_____________________________________________________________________________________________________________ Fam Proc 25:531-548, 1986 "If I Don't Get Simple, I Cry" HARRY J. APONTE, A.C.S.W.a aDirector, Family Therapy Training Program of Philadelphia (associated with Hahnemann University), Academy House, #32D, 1420 Locust Street, Philadelphia PA 19102. Poor families have taught us special lessons that are applicable to all families. They have instructed us about the problems, within families, of developing relationships adequate to the tasks of family life. One consequence is that therapists are attending more to the evolution of the structure of family relationships, particularly, the phenomenon of underorganization. Poor families have also provided insight into the dynamic relationship between families and their social context. As a result, a therapeutic perspective is emerging that focuses on the influence of the community on the individual and the family, a perspective that may be called an eco-structural approach to therapy. On rare occasions, an encounter with a family becomes a personal beacon to the therapist for work with, understanding of, and empathy for many other families. Such is the Hannon family, 1 which became for this therapist the prototype of the poor, minority family. A single consultation with the family crystalized my professional perspective of these families and provided the model for my work with them. The Hannon family is poor, black, and headed by a single parent, the mother. The family lives in an urban ghetto of a large northeastern city. The family's poverty means not enough money for daily needs, a paucity of work opportunities, limited access to medical care, poor housing in dangerous neighborhoods, and inadequate schools. In short, the family suffers from a lack of the financial and community resources it needs for its members to take care of themselves and one another. The Hannon family's minority status adds to the weight of the burden of poverty on the family's formation, development, and functioning. Mrs. Hannon's being a single parent is both one of the frequent effects of such social circumstances and an added handicap in the family's development. The result is a family that lacks the cohesive, continuous, and well-elaborated, internal relational structure necessary to meet the needs of its members and the demands of society (1). The relationships the family as a whole and many of its members have with its community are themselves fragmented, discontinuous, and limited in the ways they are structured for carrying out their life tasks. The Hannon family is the kind of family that social service agencies and mental health centers find most difficult to work with. They present a variety of personal, familial, and social problems. They live chronically from one crisis to another. Counselors and therapists often experience their sessions with them as chaotic, and the families may attend sessions irregularly and terminate prematurely. The clinicians become as discouraged as the families about the usefulness of therapy. The opening moments of the initial session with the Hannon family were disconcerting. But, as the session evolved, the family revealed itself and its pain to me with piercing clarity. THE SESSION For its first session at a child guidance clinic, the Hannon family comes with nine of its members from three generations: Mrs. Hannon, 47, her children, Vera, 22, Toby (a.k.a. Marie), 18, Joan, 17, Jack, 16, Mark, 12, and Earl, 11, and Vera's two children, Rita, 3, and Curt, 1 ½. The identified patient is Joan who was reportedly having problems in school. She is a heavy-set young woman with a cherubic face and intense manner that ranged from manic demeanor to a sweet, quiet seriousness. Her mother had made the appointment. The session begins with the family walking into an interview room equipped with an observation mirror, microphones, and TV cameras. One of the kids is loudly playing a portable radio as family members work out seating arrangements. Jack: You see the camera over there? Joan: [looking up at microphones hanging from ceiling] They just want to know how crazy we are. (In her first statement, she labels her family and herself as troubled.) Therapist: I don't want anybody in the corner over there. [pointing to blind concealing the TV cameras] Joan: Get out of the corner, Vera. (In her second statement, she joins therapist as an orchestrator of the family.) Therapist: Come on and join us somehow. Pull the chair over. Yes, right. Most of the children are talking loudly, over each other, and competing with the music on the radio. The therapist is drowning in noise, but persists in trying to seat the family and become acquainted with them. Mrs. Hannon, the mother, remains quiet and does not take charge of the children. Still, in the midst of the apparent confusion, Joan out-talks the others and gives directions and explanations. She also talks in a manic and compulsive manner, mocking herself and saying, "I ain't got no sense, no way" and "I told you I was crazy." Joan further focuses everyone's attention on her by explicitly inviting her siblings to tell how "crazy" she is. She later characterizes this demeanor of hers, which she also exhibits at 1 _____________________________________________________________________________________________________________ home, as "simple." The pattern emerging early in the session is that of the mother withdrawing from the confusion while Joan attempts to dominate it. To the therapist, Joan seems to be taking on too much responsibility for organizing communications in the session. Working on the basis of this hypothesis, the therapist chooses to avoid reinforcing this role for Joan and directs most of his remarks to the other siblings. He defers calling upon the mother. The therapist knew from previous experience that in low-income families that are inadquately structured in their relationships (that is, underorganized), as this one appeared to be, mothers often vacillate between withdrawal from the children and an aggressive, paralyzing control of them. Initially, Mrs. Hannon remained quiet and uninvolved. The therapist chose not to activate her for fear she would feel compelled to be too assertive. He wanted to allow for the natural flow of the family in order to observe their interaction and to start his work from within their rhythm. The therapist attempts to attend more to Vera, Toby, and Jack than to Joan in order to test whether with a little encouragement they could take over from Joan some of the leadership among the siblings. But all to no avail, which tended to confirm his impression that Joan had assumed some kind of special responsibility in the family. The pressure with which she describes how she, along with her siblings, were driving their mother "crazy" hinted at a function that her centrality was servingthe protection of her mother. The therapist then tries to engage the mother who appears to him to be withdrawn and unhappy. But he is not able to keep her on center stage for long. Therapist: Mrs. Hannon, everybody else looks pretty happy except you. Joan: She ain't got not sleep that's why. Vera & Mark: [speaking simultaneously, inaudible] Joan: She just got home from work. Therapist: Did you really just get home from work? [walks across room and sits next to Mrs. H] Mrs. H: Uh huh Joan: Tired as a ... [inaudible because Vera talks simultaneously and Curt yells at Earl] Earl: I bet she is gonna go to sleep as soon as she go home. Therapist: [to Mrs. H] Where do you work? Mrs. H: Horsham, Pennsylvania. Therapist: How far away is that? Mrs. H: On the other side of Willow Grove. [youngsters quiet down except for Curt, who is still fussing] Therapist: What do you work at? Mrs. H: Cleaning offices, eleven to seven. Therapist: Eleven to seven every night? Mrs. H: Uh huh. Therapist: And you have all these kids to take care of by yourself? [children are teasing Curt who suddenly yells as the noise escalates! Vera: We all take care of each other. Therapist: [to Mrs. H] Are you just tired or are you really as unhappy as you look? Mrs. H: No, I'm just tired. Vera: She's not unhappy. Joan: [Curt yelling persistently as Joan talks] Yes, she is unhappy. She just don't want to tell nobody. I'll tell you why she is unhappy. She is sick and tired of us. She wants me to go to school and get graduated, but I don't like school. She wants her [Toby] to stop acting like a fool. She wants him [Jack] to mind his business and stop messing around. She wants her [Vera] to get a house and get her kids and get together. She wants him [Earl] to get straightened out and go to school. And she don't worry about him [Mark], 'cause he ain't home. And me, I got nerves. Boy, I got some nerves on me. Earl: [pushing Curt who is wandering about] Get out of here. Jack: I don't cause no problem for you all. Therapist: No? Joan: [overlapping] Ever since I can remember I had bad nerves. I shake, shake, shake. [gesturing] The therapist learned from Joan exactly how Mrs. H was burdened. She was working all night and taking care of her family during the day. Joan made sure that the therapist knew now hard her mother's life was as she detailed how each of the children was a problem to Mrs. H. One needs only consider the overlapsthe way the siblings interrupted one another and spoke simultaneously to appreciate how, except for Joan's, the roles of the children in the family were indistinct. The therapist then tries to get a bearing on the mother's position in the family. Her Gorilla Suit 2 _____________________________________________________________________________________________________________ Therapist: Joan: Therapist: Mrs. H: Joan: Vera: Joan: Therapist: Mrs. H: Therapist: Joan: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Joan: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Joan: Therapist: Joan: Mrs. H: Therapist: Earl: Mrs. H: Therapist: Mark: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: 3 [to Mrs. H] How do you handle all this? She don't. She just ... [to Joan] No, wait a minute. [to Mrs. H] I can't even talk to you 'cause everybody is talking for you. How do you handle all of this? Put on my gorilla suit. That's all. That's what she do. She can get very violent when she gets ready, boy. [excited laughter and chatter among the children] Everybody running in all directions to get away"Don't run way from me!" [overlapping] She gets violent! [ignoring Vera and Joan, and addressing Mrs. H] I imagine you have to get violent to keep things under control. I'd better. If I don't get violent, they'll put me out of my own house. But if you ... Tell me something. If you work all night, how do you rest in the daytime? She don't most of the time. [to Mrs. H] See. I can't talk to you 'cause they talk for you. I really don't. You don't rest. I get about two or three hours of sleep. That's why you're so tired! Uh Huh. Right. How long have you been at this job? Since March. I mean, there must be something you can do in the daytime. I prefer night. See, I have my father with me. You have your father to take care of also? Yeah, He's seventy-seven and senile. So what else you going to do? That's why we're here. [ignoring Joan] Man! No! You really ... you can't get more than two or three hours of sleep if you're taking care of your father, all these kids... What did you do before March? I didn't do anything. I was on DPA. Why did you go to work? Because I wanted to. I make more money. Yeah, you make more money, but you must have gotten some rest that way. Well, sure you get rest. You ain't got nothing else to do but stay home. Do you like being out of the house to work? No. I'd rather be home, but finances is finances. You need the money. That's right. How's your health? Fine. It's holding up? Yeah. Except for one thing. Except for what? Her nerves. My nerves. Well, I'm not surprised. What is wrong with your nerves? [overlapping as he points to Curt who is standing on a chair while Mark teases him] Get down from there. [Curt yells in protest as Marks tries to pull him down] They're tired that's all. Were they like that before you went to work? [overlapping to Curt, who is yelling persistently] Sit down. Un huh. Right. [children laugh at Curt] Is anyone helping you with your nerves? Like what? Are you seeing a doctor? Uh huh. Yeah, I have a doctor. _____________________________________________________________________________________________________________ You have a doctor. Did he give you some pills? Uh huh. Do They help? Right. [to Curt, who is standing on a chair and still yelling] You had better sit. No! [Mrs. H and the therapist stop talking and all watch the struggle between Mark and Curt] [too distracted to continue talking to Mrs. H] [to Curt] You're a tough guy aren't you. [to Vera, Curt's mother] How old is he? Vera: A year. Therapist: Boy, you'd never know he was only a year old. [Mark tries to pull Curt down and Curt yells and kicks him] [to Vera] Let me see. Do you think they could take care of him downstairs or would he not stay downstairs with the babysitter? Vera: No, I don't think he'll stay. Therapist: You don't think he'll stay.[therapist is stymied by Curt and Vera offers no help] Mrs. H: [to Mark] Just ignore him. [to Curt] Sit down, boy. Hey, sit down. Down! Joan: [overlapping] Sit down, man. Mrs. H: Leave him alone, Mark. [to Curt] Hey, sit down. Sit down. I'll bet I'll bash you if you don't sit down. [children guffaw] Jack: [overlapping] Sit your behind down, boy. You better sit down. Joan: That is why he is so super mean. 'Cause he don't like nobody to tell him what to do. [Mrs. H walks over with a rolled-up newspaper and strikes Curt lightly on the legs] Mrs. H: Sit down! [excited comment and laughter from the children as Mrs. H physically takes Curt off the chair and Curt whimpers a bit and sits quietly] Mrs. H: You better shut it up. [Vera laughs like one of the children] Mrs. H: [to everybody] Now, leave him alone. It's It's not funny. Therapist: [to Vera] Would he listen to you the way he listens to her? Vera: Nope. Joan: [overlapping] No. He won't listen to nobody. Therapist: [to Mrs. Hi] So you're kind of a mother to everybody. Mrs. H: I'm the mother of all of them. This last scene epitomized for the therapist the dominant, problematic pattern in the family. While Mrs. H was seeking refuge from the events in the family through her withdrawal, Joan was the overriding personality. Although she had little authority and no acknowledged responsibility, Joan was able to draw much of the family's stress and conflict to herself and away from her mother. However, when a forceful person was needed by the family, it was only the mother who emerged to take action. When Curt took control of the session with his screaming, no one could do anything with him except Mrs. H. She spontaneously took over when the therapist signaled his helplessness to Curt's mother, Vera, who admitted she could no nothing to help. Mrs. H acted swiftly and firmly to quiet Curt by putting on her "gorilla suit." As Mrs. H began to quiet Curt, the other children chimed in to tell him to settle down, but each addressed Curt separately and ineffectively. Mrs. H. was the only person with authority in the family. At that moment, the burdensome weight of the problem was totally on Mrs. H's shoulders. When overwhelmed, she withdraws and leaves the family in chaos. At those times Joan does her best to give her mother a respite and pull the family together by becoming the emotional lightening rodfor which she paid her own price. Therapist: You know. They said that Joan here was the one with the problem. I feel more for you than I feel for anybody else in this family. [Mrs. H laughs] I'm not kidding you. Don't you have any sisters or anybody else who can help out? Mrs. H: Sure I have sisters, but they're busy with their own problems. Therapist: They got their own problems. Okay. Tell me what was the problem with Joan. Therapist: Mrs. H: Therapist: Mrs. H: Mark: Curt: Therapist: The Schools Mrs. H: Joan: Therapist: Joan: Therapist: 4 Listen. I don't know what Joan's problem was. Joan didn't want to go to school. She came and told me she didn't belong. I don't. You don't Nope. What do you mean you don't belong in school? _____________________________________________________________________________________________________________ 'Cause people make me so mad, boy. Like I go to school and so they gave me the same thing over that I already had. And If I sit there and don't write it down on paper, boy, they get so mad! And it's right. Therapist: Yeah? Joan: And like when I take notes and everything, right? Therapist: Yeah? Joan: And they give me a test. I don't even bring them home or study them or nothing, and I get a test. They say, 'You didn't study., But I say, "I got it right." They think I cheat. Therapist: Yeah? Joan: So, I ignore them. Vera: Rerun, Rerun, Rerun. Joan: I just ignore them and don't come. Vera: The stuff you get in elementary school you get in high school, and get the same thing. And you get tired of it and bored with it, and you don't want to do it, and they get all ... Joan: Like when I go to my geometry class... Therapist: Yeah? Joan: And like, say, I ain't been there in about three weeks, and I go in there, and they have a test, and I do it right, my teacher swears I done cheated on somebody. Cheated on somebody's paper. I just ignore her, tear it up, throw in the trash, don't come the next day. Therapist: And you didn't cheat? Joan: Uh uh! Vera: She had it already. Toby: The same thing she had in elementary school and junior high school, that all. Like the math... Mrs. H: Joan has repeated tenth grade three times. Vera: But they're giving her stuff that she already knows. Like she wants stuff higher than she can learn, so when she gets out of school and has kids and everything, that she'll know what it's all about. There was a dramatic difference in the tone of this part of the session after Mrs. H had brought order among the children and focused the family on Joan's problem with school. There was no talking over one another; the young women were elaborating on what each other was saying. Their perception was that the schools did not teach, did not challenge and, in fact, material was repeated as if the teacher did not expect them to learn anything more from one year to the next. The family has identified Joan as having a problem with school. Vera then volunteers her own concern about finding work. Joan: Feeling Scared Vera: Therapist: Vera: Therapist: Vera: Therapist: Vera: Therapist: Vera: Joan: Therapist: Toby: Joan: Therapist: Toby: Therapist: 5 'Cause like she [mother] said, she was going to take me down to get a job. Yeah? She's still willing to help me and everything, and I'm still willing to get out with my husband or without him. Like I want to get out on my own. Like my husband don't decide to come or whether he do. You don't know yet whether he's going to stay with you or not? No. Like I want somebody in that house with me, because I am afraid. What do you mean you're afraid? I am afraid to be in the house by myself. Like if it ain't nobody home but us kids, and I know they are all there, I will sit up all night long and watch the door, the cellar, everything, because I'm scared to be in there by myself. Are you scared even though they're home? Even though they're all there because if he's [Jack] sleeping and I go up there, "Jack, Jack, wake up!" [mimics his struggling to wake up] Somebody walked in the house, looked upstairs. She [Joan] was in the kitchen washing dishes. My brother was on the couch. He [the stranger] comes walking up there. I look up there. I said, "Hey, who's that?" He goes flying out the door, and all of us was in there, and her [Joan's] boyfriend was upstairs in the bed sleeping. He was in the back room sleeping. Yeah, in my bed. Toby, are you afraid also? Yes. [overlapping] You should... [interrupting Joan] Wait. Wait. [to Toby] Why are you afraid? You feel like you're in a room by yourself, and everything is closing in, and I can't be in a room by myself. I mean, you're afraid when you're at home, Toby? _____________________________________________________________________________________________________________ Yeah. Even when the family's there? If my mother's there, I'm not afraid. If my mother's there, it's all right. If your mother's there, it's all right. Yeah, it's okay. Like when I get off from work, she's [Vera] up waiting for me. I let them go to sleep, and she don't know I'm scared, but I sit downstairs watching television. I even watch television when there ain't nothing on there. Toby: And like, when I come in there at two-thirty [A.M.], she's up. Vera: And like, when my mother do come in, when it does come daylight then I fall asleep. I'll be so sleepy the next day I don't want to be doing anything, long as they all sleep. Therapist: Yeah, but you stay up so that they'll feel better when they get home after they're out, or what? Vera: No. While they're sleeping, I stay awake. Therapist: But why do you stay up? To watch them? Vera: "Cause I'm scared to go to sleep. 'Cause something might happen and I might not wake up. Somebody breaks in or something might happen. And then, like when I'm downstairs awake and they're upstairs sleeping, I go upstairs to check on all their rooms to make sure everybody's all right. Toby: This is why we can't move out. 'Cause we're both scared. Therapist: This why you can't move out. 'Cause you're both so scared? Vera: Right, See, like, to tell the truth, like I would of been gone a long time ago, but the situation was I knew I had to get out, right? Sooner or later. And I know my husband is not there too, right? Therapist: I understand. I understand. This was a remarkably clear statement about the sources of the fear with which these young women lived and which prevented them from moving out on their own. The family was underorganized. Their neighborhood was dangerous. In short, their mother was able to protect these youngsters, but was not able to instill in them the strength she possessed. The social context was either unsupportive or threatening, which impeded these youngsters in developing a sense of personal competence and mastery necessary to overcome their feeling of personal vulnerability. The females were looking to their mother for support and direction. The young men did not see themselves as having any role to play at home, and Mrs. Hannon did not present them as a primary source of concern. Doubtless, these boys' positions outside in the community were also ambiguous, unless they had gangs to give them some sense of belonging or some local citizen or social institution to take special interest in them. Therapist: And you're Mark, right? And who are you living with, Mark? Mark: My aunt. Therapist: [to Mrs. H] That's your sister? Mrs. H: Yeah. Therapist: How did you [Mark] get to... How come you're living with her? Mark: To go to school. Therapist: I don't understand. Why are you living with her to go to school? Mark: It's closer where my aunt lives at. Mrs. H: Because he didn't want to go to one junior high school. Therapist: Yeah? Which one was that? Mrs. H: Washington. Mark: Yeah, Washington Junior High School. Therapist: [looking at Mrs. H] Yeah? He was afraid? Mrs. H: I was afraid myself. Therapist: You were afraid. All right. Mrs. H: So I got him a transfer to Eighteenth and High Street, but in order for him to go to Bavok Junior High School, he had to live in my sister's house. Therapist: Is that a better high school? Mrs. H: Well to him, he thinks so. Fear of bodily harm in a school has forced Mark to leave home at age 12 to establish residence at a relative's in order to be able to attend a safer school. Because the school in his neighborhood could not provide for his safety, he lives out his adolescent years away from his mother and siblings. Toby: Therapist: Vera: Toby: Therapist: Toby: Vera: When Joan Falls Apart The therapist could find few resources among the children for Mrs. Hannon and Joan. He chooses to see mother and 6 _____________________________________________________________________________________________________________ daughter alone so that he can focus without distraction on Joan's particular problems. He sits facing Mrs. H and Joan. Therapist: Mrs. Hannon, I don't know how you do it. Mrs. H: Uh huh. Therapist: You know, you really have more than one problem at home. You know that? Mrs. H: The whole batch is a problem! (She speaks with a strong voice for the first time since the beginning of the interview.) Therapist: That's right. Why did you pick Joan to ask for some help for her. Mrs. H: This is suppose to be my sensible one. Therapist: Yeah? Mrs. H: And when she starts goofing off, I know the whole house is crazy. Therapist: She helps hold things together? Mrs. H: Right. And when she's blowing her stack and falling apart, it's time to find out what's the problem. Therapist: Okay. You need her to help you. You can't afford to have her...[inaudible] Mrs. H: I can always depend on her, you know. Therapist: Yeah. Mrs. H: But, when she starts falling apart, well, shucks. [shaking her head] Joan: That's why I fell apart. Therapist: That's why you fall apart. Because she depends on you? Joan: Nope. Therapist: Because what? Joan: Because when she wants me to do something and I can't do it. [buries her face in her hands and starts to cry quietly] Therapist: [to Mrs. H] She's upset. Mrs. H: [nodding] [long pause] Joan: [wiping tears away] I got tears. [giggles tearfully] Therapist: That's all right. Joan: I don't like to cry. [moves closer to mother and gets tissues] Therapist: That's all right. That's okay. Joan: No, no. That's all. No more. I get mad at myself when I cry. Therapist: You don't have to. Joan: I do. [dabbing eyes quietly and recomposing herself] Now let's talk. Therapist: Okay. Joan: [pause] If I get simple, then I can tell you what's wrong with my mind. If I don't get simple, I cry. With this statement, Joan has explained the radical change in her manner from the first part of this session to now. After the other youngsters left she no longer needed to draw their attention to herself with her "simple" behavior in order to protect her mother. Joan could now let go. But, when she lowered her defenses, the weight of her burden of trying to keep afloat her mother, her siblings, and herself, overtook her, and she cried. Her mother and the therapist were also at the point of tears. Therapist: All right, okay. What's wrong with your mind then? Joan: Boy, I worry to much. She [Mrs. H] going off to work, she have an accident. [laughs tearfully as she relates her imaginary fears] Therapist: Go ahead. Go ahead. Joan: Jack gets shot walking down the street. Earl having a train accident. Therapist: Yeah? Joan: Rita and Curt choked to death. Vera gets shot by her husband, and meI'm going crazy. Therapist: Yeah, but, you haven't always been this upset. Why are you getting upset? Why have you been upset lately? Joan: 'Cause they don't do what I say, and I know I'm right. Therapist: How long has it been? How long have you been getting so upset? Since everything's been getting so bad? Joan: Since June I guess. Therapist: Since June? What happened? What happened then? Joan: A whole lot. I can't stand it. Well, not so much, except they just get on my nerves. Therapist: No, no, something happened. Something has changed at home since June. Why is it worse since then? Joan: Let's see. They don't listen to what I say. Therapist: [to Mrs. H] Do you know what happened? Mrs. H: Think I do. 7 _____________________________________________________________________________________________________________ What? Charles and Vera. The kids been fighting, right? Tell me. I didn't hear you. Vera's husband, Charles... [interrupting] I told my sister... [to Joan] Wait, wait. [to Mrs. H] Go ahead. And, like, she feels as if they should have been gone, because I had gave them a set date in June to have themselves a place before they got married. I said, "Find yourself a place." And instead of it getting better, it just gets worse. Joan: I told my sister, "Don't get married. If you get married you're going to be sorry," and that's what she is, sorry. Therapist: Why? Joan: 'Cause it wasn't going to work out. 'Cause they wasn't even getting along before they got married. I told her, "Don't get married." Therapist: Why has that made a difference at home? Joan: I don't know. Mrs. H: It just seems to me that since then, there just hasn't been no getting along. Therapist: Do you [to Mrs. H] know why? [pause] I don't really understand how Vera's situation made it so much worse. Joan: Because she always tells me all her problems and then I try to figure them out, and when I tell her what I think, she don't want to listen, but she always wants me to figure them out. Therapist: So Vera tells you her problems. Who else do you have to worry about? Joan: I don't know. I just worry for no reason I guess. Therapist: No, but you're supposed to worry about other people in the family. Therapist: [to Mrs. H] She's really been like a part of you. Mrs. H: Uh huh. Therapist: To take care of things and hold them together, because you can't possibly do this by yourself and she's been the only one you could really depend on to handle things. Mrs. H: Uh huh. Right. Therapist: You know, when I talk to you, when you first came in here you looked very tired. You looked out of it. The kids have all left and I can really see you now and your eyes are very clear, and I think they're very clear because you see a lot, and I think maybe your nerves are as bad as they are because you see too much and there's nothing you can to about it. Mrs. H: [softly] I'll go along with that. Therapist: And she [Joan] is trying to carry this burden with you. [Mrs. H nods] [pause] I can understand why she can't worry about school; she's got the worries of any woman, not a seventeen-year-old kid. [Mrs. H nods] She couldn't have more worries if she had ten kids of her own. [pause] Therapist: You don't really have any help from the outside? Mrs. H: No, they don't even care. Mrs. Hannon had eight children. Six were still home if we include Mark. She also had two grandchildren at home and her "senile" father. It is not just the number of children. These children are facing poverty and all the other noxious social conditions that were overwhelming the mother and them. Furthermore, Mrs. Hannon was a single parent. She had no family that could help her. We do not know what Mrs. Hannon's family circumstances were when she was growing up. We do not know the problems her parents had that worked against their giving Mrs. H, as a child, all they wanted to provide her emotionally, socially, and economically. Therapist: Mrs. H: Therapist: Mrs. H: Joan: Therapist: Mrs. H: Solving one Big Problem Therapist: Mrs. H: Joan: Mrs. H: Therapist: 8 Okay. [pause] Vera doesn't talk like she's going to leave. [emphatically] Right! Now you understand. Right, right, right! Anyhow, if I stay home and watch all those kids and make her go out and get a job... Like two days ago, I woke her up and said, "Come on, Vera, you're going to get a job," took her out, and she went and got lost. I bet you she didn't get lost. She just didn't even want to go. She didn't get lost. I feel like this. If Vera was to find a place and get a job, take her childrennd I don't know what Toby's going to dond just leave the household to my five dependent children, four dependent children, which I do have, I think things would be better. I really do. You may be right. _____________________________________________________________________________________________________________ Uh huh. I told them, I said, "Look, you got your problems, I have mine. Pack your problems up and go ahead for yourself and leave me with my four dependents, that's all I ask." Joan: (She is still trying to help her mother.) She won't have to live alone, she could get an apartment. There'll be people downstairs, she could make friends with them, and then go out, and all she have to do is go downstairs or upstairs and get them. She only needs two bedrooms and an apartment got two bedrooms. Therapist: (Avoids reinforcing Joan's feeling of responsibility for her mother and addresses only Mrs. H.) You don't have any family that she [Vera] could go live with, have you? (Focuses on a single concrete issue to help relieve the pressure on Mrs. Hannon.) Mrs. H: Nope, just two sisters, that's all. One has a small apartment, the other has a small house. Therapist: I interrupted you Joan. You were going to tell me something. You said, "And there's another thing..." Joan: I just forgot. Oh yeah, I do that a lot, too. I make myself forget stuff. Therapist: Joan, you have so much on your mind that I think you need to forget a few things. You can't keep all those things in your head at once or you'll go crazy. Joan: I know I'm crazy. That makes me mad [laughing] 'cause I can't do nothing about it. Therapist: Yeah, this kind of thing would drive anybody crazy. You're crazy because you have too much to deal with. [pause] [to Mrs. H] I guess, in a way, that what we really should be concentrating on first is Vera and her kids. If we can get something done for her and her kids... Mrs. H: Right, right! Therapist: I think the other problems will fall right in place and everything will be all right. (That is, she can handle the rest herself.) Therapist: [to Mrs. H] Wait, hold on. [to Joan] Do you agree with your mother about Vera? (Tests whether Mrs. Hannon can expect any opposition from Joan on this formulation.) Joan: Well, this is what I think. I think all the older kids should hop off and get away. I think that my mother should find another place for my grandfather. [inaudible] 'cause we don't get along. Therapist: Who doesn't get along? Joan: Me and my grandfather. Therapist: Yeah? Joan: Boy, heor one thing, he throws them riddles at me. (She means the talk of a "senile" man.) and I don't know what the heck he's talking about. And by the time I figure out what he said, he done changed his mind. Like he said... Therapist: [to Joan] Wait a minute. [to Mrs. H] She wants your father out too. Mrs. H: [to Joan] And where am I going to put him? Joan: I don't know, somewhere, find somewhere. But I know she can't find no place that's safe, 'cause that's why he got put out the nursing home because of Fire Marshall laws and Health Department. Therapist: [to Joan] Because... I can't hear you. Joan: The Fire Marshall and Health Department was checking the nursing home, and she...they had to get the people out. And they only had one accident. If there was a fire, they all would of got burned up. Therapist: [to Mrs. H] We already had something like that happen in Philadelphia. (Only a couple of weeks before, there had been a fire in a nursing home occupied by mostly poor, black residents. There were some fatalities. Again, a failure of the system.) Joan: Right, so she took him out. Therapist: [to Mrs. H] And you don't want to have something like that happen with your father there? Joan: Right. Therapist: When was he asked to leave the nursing home? Mrs. H: No, I went and got him. Therapist: Okay. When was... Mrs. H: Tuesday, a week ago. Therapist: That was after that fire? Mrs. H: Uh huh. Therapist: [to Mrs. H] You know, the life in the city isn't helping you any, either. Joan: She wants to move to Jersey. Therapist: [to Mrs. H] Well, there's a lot of things working against you. You shouldn't be poor. Nobody should be poor. That would solve a lot of our problems. Mrs. H: [laughs] You can't have everything. The social circumstances that the family confronted at every turn magnified each family problem. They could not even find a safe nursing home for Mrs. Hannon's ailing and senile father. Mrs. H: 9 _____________________________________________________________________________________________________________ Taking Care of Joan Joan: Therapist: Joan: Therapist: Joan: Therapist: Mrs. H: Therapist: Joan: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Joan: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: Joan: Therapist: Mrs. H: Therapist: Mrs. H: Therapist: 10 And you know, I think things won't never go my way. Why do you say that, Joan? I don't know... 'Cause they don't! Joan, you know, right now you can't live for yourself. You're living for a lot of other people. At this point in your life, you're not thinking about what you're going to do for yourself or where you want to go tomorrow. Nope. You're thinking about what you're going to do for all of these other people in your house. [to Joan] And that will make you sicker than anything in the drug store. It will, because you can't solve everybody's problems. This you can't do. We just have to make arrangements with them and if they can't solve the problem, I can see if I can help them solve the problem and get them off your back, and maybe you can solve some of your own problems. (She spontaneously takes over from Joan, dismissing her from the job of worrying for the rest of the family.) [to Mrs. H] I'm listening. I'm with you a thousand percent. I think I need to find me... learn how to do something so I can get me a job. [to Joan] Yeah, you're not going to be able to worry about a job, or school, or anything until we solve some of these other problems. Right. Vera and... Right. And your grandfather. But, I don't want to stay home and do nothing. No, no, no, really, you're too smart for that. [to Mrs. H] She really is too smart for that. Actually, you know, your family is smart. People are bright in your home. Nobody should be doing nothing. But if you have these worries, you can't do a lot of things. [to Joan] You can't. You can't sleep or think. You can't really remember what is one and one. [to Mrs. H] And you can't help her if you're overwhelmed, because I know you would help her. See, right now you're calm, and think very clearly about what she needs. But when they were all here, you know, you were out of it. Right. I would have been out of it too, because I would have said, you know, what can I do? I was having a hell of a time myself keeping everything straight in my head. Worrying about Vera and worrying about her kids, and worrying about Toby and watching Mark, not Mark... Earl. Earl causing some trouble. Everything was just...(With a hand clap, the therapist changes direction.) Okay. Look, I think you laid it down absolutely right, and I want to see what I can do to help you. And I think first things first, and that is to try to get some help for Vera to plan her life. She needs somebody to really work with her to plan her life. Okay? True. Then I want to see what I can do about getting some help for you to see if anything really can be done about your father. [Mrs. H nods] Okay? We have medical people here. I can get other contacts, I can get a number of people working together with you. If we can take care of those two things, get some progress on them, then we will get on this, this problem with Joan. Right. We'll try to move fast because I don't want Joan to miss too much school. That's okay. I already know everything they got. Okay, girl, but you know, there's not but just one school in the city. It could be that the school is not handling things right for you, you see. If we could get your life in order a little bit, we might be able to help you get to the right grade in the right school so that you can do something with your head. Oh, that would be beautiful! [to Mrs. H] All right, but I don't see where we're going to succeed if we can't begin to do something about the other problems. Right. We got to eliminate the biggest problem. Then, I think, if you get to the biggest problem, I think the rest of it will fall in place. Right, we start taking care of this, taking care of your father, helping Joan out. And then if we can think of anything more that you needyou may not need anything more. _____________________________________________________________________________________________________________ No, I'll have peace of mind when I get rid of the biggest problem. Toby, don't forget her. Okay, I won't forget her. I'm just trying to get some order. I can't stand that girl. All right, okay. I think we did a lot of work. I think things are clear [Mrs. H nods] and I'm going to get other people in to help with this, 'cause I, I can't do it alone. Mrs. H: I know it. Joan: You want to know a little secret? Therapist: Yeah, what? Joan: When I was coming up here, I was singing a song: "When the nuts coming marching in, oh, when the nuts come marching in, all the psychs gonna jump out the windows, when the nuts..." Therapist: [smiling] Okay. Nobody's going to jump out the window. What's going to happen is that you're going to get more people connected with your family and we're going to try to get things in order. All right? Mrs. H: Uh huh. Therapist: Okay, let's stop here. Mrs. H: Come on, Joanie. Therapist: Mrs. Hannon, it's been nice meeting you. [shaking hands with her] Mrs. H: It's a pleasure to talk to you. Mrs. H: You ready, Joan? Joan: Okay. Mrs. H: Okay. [all leave] The Hannon family and other poor families have taught me special lessons that apply to all families. The link between Joan's school problem and the conditions of the schools, and between Vera's fear of living on her own and the dangerousness of the neighborhood, are readily recognizable. The Hannons offered some eloquently described examples of the relationship of social ecology to a family's problems. The eco-structural approach grew out of work with poor families like the Hannons, and is meant to address family problems rooted in their social context. Obviously, with individuals and families whose poverty is a factor in their problems, the social environment must be part of the field targeted by the therapist (2). However, the better we understand the effects of our physical and social environment on our own functioning, the more evident the effect of social context on everyone's personal and familial functioning becomes. The Hannon family, with a single, overburdened executive and a youngster desperately trying to help, also taught me about the problems of developing an organizational structure adequate to the tasks of a family. However, family underorganization, of which the Hannons are a classic example, is not limited to the poor. Degree of organization is for all families an issue that must be differentiated from family conflict, the dynamic that is more commonly discussed in family therapy literature. Mrs. H: Joan: Therapist: Joan: Therapist: THE CONCEPTS An eco-structural (3) approach to therapy is a therapuetic perspective meant to include the community along with the individual and the family in the field within which therapists conduct their assessments and interventions. It focuses on the structure of relationships within and among individuals (their psychological components), families, and communities in a social ecosystem. Joan's circumstances can be well conceptualized within an eco-structural framework. As an individual, Joan was depressed as she struggled with her own sense of self-esteem, competence, and personal boundaries. Within her family she was also trapped between the needs of her mother and siblings, and her own needs. Moreover, she found herself to be insignificant in her school and emotionally and physically vulnerable in her neighborhood. To approach a family from an eco-structural perspective, the therapist needs to identify specific issues of the family and to assess how the dynamics of the individual, the family, and the social context converge in relation to these issues. This means understanding how all these factors contribute to a problem. The therapist then looks at how and where to intervene in this complex structure so as to affect its configuration in a way that will resolve the problem. The intervention may be with the individual, the family and/or community, or at the interface between any or all of these. As on a chess board, to move any one piece is to change the configuration of all the pieces. We saw in the session itself an intervention to remove Joan from between her mother and siblings. This intervention was intended not only to alleviate the pressure on her in the family, but also to encourage personal autonomy and free her to do something about her schooling. Subsequently, the therapist might also have to work individually with Joan about some of her personal goals, as well as with her and her school. Because of the interdependence of the individual, family, and community, an intervention by the therapist in any one of these areas would need to be implemented as if it were aimed simultaneously at the other two, not discounting the possibility of also having to address the other areas in their own right. The ecosystem is so intricate that one cannot hope to address all of its components. One can only hope to discover the 11 _____________________________________________________________________________________________________________ keystone issue that locks in the complex of problems borne by the family. Therefore, a major task in this approach is to determine what issue or issues of the family to target and in what order (4). The resolution of key issues will automatically take care of or alleviate other issues linked to the family problem because of linkages in the network of the ecosystem's structure. In the Hannon session, the therapist acknowledged and committed himself to help with the problem of primary concern for Mrs. Hannonhe need for Vera to move out of the house with her children. Setting this priority facilitated the mother's allowing Joan to begin relinquishing her pseudo-parental role, which was the key structural issue in the family's relationships. The concept of underorganization (1) refers to family structures that are limited in number and complexity, lack coherence and continuity, and, as a result, are relatively inflexible. In the Hannon family there was no consistent leadership. Mrs. Hannon was effective when active, but withdrawn when overwhelmed. It was into this gap that Joan fell, but without the authority and power to change anything. Underorganized families present special technical problems for therapy. The therapist has to work with the families to create more functional family structures. The goal is to enhance the level of family organization, and not necessarily to resolve a conflictual relationship. There was no conflict between Mrs. Hannon, Joan, or Vera, for example, but there certainly was a need for Mrs. Hannon to take charge as the parent-executive of the family and to help bring about a change in Joan's role and in Vera's living situation. Without this shift in the family structure, no other family problems could be solved. The concept of underorganization can be applied to the individual family member who because of the low level of family functioning, suffers from arrested development of intellectual, psychological, and social functioning. This was apparent in Joan, Vera, and Toby, none of whom had enough sense of personal mastery over their lives to deal with a child-like fear of being left at home without mother. It can be applied to communities where leadership is weak, resource institutions inadequate, and informal, socioeconomic networking missing. So-called "slums" (5) tend to be made up disproportionately of underorganized individuals, families, and communities. EPILOGUE The last report on Mrs. Hannon and her family was that her father had died at home. Vera had reunited with her husband who joined the Air Force, and they moved to the west coast. Joan did not return to school, but earned her high school diploma by passing the GED examination. And it was rumored that Mrs. Hannon had entered some form of the ministry! REFERENCES 1. 2. 3. 4. 5. Aponte, H., Underorganization in the poor family. In P. J. Guerin (ed.), Family therapy: Theory and practice. New York: Gardner Press, 1976. Aponte, H., Family therapy and the community. In M. S. Gibbs, J. R. Lachenmeyer, & J. Sigal (eds.), Community psychology: Theoretical and empirical approaches. New York: Gardner Press, 1979. Aponte, H., (1976) The Family-school interview: An eco-structural approach, Family Process, 15, 303-311. Aponte, H., (1974) Organizing treatment around the family's problems and their structural bases, Psychiatric Quarterly, 48, 209-222. Minuchin, S., Montalvo, B. G., Guerney, B., Rosman, B. L. and Schumer, F., Families of the slums: An exploration of their structure and treatment. New York: Basic Books, 1967. Manuscript received September 25, 1985; Revisions submitted April 23, 1986; Accepted May 9, 1986. 1Unhappily, while the author would like to credit the family by name for its gift to him, professional ethics require him to disguise their identity. Their names have been changed. 12