiveness of a mother, called the social worker. He reviewed the mother's difficulty, considering as relevant to her son's problem the husband's accusations of her infidelity. The therapist, aided by just the relaxation provided by the third person's occasional intervention, was able to phrase a supportive interpretation of the problem. "Apparently this good looking husband of yours feels that just anyone can beat his time with his attractive wife." She, of course "had not thought of it this way." While the social worker and mother continued their discussion the first therapist left "to check with others." In this case the son, having completed his psychological tests hurriedly, had been sullenly keeping his conversation on neutral matters with the psychologist. When informed of the observation about his parents, he reacted as though for the first time he was being treated as one who could understand adult matters. It brought to his mind a point that confirmed the interpretation, and his conversation for the remainder of the two day period was in keeping with his real problems and needs. This pattern supported by the son's example was used in the next office in helping the father revise his grossly inadequate picture of himself. It was also useful in later team-family conference for questioning the level of maturity and observation that the parents attributed to their child. The mother's need for outside sources of validation of her womanhood was to subside in the weeks ahead as real strength in her husband appeared in support of new found willingness to bet on him. Team-Family Conference: A final team-family conference is used on the first day to take full advantage of family processes. Whereas the family members in individual or multiple-therapist situations may have maintained a resistive attitude toward team members, they now face each other as well. Team members, by openly telling of revised attitudes about the family and their situation, provide a climate for change. This is often furthered by a therapist's accepting from others, or offering as self-criticism, information on how his own involvement in the material interfered with understanding. The more resistive parent senses that he is not getting the old familiar reciprocal response as he reaffirms a resistive attitude. The once antagonizing gesture lacks impact to the family against the background of the day's study. Anticipation of the forthcoming evening that the family will spend together is a little disturbing as they sense the old barriers to intimacy may not serve quite so well. The team has learned from experience to respect the tentativeness of attitudes toward changing balance of forces in the family at this point. They remain silent about their desire that the family discuss the day's work in the evening. We permit ourselves considerable expression of the feelings engendered by attitudes of family members. This occurs in situations where one team member may respond protectively to the family member and, despite emphatically expressed disagreement, can maintain respect for the other team member. The group setting helps the family make use of this to become less afraid of fuller communication among themselves. It is a typical short-cut, to demonstrate, for example, to a paranoid person how really important he can be to another personimportant enough to make the therapist angryand at the same time undermine a delusional thought. "I'm real sore at your son over there. He seems to have decided that what Dr. Mac gets out of this work is a tape
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recording. Well, I am here to learn something, and I hope (turning to the boy) you get something out of it too." In this instance, the youngster's sullen, pseudo-inattentive attitude disappeared for the rest of the work. Second Day Procedures: The second morning follows with more variability the pattern of the latter part of the first afternoon. Often the family's evening together has demonstrated to them the breakdown in communication discussed in the previous day. They may be defensive about not having "talked things over." Often the brief early second day team-family conference is omitted because of the urgent need by at least one of the family to discuss emotionally charged matters. This is typically a rush of early life material brought to awareness by the happenings of the previous day. Relief came to two mothers with insight into the way their own growing young womanhood had been supressed from awareness by fathers who were less attentive to their wives than to their daughters. As mothers these women had great difficulty sharing physical as well as interpersonal intimacy with the husband. From one of them: "In order for father to keep me as his assistant at home, he ran off my boy friends, allowed me no make-up, and to this day I can't go on the beach in a playsuit without feeling immodest." The hard work of dealing with factors which interfere with intimacy between husband and wife is tackled in the second morning in ways that differ as therapists differ. Rehearsals and Applications: The second afternoon typically may start with each seeing individually the therapist whom he first saw but with whom he may have worked less. The therapist "hears" the work, perhaps revealing to the parent that the parent was, at times, trying to get prescriptions for handling the child or spouse instead of using the consultations to find principles that will help make constructive use of his own emotions.5 Each may be reminded that from the beginning, as in any diagnostic and exploratory procedure, the team has had an opportunity to recommend a more extensive type of treatment but that the family's ability to utilize the present preparation for a treatment program to be continued by their own processes at home has not been rejected. At this point the therapist may express curiosity about the participant's ability to handle things himself, and about the kind of use he has been making of the MIT situation. "You came here feeling that your son was being deprived of your participation. Why not start by inviting him to prepare those reports to his probation officer with you? Who's on probation anyway?" The second afternoon's work is directed toward a final team-family conference. By that time the relevant recurring patterns tend to be sufficiently well into awareness so that their repetition yields suitable warning signals to all. Normal convergence of dynamic interpretations has been aided by a noon staff conference with supervisors of psychotherapy. Final Family Conference: This is the time the family may take up specific questions such as whether Johnny goes back to the same school. Often the questioner has arrived at his own answer. Occasionally the adolescent is excused from the first part of the final conference as a demonstration of the team's attitude that he has already over-involved himself in parental problems. By asking for a follow-up visit in six months our minimum requirement for research purposeswe put the family in the position to digest and utilize what they have learned. A vote of confidence is given by virtue of the fact that they will be proceeding without supervision. Occasionally after two days, the outlook for effective change is not promising, and the other half day is invoked. With one-quarter of our cases we have repeated a single day of the procedure after about two months.

RESULTS
Preliminary examination of the data indicates the worth of its detailed analysis and presentation. Follow-up data has been obtained on fifty-five families: Twenty-two treated cases have been seen at follow-up in their home communities. Thirty treated families, including nine of those followed at home, were re-examined or treated in the office following MIT. The office follow-up contacts differed in intensity. They included a range of services from routine six and eighteen month follow-up to monthly visits of two or more family members. Scheduled follow-up of six recent cases and six cases followed through agency report, telephone and correspondence complete the total. PRELIMINARY RESULTS SUGGEST that a method of treatment is being developed having results comparable to established intensive methods. Our experience has been largely with families having a problem with an adolescent where the time commitment and the crisis, with the associated reluctance of the family to face further contact with community agencies, might exclude many from treatment. In forty-three of the fifty cases treated in the first two years of this program, family self-rehabilitative processes remain effectively mobilized. In three, while the rehabilitative processes have strengthened the home, the nominal patient, the adolescent, did not continue to live at home and does not appear to show benefit from improved family process. Of the families that appear successfully treated, nine families with older adolescents have seen the nominal patient leave after a period of participation in family rehabilitation subsequent to MIT. (One was killed in a traffic accident; five entered military service; three undertook educational or vocational plans away from home.) In seven families the presenting picture was unchanged or worse. All seven unsuccessful cases have in common mothers who have been frankly exploitive in all their social relations. The egocentric nature of their goals seemed to thwart development of family self-rehabilitative processes. Success with another seven such cases, however, suggests that on further analysis of data other factors may shed light on this problem.

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DURABILITY OF THE RESULTS of MIT as brief therapy is indicated by the fact that twenty-eight of the cases seen have continued toward self-rehabilitation after only the minimum procedures. Fifteen cases have required more attention which seems to be leading to the development of a longer term family-centered treatment method. It now appears that for some families a series of return visits at six week intervals is desirable in the first year. For a few, two month intervals seem suitable, with family sessions supplemented by occasional individual sessions with husband and wife. Typically the additional work has been done with families where the basic psychopathology is extremely severe. Nine of these cases are showing very promising results from the newly developed six week or bi-monthly repeat of procedures through the first year. These cases include the five most clinically disturbed (psychotic or near psychotic) and two very neurotic marital problems, in homes without adolescents, undertaken to increase understanding of the application of the method to other situations. We have found more recently with a number of cases where the tension of crisis is high and family pathology is lower that the one day or half day intake procedure resembling the first day of MIT with later half day follow-up conferences can yield comparable results. In addition to attributes of the nominal patient, our data for each family are analyzed in terms of (1) a fourfold division of roles appropriate to aggressive, passive-aggressive, emotionally unstable and passive-aggressive functioning; (the amount of flexibility to operate in more than one such mode is noted); (2) a related division of labor conception of sibling relationships; (3) patterns in motherhood; (4) patterns in fatherhood; (5) patterns in value transmission and several catagories of response to crisis, help and community relations. WHILE THE DIAGNOSIS of the adolescent in conventional terms has not proven useful, we have found that the families referred fall into four groups that are easily differentiated by a developmental classification of the type of arrest in development manifested by the adolescent. These are as follows: 1. Infantile maladjustment in adolescence 2. Childish maladjustment in adolescence 3. Juvenile maladjustment in adolescence 4. Pre-adolescent maladjustment in adolescence The description of levels in terms of behavior approximates Sullivan's (13) use of these terms. The arrest or delay is described in terms of failure at developmental tasks as described for these levels by Ericson (14). These research findings will be published separately. 6

DISCUSSION
It has been our experience that a crisis centering around the problems of a child can be utilized in such a way that what the parents are missing in life is acutely re-experienced. This enables them to set aside some of the usual resistances in psychotherapy. The characteristic patterns of resistance are noticed and acknowledged as worthy attempts to maintain emotional equilibrium. When a team member argues for the present need for a defensive attitude of a family member, a reduction of the barriers to intra-familial communication usually occurs. Caplan (2) drawing on Lindeman's studies of psychological reactions of people who had suffered bereavement and their approach to the mourning process, points out that the handling of a crisis is most efficient when intervention is brief. He points out that inner resources may develop when one attempts unaided to cope with a current crisis. This "grief work" functions in everyday situations as one matures and learns to give up what is obsolete. Ferenczi (15) called attention to the stabilizing function of clinging to the infantile fantasies of omnipotence. This resource recurs to the person in crisis who is faced with the loss of an old way of meeting needs. He is tempted to deny that he can lose a loved one, take "no" for an answer, or otherwise accept a limitation to his powerfulness. The crisis makes it possible to consider reality as offering a more efficient base for defining the boundaries of the self, a source of self-confidence, than the aloneness necessary to the maintenance of fantasied power. This is particularly so when reality is supplemented by a team of people convinced of the worth of all efforts the person makes toward equilibrium. We noticed that there were no serious problems related to family members becoming dependent on the team. This is in part due to the fact that our method basically involves helping the natural love object, the spouse, to be more satisfying than, for example, the heretofore exploited child, or helping the widowed mother to seek the adult satisfactions of continuing growth in preference to encumbering her child by "living for him." Gregory Bateson in a recent visit pointed out to us that some of the therapeutic efficiency in our approach may come from "cross monitoring"; that is, the person who is being talked about is there and probably listening. Repair of defective communication patterns within the family tends to follow from direct demonstration by the forthright way the team members speak among themselves in the presence of the family. Usually private matters are considered too important to be quiet about. OUR ATTITUDE IS one of keen attention to the parents. We attempt to appeal to their own needs for attention which are, of course, high as in all times of illness and stress, with the attitude that they can do something constructive about

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themselves and their teen-ager. We communicate our belief that the direct benefits to themthe interruption of patterns that have interfered with happiness in their liveswill be what is best for their teen-ager. In the early stage of the work, having the adolescent tested and thoroughly appraised before we have specific comments to make appeals to them. It helps the parents accept our turning attention to their personal lives. The mother may find that there is a more rewarding route for relief from the feelings of unfulfillment as a woman. These may be feelings which typically come from having substituted a competitive relation with her husband for a more tender one or from having exploited her child to gratify unmet tenderness needs. That this new route may be through her participation with her husband in reducing his doubts about his own masculinity is usually sufficiently gratifying so that she can make short work of her initial attempts to blame her husband, his ancestors, and the school teachers of her youngster. She gains a renewed appreciation of her own femininity and the child need only cope with the problem appropriate to his being a product rather than the object of the marriage. Murray Bowen in his study of schizophrenia has for several years brought families into the hospital to participate in the treatment. He made an observation which epitomizes this basic family process. "The striking observation was that when the parents were emotionally close, more invested in each other than either was in the patient, the patient improved. When either parent became more emotionally invested in the patient than in the other parent, the patient immediately and automatically regressed. When the parents were emotionally close they could do no wrong in their "management" of the patient. The patient responded well to firmness, permissiveness, punishment, "talking it out," or any other management approach. When the parents were "emotionally divorced," any and all "management approaches" were equally unsuccessful." (16) We have been able to involve fathers in MIT who would not submit to conventional child guidance work and indeed have had little difficulty in keeping the significant members of the family participating. This may particularly recommend our procedures to outpatient clinics. Originally we felt the two day program was especially feasible for cases from remote parts of the state where fathers typically had to take time off to bring the family to Galveston. Yet it has turned out to be equally practical for cases involving local families with wage earners who are willing to commit themselves to a two and a half day treatment period. In the current series half of the families have come from our own and neighboring counties. A particularly useful by-product of our study has been the speed with which an additional professional can become a member of the team. Turnover in clinic personnel has created a demand for something quicker than the full year of working together required by the National Association of Psychiatric Clinics for children. From regularly augmenting our team by using residents in psychiatry or psychology, and from the practice of including the probation officer or child welfare worker who may accompany the family, we have found that the added professional can become a full fledged team member in weeks. The effect of MIT on communication within the team is not unlike its effect on families. Established clinics might well schedule two and a half days every second week. On the alternate week one or more days may be scheduled for intake or follow-up procedures with team and family.

REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. PARLOFF, MORRIS B., (1960) "Psychotherapy Research with Families," paper read in a symposium at American Psychological Association, Chicago. CAPLAN, GERALD, (1956) "An Approach to the Study of the Family Mental Health," Public Health Reports, 71, 1027-1030. PECK, HARRIS B., (1953) "An Application of Group Therapy to the Intake Process," Amer. J. Ortho., 23, 338-349. WHITAKER, CARL A., WARKENTIN, JOHN and JOHNSON, NAN L., (1949) "A Philosophical Basis for Brief Psychotherapy," Psychiat. Quart., 23, 439-443. DYRUD, JARL E. and RIOCH, MARGARET J., (1953) "Multiple Therapy in the Treatment Program of a Mental Hospital," Psychiatry, 16, 21-26. JOHNSON, ADELAIDE M., (1953) "Collaborative Psychotherapy: Team Setting," in Marcel Heiman, Psychoanalysis and Social Work, New York, Int. Univ. Press. STARR, PHILLIP H., "The Triangular Treatment Approach in Child Therapy: Complementary Psychotherapy of Mother and Child," Amer. J. Psychother., 10, 40-53, 1956. STANTON, A. H. and SCHWARTZ, M. S., (1949) "The Management of a Type of Institutional Participation in Mental Illness," Psychiatry, 12, 13-26. ACKERMAN, NATHAN W., (1958) The Psychodynamics of Family Life: Diagnosis and Treatment of Family Relationships, New York, Basis Books. LAUFER, MARIE L., "Casework with Parents," Child Welfare, 32, 3-7, 1953.

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11. 12. 13. 14. 15. 16.

ROSENTHAL, MAURICE J., "Collaborative Therapy with Parents at Child Guidance Clinics," Soc. Casewk., 35, 18-25, 1954. POLLAK, OTTO, (1956) Integrating Sociological and Psychoanalytic Concepts, New York, Russell Sage Fnd. SULLIVAN, H. S., (1954) The Psychiatric Interview, New York, Norton. ERICKSON, E. H., (1959) Identity and the Life Cycle, New York, Int. Univ. Press. FERENCZI, SANDOR, "Stages in the Development of the Sense of Reality," in Sex in Psychoanalysis, New York, Basic Books, 213-239, 1950. BOWEN, MURRAY, (1960) "A Family Concept of Schizophrenia," in Jackson, Don D. (Ed), The Etiology of Schizophrenia, New York, Basic Books.
1This paper is a report of a demonstration project supported in its pilot year by a grant from the Hogg Foundation for Mental

Health and presently supported in part by Mental Health Project Grant OM 76 R. The author is Research Director. Acknowledgment is made for participation in all phases of the project to its co-directors, Harold A. Goolishian, Ph.D. and Eugene C. McDanald, Jr., MD. and to the other basic team members, Agnes Ritchie, M.S.W., Psychiatric Social Worker, Franklin P. Schuster, MD. Psychiatrist, and Alberto C. Serrano, MD., Psychiatrist.
2Gerald Caplan "An Approach to the Study of Family Mental Health" (mimeo), A summary of this paper appears in Public

Health Reports 71, 1027-30, 1956. (2)

3The experience of two other clinicians with the method are described in the following papers: Goolishian, H. A., "A Brief Psychotherapy Program for Disturbed Adolescents", Amer. J. Orthopsychiat. (In Press). Schuster, F. P. "Summary Description of Multiple Impact Psychotherapy", Texas Reports on Biology and Medicine 17: 3, 426-430, 1959. 4Ritchie, A. "Multiple Impact Therapy An Experiment", Social Work 5: 3, 16-21, 1960. Agnes Ritchie discussed the overlapping interview in more detail in another paper. 5The procedure adapted from control supervision of therapists is one particularly useful when a participatory community representative, or the doctor who worked with the patient in the hospital and referred him for MIT has been coached by the team to be one of those who performs this function. 6Serrano,

A. C., McDanald, E. C., Jr., et al., "Adolescent Maladjustment and Family Dynamics," Am. Jrn. Psy., (in press).