INTERVENTION IN MATURATIONAL CRISES RISES can be classified as either sit- C uational or maturational. In both

types, a person experiences a crisis when he perceives a stressful event as a threat to his equilibrium. His usual adaptive coping mechanisms are not sufficient to handle the disturbing event, and a period of disorganization ensues. In contrast to maturational crises which are discussed in this article, situational crises stem from unexpected or sudden events - natural disasters, sudden relocation, sep- arations, illnesses requiring hospitaliza- tion. Maturational crises occur as part of the normal process of growth and devel- opment. The onset of a maturational crisis is gradual and occurs as a person moves from one stage of psychological, biological, and social development ro another, slowly progressing to a different level of maturity. Marriage, parenthood, the beginning of school, and involution are some developmental times that are potential sources of maturational crises.

What causes crises for some people at these times? They are certainly normal growth periods through which most of us pass.

Why these rimes leave people vulner- able to crisis is clarified by some concepts

of role theory. Spiegel defines a role as “a goal-directed pattern or sequence of acts tailored by the cultural process for the transactions a person may carry out in a social group or situation.”’ He further states that “. . . no role exists in isolation but is always patterned to gear in with the complementary or reciprocal role of a role partner . . .’I2 In other words, roles do not exist in a vacuum. Thus, when one person in a system changes his role, the other people in that system undergo reciprocal role changes.

These aspects of role theory are im- portanr to keep in mind when deciding how to intervene in maturational crises. It is necessary to determine not only what the crisis is but who is in crises, in order to direct intervention with maximum effectiveness. In each intervention, the therapist must also determine why the situation is a crisis to the person, why he is unable to alter his lifestyle in order to cope with the situation, and what in his lifestyle can be altered so the crisis can be solved.

Marriage, parenthood, the beginning of school, and other times when matura- tional crisis occur are mainly periods of numerous role changes. These changes

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by Florence Williams

“. . . Maturational crises occur as part of the

normal process of growth and development.. . 77

are slow and gradual; in adolescence, for instance, a person takes four to five years to make all the various changes from his role of a child to that of an adult. A maturational crisis occurs when the per- son is unable to make the role changes appropriate to his new maturational level. The “stressful event” is the social and biological pressure on the individual to see himself in a new and different role.

There are three main reasons why someone may be unable to make role changes necessary to prevent a matura- tional crisis. First, may be one person’s inability to picture himself in the new role. Roles are learned, and he may not have had adequate role models present in his environment. This was true in the following situation:

A family applied to the mental health center for help for a 13-year old son who was refusing to go to school. The boy’s parents were concentration camp survivors who had experienced the extermination of many members of their original families. As a result of these experiences, both parents felt powerless to control or influ- ence their personal situations in any way. In the concentration camp they had been dominated by guards who used their authority irrationally. The guards’ deci-

sions could be, and often were, cat- astrophic for the inmates. Both parents, as a result of the loss of adequate role models (their own parents) and the substitution of inhumane guards as models of authority, had difficulty in assuming the executive, authority aspect of their parental role. Their inability to make decisions and to demand things for them- selves was carried over into their marriage. Their son, their first child, moved into the vacant executive role in the family, but he also did not have role models for his executive functions and so he carried them out in inappropriate and dysfunctional ways. When the family was first seen in the menral health center, the son exerted his control over the family by stating, for example, that he did not want to continue the interview. The parents would accede to his decision by making moves to leave the interview. The son would also state that his father must always sit next to him and the father would comply by changing his seat.

The beginning stages of treatment for this family were geared toward helping the couple assume the parent role more adequately, thereby relieving the son of this difficult burden.

The second reason some people are unable to make role changes seems to be a lack of intrapersonal resources (such as a lack in communication skills needed

Perspectives in Psychiatric Care Volume I X Number 6 1971 241

in marriage). In the following example, the woman was unable to make the role change to middle age because she lacked the flexibility needed to alter her goals.

A 40-year-old woman applied to the mental health center for help because of feelings of depression that were beginning to immobilize her a t home. I discovered that the onset of depression had been a few weeks prior to the first interview. At that time her husband had hit her so hard that she had fallen down the stairs and required stitches in her head. She said that her home situation had been getting progressively worse over the past five years, during which her husband had not been working because of strained ligaments in his neck. I then attempted to get her to elaborate on why her husband’s hitting her had precipitated her feelings of depression. She said she realized then that her monetary situation would never im- prove as her husband refused to go back to work, and that the family would be on welfare from now on. She had hoped for a better life for her three daughters than she had had, and the lack of money cur- tailed her plans for them. This woman had centered most of her married life on help- ing her daughters become “ladies” and “know how to live nicely.” When she felt she would not achieve her life goals for her daughters, depression ensued.

An attempt to work with the marital couple in order to explore their situation failed. The husband adamantly refused to be seen. Intervention with this woman centered on helping her to formulate more realistic goals for herself and her children.

The involutional time of life is a time for assessing what we have accomplished and deciding what we want to and can realistically accomplish with the rest of our lives. For this woman, involution brought the realization that she would probably not achieve her life goal. More-

over, she did not have the resources to make the goal changes necessitated by this maturational level. She was unable to see alternatives to her present lifestyle, such as the possibility of her working to make her goals more feasible.

A third reason someone may not be able to make a maturational role change is the refusal by others in his social situation to see him in a different role. This occurs frequently in adolescent maturational crises: The adolescent may be making attempts to move from the child role to the adult role but his parents may persist in seeing him only in the child role. This concept of role reciprocity brings up a problem parti- cularly important in maturational crises - namely, who is in crisis? Is it the adolescent, who is usually labeled the pa- tient, or the parents, who need to main- tain equilibrium by keeping their adoles- cent child in the child role? Is it the entire family system that is undergoing a stressful event and unable to adapt to it? In the situation below, the daughter, who was initially referred for treatment, was not the person who was experiencing a maturational crisis. The daughter was reacting to the crisis her mother was experiencing.

A young, pregnant girl was sent to the mental health center from the antepartal clinic because she had burst into uncon- trollable crying while waiting to see the obstetrical resident. The resident thought the girl was upset over being unwed and could benefit from psychiatric assistance.

A worker from the intake team quickly determined that the young girl was not upset by her out-of-wedlock pregnancy but rather by a heated argument her mother had had the previous evening with the boy friend who was the father of the

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unborn child. (The boy friend lived in the mother’s household with the daughter.) Since the girl seemed unable to state why the argument was so stressful to her, the worker decided to call all three family members together with the girl’s permis- sion for a discussion of the problem.

Within a short time the three were together at the center. The intake worker began by explaining what had happened in the antepartal clinic, and then asked what had happened the previous evening between the mother and daughter’s boy- friend. The mother said she had dis- covered then that her daughter was p r e g nant, and asked the boy friend about the possibility of marriage with her daughter. He said that marriage had not occurred to him, and the daughter stated that marriage was not important to her. The mother became angry and the argument ensued.

The worker encouraged the mother to elaborate on her feelings concerning the unmarital status of her pregnant daughter, The mother said she didn’t mind that her daughter’s boy friend was living with them but if a child was on the way she wanted them to be married. She explained that her daughter had been an out-of- wedlock child, and the daughter’s father had left the household shortly after her birth. The mother had to struggle to raise the child by herself, and did not want the same thing to happen now to her daughter.

Obviously, the daughter’s pregnancy had awakened unresolved feelings in the mother, and she had transferred these feelings to the daughter’s present situation. The worker helped the mother explore these feelings, work them through, and come to a healthier resolution. The mother was able to say that she guessed her daughter and the boy friend would have to make their own decision regarding marriage.

Many interventions take place within a family situation. Many involve much time and energy. And, in many, it is

important to get, as quickly as possible, enough information on which to make a fast decision. The following case history exemplifies all these characteristics of maturational crisis intervention.

A young woman called the mental health center at three o’clock one Friday stating that she was fearful about caring for her 10-day-old child. The baby’s grandmother had come in from Canada to help care for the newborn child but would return to Canada on Saturday. The young woman felt that she’ would panic during the hour when her husband was out of the house taking her mother to the train. She would then be alone with the child and was fearful of what would happen during that time.

The woman would not elaborate on her difficulty nor would she give her name and address: She just wanted a doctor who spoke Yiddish to tell her husband not to leave her alone. The paraprofessional who took the call got the woman’s phone number, after promising to call back as soon as she had consulted with the clinician on call.

How would you begin to assess the above situation? From our knowledge of ma- turational crises, it is obvious that the birth of a child presents a stressful event to a marital couple. The woman felt fear- ful, as many new mothers do, about car- ing for the child. Why was this woman unable to accept the new role of mother without feeling that she would panic when alone with the child? Was this a postpartum depression?

The paraprofessional returned the wo- man’s call and asked the woman to speak to me. I told her that it was difficult for m e to assess her situation and to know what would be helpful to her and her husband without seeing them either in the center or at home. T h e woman said that because of her husband’s religious beliefs

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she would not be able to convince him to come to the center with her. I suggested that I come to her home with another therapist who spoke Yiddish, and she agreed.

Within a half hour my co-therapist and I went to the K apartment. Soon after we entered, Mr. K arrived. Mrs. K had phoned us during his absence, he looked bewildered by our presence. My co-thera- pist explained in Yiddish that Mrs. K had called us for help because she felt unable to care for their child. Mr. K did not feel this was a problem but he yielded to Mrs. K’s insistence that she see me alone in the next room. Mrs. K then told

had been hospitalized during her adoles- cence for a mental disorder, but had never told Mr. K because she felt he would not have married her under these circumstances.

I thought Mrs. K should be hospital- ized. The infant was in danger of being hurt by her and we had no time to work out any alternate course of action since sundown was approaching and Mr. K refused to spend more than the next half hour with us because of religious obliga- tions. Ordinarily I would have spent more time in getting the couple to further de- fine what they saw as the difficulty, but it was more important to respect the

“. . . A maturational crisis occurs when the

person is unable to make the role changes

appropriate to his new maturational level.. . 77

me she felt guilty for past mistakes she had made and, for the past two days, had been hearing sounds such as slamming of the incinerator door, and ambulance sirens, even when her mother didn’t hear them. I asked if she had been having thoughts about harming the baby; she said yes, and that was why she felt she couldn’t be alone with the child. She had not told anyone else about these thoughts. She then explained that she had married her husband ten months ago through an arranged marriage. In accordance with the custom of her religious group, she had seen her husband twice before the wed- ding. She had expected more comfort and more conversation from her husband than she had gotten. She also said that she

religious views of the husband. I have found that cultural and religious values have a strong influence on which stressful events are perceived as crises.

In conferring with my co-therapist I learned that Mrs. K’s father had died two days before the birth of her child and, on the advice of the rabbi, Mr. K had not told his wife of the death. Both Mr. K and Mrs. K’s mother were very happy about the child’s birth, but at the same time Mrs. K’s mother was secretly mourning the death of her husband.

W e adamantly insisted on Mrs. K’s hospitalization, and accomplished this with the understanding that my co- therapist and I would meet with Mr. K and Mrs. K’s mother on Monday morning.

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From the amount of information we had it seemed that ( 1 ) Mr. and Mrs. K had not worked out their maturational crisis of marriage to a mutually satis- factory resolution; ( 2 ) Mrs. K had had difficulty in working out the niatura- tional crises of adolescence and of mar- riage, and was now unable to solve the crisis of motherhood without professional assistance; and ( 3 ) Mrs. K’s mother was working through the crisis of grief yet could not mourn openly.

On Monday morning my co-therapist and I decided the most immediate stress in the family was the covert feeling of grief. W e felt that the death had to be made known to Mrs. K so she could understand the confusing message of happiness mixed with mourning.

W e met with Mr. and Mrs. K, Mrs. K’s mother, and the newborn child. As the session progressed, Mrs. K said she felt that her husband and her mother were keeping something from her. However, her husband and her mother persisted in their silence about the death. At this point we asked Mrs. K to leave the session and we told Mr. K that if the rabbi knew his decision was causing so much stress, the rabbi might change his decision. Mr. K agreed to phone the rabbi immediately. The rabbi said Mrs. K could be told of her father’s death, and we resumed the session with Mr. K and Mrs. K’s mother to determine who would tell Mrs. K. Mrs. K’s mother agreed that it was her job.

After Mrs. K returned to the session, and heard the difficult news, she expressed relief about knowing the secret, and grief for her father. Mrs. K asked her husband to say a prayer for her father which was done in the session, and also then excused herself to call the rabbi to find out what she should do as a part of her religious mourning process. After she learned this, we continued the session to help the

family deal with the mourning process, and then arranged to meet again the next day. This session took four hours.

Mrs. K stayed in the hospital for the rest of the week. After the session on Monday, her hallucinations began to decrease, I met daily with Mrs. K, and my co-therapist and I met daily with the couple to help them explore their expec- tations of each other.

The concept of crisis intervention can be helpful in working on all levels of prevention; primary, secondary, and tertiary. Primary prevention or reduction of conditions that lead to maladaptive functioning, can be achieved by helping people to work through developmental periods. Premarital counseling groups for adolescents for example can increase the chances of their reaching a healthy resolution of stressful events in marriage. Counseling groups for those nearing re- tirement could help them make a better adjustment to the maturational crisis of old age. Both these types of counseling groups reach out to people before and during the crisis, to help them find con- structive coping mechanisms to solve potential crises.

Secondary prevention involves early diagnosis so that effective treatment can be started as soon as possible. For ex- ample, a nurse from the mental health center, who used to spend time in the postpartum clinic, was concerned with intervention on this level. At the clinic she was able to pick up for treatment those new mothers who showed signs of not having worked through the crisis of motherhood. For instance, she noticed one mother who never handled her baby; the woman’s mother cared for the baby. A discussion with the young mother dis- closed her fear of, and her difficulty in,

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assuming responsibility for caring for the child. Another example of secondary prevention: As a consultant in a school I was able to start a group for mothers whose children had shown disturbances such as hyperactivity or withdrawal in the first grade. The children's symptoms demonstrated an inability to solve the maturational crisis of entrance into school.

The goal of tertiary prevention is to prevent decompensation and to maintain the patient in the community. This means that some patients, especially the chronically ill, will need a tie with a helping agency so that a source of sup- port is readily available. As part of my work as a clinician in the mental health center, the art therapist and I lead a group for chronic patients that met weekly. The patients painted pictures for part of the session and then, as a group, discussed their paintings and how they had been during the week. The purpose of the group meeting was not for psycho- therapy, but to provide group support for each patient.

W e noticed that few of these patients were able to solve maturational crises without an increase in symptoms. For example, in this group were a man and his girl friend of nineteen years. Both had had several hospitalizations during that time. Suddenly, they decided to

marry. About two weeks after the mar- riage, the man began to feel bugs crawl- ing about in his stomach, a delusion that had led to his other hospitalizations. This time, by working with the newly married couple and helping them ad just to their new roles, we were able to prevent an- other hospitalization of this man.

REFERENCES

Spiegel, John, "The Resolution of Role Conflict Within the Family,'' A Modern Introduction to the Family, Norman Bell and Ezra Vogel ( e d s . ), T h e Family, p. 363, 111: The Free Press of Glencoe, 1963. ' Ibid, p. 363.

BIBLIOGRAPHY

* Aguilera, Donna, Messick, Janice, and Far- rell, Marlene, Crisis Intervention Theory and Methodology, St. Louis: The C. V. Mosby Company, 1970.

"ell, Norman, and Vogel, Ezra, A Modern Introduction to the Family. Ill: The Free Press of Glencoe, 1963.

'' Bellak, Leopold, and Small, Leonard, Emer- gency Psychotherapy and Brief Psycho- therapy, New York: Grune and Stratton, 1965.

' Cumming, John and Elaine, Ego and Milieu. New York: Atherton Press, 1967.

,' Parad, Howard, (ed.) , Crisis Intervention: Selected Readings, New York: Family Ser- vice Association of America, 1965.

" Stokes, Gertrude (ed . ) , The Roles of Psy- chiatric Nurses in Community Mental Health Practice: A Giant Step, New York: Faculty Press, Inc., 1969.

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