On the Boundary: Family Therapy in a Long‐Term Inpatient Setting

Abstract

The paradigm for inpatient family therapy presented here is intended both as a description of, and a means of thinking about, family therapy in a long-term inpatient setting. It is meant to contribute to a delineation of treatment goals and strategies within a conceptual framework that is rooted in and expresses the complex clinical realities of inpatient treatment, where the locus of family therapy is the family-hospital boundary. The four functions described here are hierarchical in their relationships to each other, each function emerging only in the context of the logically prior function. Although, clearly, inpatient family therapy moves through stages parallel to those of other treatment modalities (14), the purpose of this paper is to explore therapeutic functions rather than present a prescriptive, linear description of successive phases of treatment. Joining, once achieved, cannot be left behind: it needs constant attending to, though more so at some times than others. Similarly with the other functions. It is helpful when pausing to examine one's work to note those functions that, at any given time, seem to be most at issue. For instance, the family of a patient well along the road toward discharge may promote a crisis (e.g., another family member may become symptomatic, the parents' marriage might suddenly seem in danger of falling apart, or the whole thrust of the treatment may be rejected peremptorily). On such occasions the inpatient family therapist must look for precipitating factors, not just in the domain of the family and its functioning and not just in his or her relationship with the family, but also in the context of the family's relationship to the hospital. Is the hospital riding roughshod over the family's feelings? Has important information from the family been ignored? Or, has important information been neglectfully withheld from the family? Is the treatment team moving too quickly toward discharge? Are staff, then, subtly pulling back from the patient or other family members as a way of coping with their feelings of loss? Have staff somehow communicated disappointment or pessimism or despair to the family? Has the family therapist somehow inadequately represented the family's needs to the treatment team or floor staff? Do treatment decisions therefore strike the family as insensitive or thoughtless? Has the family therapist been unable to frame treatment decisions in a way the family can accept and use constructively?

When the boundary opens: family and hospital in co‐evolution

“…Some similarities can be seen between our practice and that of others such as Cooklin (1974), Hunter (1985), Hanrahan (1986) and ImberBlack (1988). Our practice seems to differ, however, in the way the treatment team regards itself as being on the boundary.…”

“…Imber-Black (1988) emphasized the analysis of larger treatment systems in order to avoid the replication of problematic family patterns. Hunter (1985) pointed both to parents' tendencies to displace hostile feelings towards the patient onto the hospital, and to the often considerable resistance on the part of hospital staff to attend adequately to the emotional needs of parents and other members of inpatients' families. He described the family therapist in a long-term inpatient setting as a boundary dweller, a cultural broker whose constant task is to make the hospital and its treatment of the patient intelligible and acceptable to the family and, conversely, to render the family human and comprehensible to the ward staff (Hunter, 1985).…”

The Hospitalized Elderly and Intergenerational Conflict

“…The family may feel overwhelmed by the activity occurring during the initial phase of hospitalization, and the potential for development of negative feelings exists as family roles are restructured (Mandelbaum, 1984). Hunter (1985) suggested that during the initial phase of hospitalization, staff may not attend to the emotional needs of family members and thus may create the potential for negative feelings and conflict. Evidence suggests that it is perceived control over a situation, not actual control, that is important (Kelley, 1967;Langer, 1978).…”

‘Strangers in a Familiar Place’: The Evolution of a Family Therapy Clinic Within an In‐Patient Adolescent Unit

“…But, on the other hand, because of the feelings of failure and blame which suffuse the treatment system, staff groups may be induced into partisan bias either for or against the family. This can lead to intense competition between, for instance, parents and staff over the care of a young person (Harbin, 1979;Jones, 1980;Hunter, 1985). These tensions add to the already complex task of adolescent residential treatment with its mixture of high emotional tensions, group dynamics, individual volatility and staff/family transference (Hunter, 1985;Steinberg, 1986).…”

“…This can lead to intense competition between, for instance, parents and staff over the care of a young person (Harbin, 1979;Jones, 1980;Hunter, 1985). These tensions add to the already complex task of adolescent residential treatment with its mixture of high emotional tensions, group dynamics, individual volatility and staff/family transference (Hunter, 1985;Steinberg, 1986). Clearly these factors indicate how crucial a family therapy service is for inpatient units but they also explain why family therapists are wary of providing such a service.…”