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The Family Therapy Program
Vermont State Hospital
December 21, 1970
H. Peter Laqueur, MD
History:
When the present director of the Family Study and Treatment Unit (H. Peter Laqueur, MD) was hired by Vermont State Hospital in October 1968, he immediately started to organize a Family Therapy Program. The groundwork was laid in about six meetings on consecutive Sundays attended by both hospital personnel and hospital patients with their families. These meetings lasting 1 1/2 to 2 hours served to acquaint personnel and patients with family therapy in general and Multiple Family Therapy, (MFT), as developed by the program director over the preceding nine years in New York in particular. Simultaneously, a house organ of Vermont State Hospital (VSH), the "VSH Observer", was founded and carried articles on the subject of family therapy.
During this same period meetings with the staff of the hospital's Group Dynamics Program were held and training in family therapy observation and treatment techniques was begun. Two physicians and two psychologists of the hospital staff also took part in this training.
In January 1969, the combined staff of the Mental Health Clinics of Rutland and Bennington attended a three-day workshop in MFT conducted by the program director in Manchester, Vermont. The interest for MFT generated by this workshop led to the incorporation of MFT into the treatment program of the Rutland Mental Health clinic, and also a group of workers at the Bennington Mental Health Clinic started experimenting with this treatment modality.
Furthermore, in the early part of 1969, the program director gave lectures on the subject in St. Albans and Springfield and later on held seminars at VSH for groups of workers from Mary Fletcher Hospital, Howard Family Service and other agencies to acquaint them with our techniques.
Two three-day workshops in MFT were held at VSH in June and December 1969, respectively, each attended by approximately 17 workers in related fields of mental health, education, etc. Also a summer workshop of one afternoon per week for ten successive weeks was organized for hospital staff to familiarize them further with family therapy techniques.
Description Of Program:
The Family Therapy Program offers as its main treatment modality Multiple Family Therapy, but complements this with Conjoint Family Therapy (single family) and individual therapy sessions as needed.
MFT consists of regular meetings of four to five primary patients, together with their families (parents, spouses or siblings). These meetings are led by a therapist and a co-therapist. One or more observers are present who submit written reports of their observations. These 1 1/2 hour psychotherapeutic group sessions now take place once a week. (In the beginning they were held once every two weeks.)
In order to obtain participation of the whole family, it is nece3ssary to hold the sessions at times when the working members of the family are available. This means that most MFT group sessions must be held on Sundays or in the evening hours of weekdays. If they were held during the regular hospital work hours in day time, we might get mothers to attend, but fathers would only sporadically be able to participate. This would defeat the purpose of family therapy, which is to get ALL members of the patient's family into therapy as we work from the premise that we do not deal with a sick individual but with a family who suffers from sick relationships. We go even a step further and do not a-priori accept the so-called "primary patient" as being the one who is most in need of therapy. We do not infrequently find that other members of the family require as much if not more therapy than the primary patient.
There is no selection of families either according to their socio economic background or their presenting problem, because we have found that a homogeneous group is rather unproductive, while a heterogeneous group provides much more material to work with. The groups are open-ended, i.e. if a family terminates treatment and leaves the group, a new family enters it.
The theoretical basis of MFT has been discussed repeatedly by the program director in papers read at scientific meetings and published in psychiatric journals. Reprints are available. Suffice it to say that in his work with about 900 families at Creedmoor State Hospital, New York City, the program director has found that MFT helps to reintegrate the hospitalized patient into the family and thereby reduces relapse and rehospitalization of discharged patients. Statistics as to outcome of treatment on the work in VSH cannot be offered because the program has not yet existed long enough.
Staff:
The program director was in the beginning the only experienced family therapist on the staff and a core of workers for this program had to be built up. The Family Study-and Treatment Unit was at present as regular hospital personnel besides the program director, one assistant who is a psychiatric technician specialist, and a secretary. The workers directly active in MFT as therapists, co-therapists, observers a.o. are interested people from related fields. Some are on the staff of the hospital, others are not.
Hospital staff, with the exception of the program director, receive compensation time for Sunday and evening-hour work. The program director gives his time on Sundays and in the evening, in addition to his regular work week in the hospital, without compensation.
Outside workers are paid by Washington County Mental Health Center under a contract between VSH and that agency. None of the workers on the staff of the hospital receives any pay beyond his regular salary.
Training of Staff:
In addition to a general educational program in family therapy as mentioned under the first heading of this report, a therapist-in-training undergoes a systematic education by first auditing at least six MFT session, then sitting in as formal observer at another minimum of six MFT sessions, during which phase he is required to submit written reports about hs observations to the program director; during the next six sessions, he may act as co-therapist, and finally he will conduct another six sessions as therapist at first with a more experienced therapist acting as his co-therapist and lastly on his own.
There is an on-going in-service training program consisting of formal evening-long training sessions every two weeks and short informal conferences between the program director and the therapist, co-therapist and observers after the MFT group meetings. In addition, the program director is always available for individual consultation with the therapist-in-training at his or the program director's request.
Video Tape Recording:
A very important tool in the teaching of therapists as well as in the actual therapy, is the recording of MFT sessions on video tape and the study and analysis of thee tapes. The audio-visual equipment was obtained through contributions from private donors to the Vermont Research Foundation for Mental Health, Inc. which had been established by the program director in collaboration with other members of the staff.
The manpower to run the equipment and record the sessions is partly furnished by devoted volunteers, partly by therapists-in-training. WE encourage trainees to serve part of their observer's time as camera men if they show the necessary talent for this work, as we have found this to be 3excellent training of their observing faculties. Servicing of the equipment by a video technician is paid for by the Vermont Research Foundation for Mental Health, Inc. through private donations.
The tapes produced are of excellent quality so that they could form the basic material for a professional film about our work produced by Sandoz Medical Education Department. More about this under a later heading.
Patients:
The program is theoretically open to every patient of the hospital. Patients are being referred by the clinical staff and by the directors of other programs in the hospital, notably the Alcohol and Drug Rehabilitation Program. Lately, the program director attends the Planning and Evaluation Meetings of the recently established six Clinical Unit Teams whenever possible to determine in cooperation with the clinical treatment team the need of patients for family therapy.
In addition to in-hospital patients and their families, the program serves after-care patients of the hospital and also receives patients referred by Washington County Mental Health Center and other mental health agencies of the State of Vermont.
Finally, there are referrals of patients by private physicians and self-referrals.
Chart A
In the two years of its existence, the program served 123 families (over 300 individuals).
Of these:
16 families attended more than 20 sessions;
48 families attended more than 8 sessions;
32 families attended between 4 and 8 sessions;
27 families attended from 1 to 4 sessions only.
Results:
Although in family therapy lasting improvement in family relation can hardly be expected before twenty or thirty sessions, we have reviewed our 64 cases of more than eight sessions and find the results shown in the following:
Chart A-1
Much Improvement Some Improvement No Change
Number of Cases 23 31 10
It must, of course, be kept in mind that all psycho-therapy runs in three phases: Phase 1 -- patients experience some initial relief because of the feeling that something is being done for a pressing problem; Phase 2 -- a period of resistance follows phase one when painful areas are being touched and patients become aware of the need to face up to deeper problems; such periods of resistance can last from 50 to 50 sessions and in individual psychotherapy as well as in family therapy it can sometimes take years before patients enter Phase 3 -- which is when the resistance decreases and problems are being worked through emotionally with a final resulting change in behavior, better insight and lasting recovery.
Furthermore, since problems in families have been building up over many years before the family feels compelled to seek help, it would be unreasonable to expect that significant changes in internal, mutual behavior in the family can be obtained in a short time. It would certainly be unwise to conclude that a family situation is incurable because no changes can be observed after only eight sessions or less. Experience in the program director's work in New York has shown that remarkable improvements and sometimes full social recovery can be achieved even after 4 to 5 years of Multiple Family Therapy. Therefore, the effectiveness of any therapy, but more in particular Multiple Family Therapy, cannot fully be judged until three or four years of a sustained program have elapsed. We are not prepared to conclude that those cases which have not shown any effect of the treatment so far are necessarily those who would not profit in the long run.
In an appendix to this report we give a short description of each of the 23 much improved cases to illustrate the results of Multiple Family Therapy as observed so far in this program at Vermont State Hospital.
Diagnosis:
The presenting problem in the primary patient leading to his referral to family therapy is shown in the following:
Chart B
Number of family cases:
Schizophrenic syndromes 18
Depressive or manic depressive 31
Alcohol or drug addiction 24
Adolescent maladjustment 8
Marital discord 32
Undefined or multiple problems 10
Adjunct Therapies:
As mentioned before, the MFT sessions these 123 families attended, were in many cases not the only contact the family Therapy Unit had with them. Individuals and whole families are sen additionally in individual sessions when needed. We are more and more convinced that home visits should be made whenever possible. These not only add valuable background information but often provide us with new insights into a family's total situation not otherwise obtainable. Many hours of therapy may be saved or at least made more productive by a single home visit. We would like to start a regular program of at least one home visit for each family in treatment bu lack the necessary manpower, except for a pilot project on a very small scale.
Education:
Family therapy is a relatively new psychiatric treatment modality. It is, therefore, desirable and necessary to consider education in this area as an essential goal of the hospital. One of the broadest means of education for professionals will be the educational film produced by Sandoz Medical Education Department mentioned earlier.
First, a short (18 minutes) film was completed in February 1970, and shown as part of a scientific exhibit on "MFT at Vermont State Hospital" so far at five scientific meetings i.e. Annual Meetings of the American Psychiatric Association, the American Medical Association, the American Academy for General Practice, the Interstate Association for Postgraduate Studies, and Transcultural Conference on Psychiatry arranged by Northwestern University, Forest Hospital in Illinois.
This film will also be shown in approximately
360 state hospitals throughout the United States and Canada, several hundred
Mental Health Clinics and private hospitals as part of the Sandoz Medical
Education program. Requests for the film have been received by Sandoz also
from
Europe. (Note: The film is no longer in the Sandoz archive library.
IF you have a copy please contact the MFGT Resource Center. We would like
to have a copy too.)
A longer film (45 - 50 minutes) on the basis of our video tapes and of film taken in 26 sessions of one of our MFT groups is in the process of being completed. The actual filming has just been finished and the film should be ready for distribution within a month or two. (We at the MFGT Resource Center have not seen this film.)
Another important part in the educational program of the hospital in the area of family therapy is its membership in the Council on Family Study and Treatment in New York City. This Council is an independent working group of family therapists which was founded in May 1967, and is concerned with providing assistance in training or in developing training programs for family therapists. Thirteen of the more important family therapy centers in the Northeast are represented by 18 family therapists, one of them being the Vermont State Hospital which is represented through the membership of the program director of its Family Study and treatment Unit.
Additional three-day workshops similar to the ones held in 1969, and mentioned earlier are being planned for 1971.
All medical students from the Medical School of the University of Vermont, during their four-week assignment to Vermont State Hospital, receive an introduction to family therapy by the program director and some participate as observers in MFT sessions. Thus, they may obtain a greater acquaintance with family therapy than is customary in the psychiatric affiliation program of other medical schools. An exchange of our video tapes with the University of Vermont is also planned.
Finally, an effort is being made by the program director to take part in community education by means of lectures and demonstrations to groups of laymen, popular writings, etc. --to acquaint the public at large with the possibilities of family therapy.
The intensive teaching program for staff and prospective therapists has been described earlier.
A closer cooperation with the eleven Mental Health Clinics of Vermont preferably in collaboration with the clinical teams of the six Regional Units of Vermont State Hospital to coordinate treatment and aftercare plans for each patient much more closely than is done now is being planned for the near future.
Summary:
Although the Family Study and Treatment Unit of VSH has suffered from a lack of adequate space for group therapy rooms combined with a permanent television studio, and so far had to improvise in this area, it has build up its program in the last two years from two MFT meetings per month in November 1968, to eight in 1969, and 26 meetings per month in 1970. The Family Therapy Program and training facilities for professionals in the field have been developed at little cost to the State through the help of the Vermont Research Foundation for Mental Health, Inc. and its friends.
Permanent, adequate quarters for the unit and a more complete integration of family therapy in the total treatment plan of patients will undoubtedly increase the Family Study and Treatment Unit's future contribution to the hospital.
Vermont State Hospital Family Study and Treatment Unit Team:
H. Peter Laqueur, MD Program Director
James Rice Psych. Tech. Spec. Program Coordinator
Kay Mason Secretary
(Note: Doris Thorington, RN, mother to Paul Thorington knew Peter Laqueur at the VSH and introduced Paul to Peter.)