One of Brodey’s early papers, emphasizing the systemic nature of psychiatric treatment — not just in terms of the relationship between the psychiatrist and the patient but also that between the psychiatrist and the nurse.

INTRATEAM reactions as studied in this paper are the emotional reactions of the team members to one another. These reactions are most obvious when actively unharmonious but are always present. Just as the personal involvement of the therapist is necessary and valuable in forming a relationship with the individual patient, so the emotional involvement of the team is necessary and valuable in forming a relationship with the family. Recognition of this involvement is often avoided because of the feeling that it has no part in the case.

This paper, based upon our clinical experience, is a study of the importance of intrateam reactions. Over a period of 18 months, the hypotheses presented were tested in many cases, including those seen by us in our role as supervisors.

In order to evaluate the factors determining intrateam reactions, five cases were selected for review in which there were outstanding problems of team disharmony. Following this initial study, in three cases intrateam reactions were studied during the process of therapy and used as an integral part of therapy. In order to reduce the subjectivity inherent in this subject, the cases were selected to include six different teams. In six of the eight cases, we took the role of observers, gathering our impressions from attending team conferences, interviewing team members, and reviewing the case records.

The first part of this paper is a report of the concepts derived from the initial study, with brief illustrations from three of the five cases; the second, a report of the further development of these concepts, illustrated by one case in which intrateam reactions were studied during the therapy. For the purpose of simplicity the team will be spoken of as the therapist and worker, the therapist treating the child, the worker treating the parent.

I

The team is constituted when the therapist and the worker are assigned to a case. Each member brings to the team his own particular personality, but the team is a dynamic unit whose equilibrium depends upon not only the individual personalities but their impingement on one another. The parent and child also constitute a dynamic unit. It is the purpose of therapy to alter the balance of forces between parent and child. This process brings stresses to bear upon the team which in turn produce shifts within the team. The power of the stresses added by the family in treatment to produce this alteration depends on 1) the power of the conflicts in the family, and 2) the sensitivity of the team dynamics to these particular conflicts. This accounts for the observed differences in the reactions of the same team to different cases. Many cases may be handled with comparative ease, but in certain cases the team reacts in ways and to a degree for which it cannot readily account, In these cases the examination of the influence of the particular case upon the team can explain the intrateam reaction, for in varying de- grees these reactions are a reduplication in diminished form of the family conflict. This is illustrated in Cases A and B.

In Case A the predominant feature of the intrateam reactions was the mutual mistrust of the team members for each other combined with a strong sense of apparently unreasonable urgency and anxiety. In spite of these feelings there was little communication between therapist and worker. The team had worked easily together in other cases; this reaction was peculiar to this case.

In reviewing the team reaction it was seen that both members were embarrassed by the extent of their feelings about the case and toward each other. In part, each projected his own anxiety onto the “incompetence” of the other, thereby keeping secret his real concern.

The predominant theme in the family was fear, and this fear was handled by denial and projection, the members of the family attempting to keep secret from each other (and themselves) the fact that their lives were in danger-the father was actually homicidal. As long as the intrateam reactions reduplicated the denial and projection within the case, the importance of these mechanisms within the family was not fully comprehended, and consequently the extent of the actual danger was not realized.

In Case B both therapist and worker felt devaluated by each other and responded by attack. They created crises which were out of proportion to the precipitating event. In examining the case, the predominant theme was the mother’s feelings of worthlessness and insecurity in her role as mother. She constantly demanded reassurance of her worth from both her children. When this was not given she created a crisis, for example, threatening to place her “impossible” children. The children in turn were afraid of being thrown out and reacted to this by belligerence.

The family conflict was related to the team conflict. However, the factor of team sensitivity to this particular conflict was important. The therapist felt insecure as a new member of the staff and devaluated the worker as a means of handling this. The worker, in turn, was sensitive about her professional role, and therefore vulnerable to the therapist’s attack. Her retaliation was such as to increase the therapist’s insecurity about his job. Until the team reactions were understood, the tensions within the family could not be fully appreciated.

The mechanism by which the reduplication of the family conflict takes place is in its simplest form the therapist’s identification with the child, and the worker’s with the parent, a necessary part of the therapeutic process. The worker, being identified with the parent, sees the child in accordance with the parent’s concept of the child. Likewise, the therapist’s objectivity is interfered with by seeing the parent “through the child’s eyes.” Both, through their separate identifications, may be unaware of the total dynamic conflict within the family relationship, but may act out the portion of the conflict of which they are not aware toward the other member, whose own identification makes him more liable to respond. When the feelings created by the identifications are acted out without conscious awareness within the team, they are often not appropriately handled within the therapy. The team members may in fact share the fantasies and often the defenses of the individuals in treatment as well as of the family unit. If the conflict is powerful enough to cause team disharmony it is usually a central conflict in the case. The importance of this is illustrated in Case C.

In Case C the worker felt a lack of conviction about the relatively healthy picture the therapist had of the child. The therapist felt that the worker was not objectively evaluating the mother. This disparity resulted in confusion and fighting, which interfered with communication within the team. In reviewing the case, when the question was asked, “What in the dynamics of the case might be related to this problem?” it was found that the mother because of her own problems had a picture of her child as psychotic, and the child had the fantasy of her mother as an evil, devouring witch. Life in the home consisted of bitter and endless fighting. It was seen that the worker’s identification with the mother resulted in an unrealistic appraisal of the child just as the therapist’s identification with the child resulted in a similarly unrealistic conception of the mother. As long as the fighting continued in the team it was not possible to deal realistically with the struggle at home.

II

The examination of team disharmony in the initial group of cases led to the belief that if intrateam reactions were studied during the active therapy, reactions that interfere in the case could be avoided through relating them to the dynamics of the case, and increased insight into the conflicts of the case could be gained through the understanding of the dynamics of the team. It was decided to study not only the reactions of the team which demanded attention but also the more subtle ones.

Three cases were studied in this way. It was planned to spend one hour in team conference for every hour of therapy. The factor of the sensitivity of the team to specific conflicts was handled from the point of view of what in the case was arousing intrateam reactions, rather than from that of what in the personalities of the team made them sensitive to the pressure from the case.

An honest effort was made to express and evaluate the team’s own feelings toward each other, the family, and toward the individuals in treatment. The aim was to be particularly sensitive to all changes in the emotional climate within the team, reviewing these in terms of the case. It was understood that this was in part a subjective process. Acceptance of the understanding that emotional reactions in the team are valuable and a necessary concomitant of team therapy was an important factor in making the discussion of team feelings possible.

To illustrate this process one of the three cases studied is presented. It is the brief treatment of a five-year-old girl who refused to go to school or to separate from her mother. Mother and child were seen for eight interviews and the team had eight conference hours together. In the first three interviews the child would not separate from her mother, so for a portion of each interview worker, therapist, mother and child were in the same room. The case is recorded from the viewpoint of the team conferences.

At the beginning of Case D, therapist and worker discussed with animation the quantity and quality of the fantasy material the child produced. It was only after they had expressed their fascination in the child that they realized the mother had been left out. Further discussion revealed that both therapist and worker were identifying with the child and sharing her hostility toward the mother. They were surprised, on reviewing the intake interview, to find that the mother was not so inadequate as the child had led them to believe.

In the three interviews that therapist, worker, child and mother spent largely together, the therapist and child monopolized the stage. The mother was at first dumb-founded at the therapist’s understanding of the child’s play; later she became frustrated, asking, “Are we getting anywhere?”

The team intra-action was one of increasing separation, hostility and guilt. The therapist expressed his guilt about his and the child’s taking over most of the action. At first herelated this to the volume of fantasy material he felt he had understood and interpreted, but it developed through the team discussions that his guilt was really attached to allowing himself to be seduced by the child. The worker still had trouble relating to the mother, but at first projected her frustration onto the therapist, blaming his overwhelming activity. When this was examined it was seen that the worker was resentful of the passive role she felt obliged to take. She was vicariously enjoying the seductive relationship of the therapist and child, and by her withdrawal was encouraging this relationship. Her frustration was seen as her anger at herself for giving up her proper role. Though this was ostensibly a passive acceptance of the therapist’s wish to have the child, still it was a hostile gesture. There was no “mother” with whom the libidinous onslaught of the child could be shared. With amusement, the team realized that the worker’s apparent passivity served as a hostile paying back of the therapist for taking the child.

It was understood that these feelings were a repetition of the mother’s feelings and that the same process occurred at home. As a result of the team discussions the therapist and the worker felt relieved, realizing that they need not be divided, for the separation was due to their acting out of the conflict. In subsequent interviews, when they were able to act together, they saw the forces of separation in the case, the child’s aggressive attempts to manipulate the mother and interchange roles with her, and the mother’s refusal to give the child the necessary support to prevent this. The importance of the mother’s taking a real role in the family was emotionally felt, and pointed the way toward the worker’s no longer acting out with her by being passive in the therapy, but instead, confronting mother with her own refusal to assume the mother role, and exploring with her the hostile aspect of her passivity. The therapist was also able to support the mother in taking a firm hand with the child, and because he was no longer acting out was able to direct his interviews with the child toward helping her to recognize both the unreality of her oedipal fantasies and the aggressive aspects of her behavior. Both therapist and worker were able to take a firm stand in insisting that mother and child could and must separate in the interviews and that the child should go back to school.

About the fifth interview, there was an alteration in the emotional climate of the team. The therapist seemed to withdraw his investment in the case; he had difficulty in remembering interviews and felt frustrated because the control of the case was passing into the worker’s hands through her work with the mother. The worker felt triumphant. In examining this, the team realized that in essence the therapist, in order to help the child undo the fantasy relationship with the father, himself had to give up his identification with the child’s fantasy and accept the reality of the child’s need for the mother. The worker’s feeling of triumph was related to the therapist’s final acknowledgment of the importance of the role of the mother, with whom she was identifying. Following this understanding the team was together again, and realized with surprise that the father had been completely left out. Only when the worker and therapist were able to give up the fantasy roles imposed on them by the mother and child were they able to see objectively the importance of the father in the life of the family. A family conference was arranged in which the team worked together to help both mother and father to help the child themselves.

The therapist’s remaining work with the child was entirely reality oriented. His knowledge of the child’s fantasy life was helpful in understanding the reciprocal fantasies in the mother. The worker’s remaining work with the mother was the clarification of the transference relationship. Through this it was seen that the mother’s hostile, dependent relationship with her own mother was the core of her difficulties.

The team intra-action was in many ways a reduplication of the oedipal problem being worked out in the home. At the outset the case material clearly showed that the oedipal problem was a primary one, but it was by means of the conferences that the emotional reduplication was seen and could be used by the team. This reduplication process would have occurred whether observed or not, but its being observed enhanced rather than impeded the progress of therapy.

Examples were given in Part I illustrating how reduplication of the family conflict when acted out can interfere significantly with the progress of the case. Conscious knowledge of the emotional intra-action imposes limits on this acting out. It can also be used positively in focusing the work of the team toward significant dynamic trends serving to accelerate the process of therapy.

Further consideration of the process of identification reveals that this is more complex than the simple identifications of worker with mother and therapist with child as presented in Part I. Each worker has partial identification with each member of the family. These are based on the therapist’s and worker’s own earlier identifications and so have countertransference value. This process is an emotional one and to a large extent unconscious. Each team member, in relating, becomes unconsciously as well as consciously involved with each individual in the family and their conflicts. It is important to recognize this involvement in order to use it to the maximum advantage of the client or patient.

This is especially true in team therapy, where each therapist's unconscious responses to the person whom he is treating may readily be acted out within the framework of the team, since the other team member may be responding not only to another person in the family but to another side of the family conflict. When this occurs they are less able to evaluate the total family interaction, thereby undoing one of the great advantages of team therapy- insight into the dynamics of the family as a unit.

Though countertransference is not usually studied directly within the clinic situation, its manifestations can often be controlled and utilized through the recognition of intrateam reactions and their relationship to the conflicts of the family in treatment.

SUMMARY

1) Team intra-action, whether observed or ignored, is part of the therapy process. It is most obvious when there are team conflicts. 2) There is a dynamic system set up between the therapist and the worker which is sensitive to the conflicts of the case. 3) The ability of the family conflicts to influence the intrateam reactions depends upon the power of the family conflict, and the sensitivity of the team equilibrium to this particular stress. 4) The intrateam reactions may be a reduplication in diminished intensity of the significant family conflicts. This reduplication depends upon the process of identification and has an unconscious component. 5) Intrateam reactions that are an acting out of the stresses imposed on the team by the conflicts of the family can serve as a substitute for the direct handling of these conflicts. 6) Intrateam reactions can be used to focus on significant dynamic trends and to accelerate the process of therapy.

DISCUSSION

OTHILDA KRUG, M.D. It is a pleasure to discuss this carefully planned, well-organized and clearly presented clinical study which deals with such an important aspect of collaborative treatment. It has long been recognized that therapeutic relationships are usually more complicated when two or more members of the family are being treated concomitantly by different therapists, and that frequently in child psychiatry, treatment blocks develop because of the unrealistic friction and rivalry between the parents and the child's therapist.

However, this study clarifies the nature of the team relationship as a reflection of the significant conflicts within the family being treated. More over, it indicates that the repetition of the pathological patterns of the family in the intrateam reaction occurs through identification, often as a simple direct overidentification by each team member with his own patient. But the same type of positive correlation of the conflicts is illustrated in the last case, in which there is also excessive identification by a team member with a different family member. Perhaps continued future studies of this type will indicate whether there is always an exact reduplication of the family conflict in the team reaction or whether a different type of conflict between team members might develop as a result of their own illogical countertransference attitudes to a particular kind of family conflict.

One of the many interesting aspects of this study is the method of closely examining the intrateam reactions and utilizing such understanding in treatment by means of regular conferences following each treatment hour. It is interesting to note, too, that the difficulties in the team reaction could be utilized to further clarify the nature of the family conflict in much the same way that an awareness by an individual therapist of his own counter-transference attitude can contribute to understanding the dynamics of the individual patient.

Especially important in this study is the observation that a conscious awareness of team conflicts can limit their being acted out to perpetuate the family tensions. Although the procedure in accomplishing this is clearly stated as an expression and evaluation of the team’s feelings to each other, to the family as a whole and to the individual patient, one wonders about the types of problems that may arise despite the team members’ intellectual acceptance of the fact that an awareness of their own emotional reactions can be extremely valuable to facilitate both the dynamic diagnosis and the progress of treatment. As the authors indicate, this is a highly subjective process, and it is possible that the same countertransference attitudes which entered into the relationship with the patients might also cause resistances and distortions in their recognition. It would seem, too, that there might sometimes be difficulties in limiting the discussion of the team’s feelings to those factors in the case which stimulated intrateam reactions, and in avoiding excessive preoccupation with or anxiety about their own internal conflicts causing them to respond illogically to the family. The achievement of this is extremely important in order to avoid setting up a treatment situation with the team rather than a supervisory relationship.

Further knowledge about the techniques of dealing with these problems during the conference would be a very important contribution to our supervisory methods.

In this paper Dr. Brodey and Mrs. Hayden have added significantly to our understanding of the collaborative treatment process.