Socially Induced Anxiety (SIA) – a ‘new’ Source of Stress

The Split Field::Relayer System as a Factor in the Etiology of Anxiety (a study of 48 cases)

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The broad goal here is to further the translation of psychopathology (or unitary psychology) into the language of social behaviour.i That is, to emphasize what actually goes on between people instead of what is thought to happen inside just one person’s head. More narrowly, one mechanism through which a particular interpersonal process is linked with a specific type of individual outcome will be presented. A new term, the Split Field :: Relayer System (or SF:RS) has been coined to describe this mechanism. The SF:RS, a noxious human triangle, is explained in detail with clinical examples. The outcome seen to be associated with the SF:RS is anxiety. Examples are followed by description of a preliminary study that presents solid evidence of the association of clinical anxiety with the Split Field :: Relayer System.

Some brief historical background will be initially helpful in approaching the key concept of the Split Field :: Relayer System. In 1954 Stanton and Schwartz noted in their book, The Mental Hospital, that a conflict between an administrator and a therapist could cause a patient to erupt in a disturbance.ii The phenomenon, encompassing the patient in a staff communication block, has been conceptualized as a split social field. Figure 1 illustrates it. Two significant power-wielding persons (administrator and therapist), denoted as P1 and P2, are in covert conflict, and the patient (R) is in communication with both, as indicated by the dotted lines.

Fig. 1: A Split Social Field

Haley made explicit the age-old intuition that some situations involving three people may result in abnormal behaviour. He recommended use of a new term, “perverse triangle,” to describe this broad generic concept.iii Because of the connotations of the word ‘perverse,’ a more preferable referent, ‘pathological’ triangle, will be used herein.

Fig. 2: The Split Field :: Relayer System (SF:RS)

(A specific human triangle inducing clinical anxiety.)

The framework of the Split Field :: Relayer System combines the pathological triangle concept with the more circumscribed situation of the split social field. As in Figure 2, the split field forms one edge of a triangle at the opposite apex of which is the victim or relayer. The word ‘Relayer’ and the dynamic significance of the arrows in the diagram will be clarified now with some clinical anecdotes.

CLINICAL EXAMPLES

Five cases have been selected to demonstrate both the nature and sequential development of the Split Field :: Relayer System. The first is a situational one in which a doctor inadvertently became the victim.

(1) A 41 year old general practitioner, Dr. Y, consulted about a prominent married couple he was dealing with. The wife had brought in her young daughter as the identified patient, but quickly began complaining about her husband in many areas. Dr. Y transmitted her concerns to the husband, who in turn launched into a list of his wife’s shortcomings. Dr. Y dutifully acted as go-between. After several such visits, he felt he was getting nowhere and was seriously doubting the usefulness of doing office counselling. When questioned as to his own feelings during the counselling sessions, he spontaneously admitted to a sense of nervousness, ‘butterflies’ in his stomach, irritation, decreased attention span, and a desire to terminate the interviews almost as soon as they had begun.

Dr. Y was obviously suffering acute situational anxiety of a subjective kind. His symptoms were confined to the actual interviews as they took place and otherwise occurred only when thinking about the couple he was attempting to help.

His task as a therapist was proving to be increasingly difficult, for despite his efforts, the couple’s problems seemed to be escalating. His own self-image, as a conscientious physician who prided himself on his willingness to respond to his patients’ emotional problems as well as their physical concerns, was being threatened. Thereby, somewhat in the couples’ power and apparently not able to succeed, he felt compelled to denigrate office counselling in general.

Essentially, his position was that of an unwitting transmitter of covertly held antagonistic feelings between husband and wife. With each separate office visit the doctor was being utilized as a convenient and safe message bearer to the other spouse. That is, he had become a Relayer in a split social field and concurrently was developing the early symptoms of anxiety.

In Figure 2, the sweeping back and forth of covert messages via Dr. Y is represented by arrows encircling ‘R,’ the relayer. Their conflictual polarity is indicated by the sign on the small letter: m represents an opinion wife (P1) holds for husband (P2), and -m is the rejoinder.

An interesting sidelight in this case is a peculiar reversal in power complementarity that occurred in the doctor-patient relationship. The key to a cure is in itself power, vested initially in the doctor. But the introduction of a third person, creating a triangle which became pathological, effected a radical, unrecognized switch. Each individual blithely continued to act as if in a traditional two-person system. As messenger in a split field, he unawares had become subservient to the married couple. Hence the power reversal.

This unusual instance of power reversal highlights a regular requirement in the Split Field :: Relayer System; the covert conflict existing between two permanent or temporary power figures must utilize a permanently or situationally dependent relayer.

Let us now see how Dr. Y’s anxiety was managed.

Consultation consisted of pointedly asking the doctor whether he considered himself a messenger boy or physician. He was advised to tell the wife that he wasn’t her husband – that airing bitter feelings, while nice, wouldn’t necessarily change things at all. The couple could talk their problems over with each other at home, or, if they wished, do so together with him in his office. But the onus for action was to be placed directly on the husband (in order to restore healthy marital complementarity).iv

At first, Dr. Y was reluctant to have them both in his office – an explosion might occur that he couldn’t handle. The possibility that he might lose some reputation – as well as the whole family as patients – if he didn’t see them together, finally convinced him to try a conjoint session. The first lasted only a half hour and he was pleasantly surprised that no dire outburst resulted. Actually, the couple thanked him and asked for second and third meetings in which to safely talk with each other. They saw him as the presence that would allow them to discuss their differences without fear of physically attacking or verbally blistering each other.

Incidentally, Dr. Y’s anxiety in the situation was replaced by a sense of calm competence and a three month follow-up revealed that the original patient, the little daughter, was behaving in a more acceptable way.

The next example is presented to show the Split Field :: Relayer System at its most incipient stage, when the relayer is in a very passive, receptive, dependent position and before a true two-directional relayer process has become established.

(2) Michelle, age 6, was brought in by her adoptive mother because of nighttime wandering about the house. Observation in her mother’s presence revealed her to be silent and apprehensively inhibited. Her posture at times was almost cringing and her heart rate was rapid. She was obviously an anxious little girl.

When alone in the playroom, however, she became alert, responsive, and fairly relaxed, and talked easily. Some probing brought out that Michelle’s anxiety was greatest immediately upon returning home from school, especially on days when bringing home her school work.

At school she was a model student, but reference to this later evoked an unusual response from her mother, who became notably irritated. She said, “How can these teachers give a child a star for work that is riddled with mistakes? Teachers nowadays are altogether too soft.” It became apparent that the mother’s philosophy was that awards should be reserved for actual accomplishment, whereas the teacher was encouraging effort. The mother had never conveyed her sentiments openly and directly to the teacher, but her upset feelings and adverse comments about “modern education” regularly got through to Michelle.

Michelle’s position was that of an unknowing potential transmitter of covertly held antagonistic ideas between her mother and teacher. With each piece of work she carried home, Michelle was effectively conveying the teacher’s philosophy, which was in disharmony with that of her mother. This resulted in unpleasant things being said about the teacher by an upset mother. Michelle never conveyed these negative feelings back, so in a sense she was a unidirectional relayer, not an uncommon state in the early phase of generation of a Split Field :: Relayer System. The outcome for Michelle was moderately intense situational anxiety. Treatment consisted of a fairly simple compromise that did not entail externalization of the split field conflict.

Because of the mother’s rigidly held theme interference (it stemmed from values acquired while herself in school, reinforced by an indifferent, passive husband), a meeting on the issue of educational philosophy between the teacher and mother was deemed inadvisable. It might have turned into an unpleasant diatribe, unnecessarily alienating a teacher whose objective cooperation would be needed. Instead, treatment consisted of diplomatically arranging for the teacher to give silver stars for effort and gold stars for accomplishment. This pleased the mother and a three-month follow-up indicated that Michelle’s acute anxiety, which had abruptly abated after the planning interview, had not returned. At this point, marital counselling for her adoptive parents was begun.

The following sequence of transactions, reconstructed, exemplifies the unconscious nature and escalating quality of the Split Field :: Relayer System. It involved the identified patient, John, who was a 14 year old Children’s Aid ward, his worker, and his foster father.

(3) “How are things at school, John?,” asks the worker during her weekly visit, leading up to a subject of concern, for she had learned from the principal of discipline problems. “Oh, okay, I guess,” is the reply. Coming at it from another angle, she queries, “Has your mother been in touch with the teacher? I hope so.” “Sure, but Dad sticks up for us: he says that school gives the rich kids a better break.” “He does? But don’t you think you ought to try to get along better?”

Later, back at the foster group home: “Well, lad, how was your visit with Miss Jones?” “Oh, we had fun, she bought me a milkshake, but she said the school knows best and you should see the teacher more often.” “That’s easy for her to say but she doesn’t have to hold down a regular job and look after all you kids, too.”

Next visit with worker: “Dad thinks you have it easier than Mom and him. He works hard at two jobs.” “Well, young man, when it comes to you, you’re legally in my charge. And we’re going to have to look into your school performance if it’s too much trouble for your foster father. You can tell him that I’m going to have a talk with the agency director. It’s not just coincidence that the school is having trouble with most of the boys at the home.”

Worker to director: “The group home parents are giving trouble again. The old story of fighting with the school. And too permissive at home. This inconsistency is bad. Also, John’s behaviour is worse and he’s really jumpy and nervous. Do you think we could have our consultant psychiatrist see him?”

Exchange between foster parents within earshot of John: “I hardly know whether it’s worth the money we get. If it isn’t one it’s another worker interfering.” “Yes, and the school doesn’t really understand these boys and take their tough backgrounds into account.” “It seems we’re always in the middle.”

John daydreaming in class: “Wherever I go they’re at it. I’m puzzled; can’t concentrate in school and hate it anyway. I’ll be glad when I’m 16 and can quit and get out on my own.”

In this instance there is a split social field involving the Children’s Aid worker and the group home parents, with John, the identified patient, quite obviously dependent upon both, acting as relayer. (Note also, the split field between school and foster parents.) The messages John bears back and forth become mildly distorted with each pass, and as a result the covert conflict between agency and parents escalates – culminating in psychiatric referral of John! The worker also is doing some distorting, verging on relaying. Conceivably, the pathological position of relayer in a triangle could rotate from one to another participant. Had the agency director not been supportive, a shift of power complementarity might have resulted in the worker developing anxiety symptoms!

The next case illustrates the end-product of years of relaying: a tendency on the part of the relayer to actively and selectively create split social fields where they didn’t previously exist. It also exemplifies a specific social complication of chronic relaying: the inevitability that the relayer will become the focal point of small-group intrigues.

(4) A 27-year-old married but childless nurse displayed symptoms of chronic anxiety, particularly at work. She was jumpy, too eager to please, had constantly damp palms and sweat stains under her axillae, a strained voice pitch, and a tendency to stutter. She seemed regularly involved at the edge of little squabbles at work. To her supervisor she brought bits of gossipy information about her colleagues, but always in a “helpful” way.

Before long on the job, she began to miss too many days of work with minor ailments. A senior administrator called her on the carpet and wanted to fire her because she was a “hopeless neurotic,” and enquiry of a previous hometown employer indicated that her family was composed of a “bunch of neurotics” also.

On the positive side, however, this nurse was energetic, original, and, when present, genuinely devoted to her work.

Discussion with her brought out that she had been raised in a family environment that bore all the earmarks of a split field between her mother and father. She had throughout her developmental years learned to become an adept relayer between them. Now she could be described as a chronic, compulsive relayer who attempted to recreate triangles wherever she went. She was most successful, being a well-trained expert in the field of triangular architecture. At work she exercised an almost uncanny sense of recognition of subtle differences between essentially friendly co-employees, and she craftily played these up behind the scenes. Her reward: a bit of limelight and the establishment of, to her, a familiar system of interpersonal relationships. The one drawback for her was the resultant continued high level of chronic anxiety she suffered. The social effect of her gossipy tale-bearing – getting caught and almost dismissed – was her narrowly missed punishment.

Treatment consisted of a forthright discussion of her problems with her. She responded with a virtual “Ah, ha!” reaction of flooding insight. She agreed to try voluntarily to avoid searching out covert differences between colleagues and the ensuing transmission of conflictual messages. Her resolve was reinforced by a period of work probation plus the attentive and watchful eye of her now enlightened supervisor, who, whenever she slipped back into the old pattern, arranged for a three-way discussion between the involved parties.

Results were dramatic. Her productivity at work increased, her natural creativity gained fuller expression, her basically empathic nature soon came to the fore, and she emerged as one of the best-liked work group members. Incidentally, as a side effect, her marital relations, which had been strained, improved concurrently with the virtual disappearance of her anxiety at work.

To further clarify the Split Field :: Relayer concept, the last case, a near-fatal emergency, is presented in considerable detail. The setting for this triangle was a university-affiliated general hospital paediatric ward.v

(5) Timothy, age 10, had been admitted in a stupor with a blood alcohol of 256 mg/100 cc; he weighed a cachectic 15.4 Kg or 34 lb. He could not hold down any food, vomiting on an average of 20 times an hour while awake. Paediatric management had consisted of exhaustive investigations and increasingly frantic efforts to maintain his nutrition, electrolytes, and fluid balance. Blood sugar, protein bound iodine, stool for parasites, electroencephalogram, blood cultures, adrenal function, liver functions, extensive x-rays, sex chromatin, etc., etc., were all normal. After one month no diagnosis had been established and it was feared Tim was on the verge of death.

A psychiatric consultation was requested.vi Examination focused on two system levels: (1) that of the patient and, later, family, and (2) that of ward work-relationships.

The patient: Despite his severe under-nutrition, Tim was markedly hyperactive and both wrists and ankles had been tied to the bed to keep him from running off. His facial expression was one of worried, fearful anguish. His pupils were widely dilated, eyes bulging, and his palms and forehead wet. Portions of his hair had been pulled out in tufts. Staccato bursts of repetitive one-way phrases characterized his speech. He referred to me as, “cookie machine, cookie machine.” Tim had never lost his appetite and his hunger pangs caused him to voraciously bolt down food, liquids, and almost anything he could get his hands on, including a bottle of his father’s liquor just prior to admission. Whatever else was wrong (he was suffering a severe ego disturbance eventually labelled as childhood schizophrenia), intense anxiety was an obvious accompaniment.

The ward: By the time of the psychiatric consultation, the staff involved in Tim’s management were in a turmoil. A sense of frustration and hopelessness, insofar as Tim’s case was concerned, pervaded the ward. (With other children the same staff were functioning smoothly and calmly as usual.) As on any paediatric floor, numerous people were directly or indirectly involved with Tim, these boiling down to three groups – attending paediatricians, house staff, and nurses including aides. It was notable the the original paediatrician was no longer visiting the ward. The resident was incensed at his chief. Also, the head nurse was observed to become very fidgety when discussing Tim. The resident felt that Tim should be immediately transferred to “some more appropriate place” while the paediatrician insisted that “our hospital has all the facilities necessary.” This originally overt but now simmering conflict had assumed an interesting form: through his interns, the resident had been trying to hit upon a successful feeding method by every so often changing from small meals to tube feedings to intravenous cutdowns, with the cycle repeating; the paediatrician – often by telephone, always through the head nurse – had periodically vetoed some of the resident’s more heroic efforts. And being unable to make a definitive working diagnosis, he had called in second and third paediatricians. The nurses as a group seemed particularly disconfirmed in their professional sense of duty and competence because of their inability to nurse Tim back to health. (This phenomenon is so familiar that I term it paediatric nurse syndrome.) Finally, the unwittingly uttered complaints of residents and interns, had, as it turned out, encouraged the frustrated nurses to quietly ‘cool out’ the original attending paediatrician, who was soon greeted on the ward with rationed words or actual silence. As a result his visits became less frequent and finally stopped altogether.

Perhaps the most important observation of all, however, was that none of these people involved in Tim’s treatment had at any time openly discussed with each other their points of contention, disappointment, etc. (The fast pace of a paediatric ward sometimes supports isolation and denial. And it is notable how one critical, puzzling case can bring out hitherto unrecognized conflicts and pathology in an otherwise smoothly functioning team!)

The key: A clue that helped open up the way to linking Tim’s current clinical problem with the unsettling events surrounding him came from the chance observation of an attendant. Tim had been found to be able to hold down small amounts of chocolate eggnog. This news had been passed on by the head nurse to his mother as a hopeful sign. The attendant, later, while standing outside Tim’s room, had overheard his mother say to him, “Now, Tim, you know that chocolate upsets you.” This exchange was unrecorded, but Tim’s ensuing ‘distaste’ for eggnog was duly noted.

The chief conflicts as they ultimately affected Tim on the ward can be shown diagrammatically as in Figure 3, which has been simplified for greater clarity.


Fig. 3: Case 5: Tim

In Triangle i, paediatrician (P1) and resident (P2) disagree regarding Tim’s treatment and their open communication about this is blocked. The head nurse (N) is in regular contact, however, with each. The incongruent orders she receives have a crucial bearing not only on Tim, but also on her own professional functioning and self-image. Although trained to discriminatively obey, it is impossible for her to discharge conflicting orders simultaneously. And for her to try to clarify or question the situation, considering its threatening context, is for her to chance an open interpersonal wound in the team. The closest she comes to a compromise is to arrange for the orders to be carried out sequentially as given, and to try to dispassionately relate to each doctor the actions of the other. She thereby extricates herself from instrumental responsibility, but cannot escape being trapped at the emotional level, for being human she necessarily conveys something of how each doctor is thinking and feeling about the other. She has inadvertently become a typical relayer in a split social field and the outcome for her, as evidenced by her fidgetiness, is an increasing level of case-centred anxiety.

Returning to Figure 3, it is seen that Tim (T), although affected by it, is not a participant in this particular pathological triangle. He is, though, caught right at the nexus of at least two others. The chance remark of the attendant served to establish a basis for a split field between the head nurse, advocating chocolate eggnog, and the mother (M), covertly disconfirming its value (Triangle ii). Tim could never be demonstrated as an actual relayer of conflictual messages on the ward, except perhaps via symptomatic metamessages, so he is shown only as the final recipient in this triangle.

Subsequent family group examination brought out the fact that an alternately covert and open rift chronically characterized the spouse relationship, with Tim the unfortunate go-between (Triangle iii).

During his treatment, the mother proved to be an agile manipulator who on numerous occasions attempted to subvert the staff-consultant relationship. It was finally concluded that she was the subtle praxic determinant of the numerous pathological triangles discovered to be enveloping Tim and the people trying to help him.

The emergency psychiatric management of this case, as it turned out, proved to be difficult but quite straightforward.

First, in an attempt to tackle the work group conflicts, hostility, and pervasively tense ward climate, a meeting of all directly involved hospital personnel was insisted upon. In an initially rather charged atmosphere, staff were brought to air their differences, if not to actually resolve them. The resident came to realize that no magical diagnosis in another setting would suddenly open up a cure. In fact, it became clear that no exclusively psychiatric institution such as he had held out for would admit such a seriously ill boy. This accepted, it was then possible to set up some consistent treatment approaches. It was agreed to stop all the heavy doses of tranquillizers, sedatives, antinauseants, etc., that were being given parenterally. Feedings were to be small, frequent, fluid, and oral. Ideally, it would have been best to thoroughly work through the mutually hostile feelings between the original paediatrician and the resident, but these stemmed from many other sources as well, and Tim’s critical condition demanded swift action. Since the resident was in constant attendance in the hospital, he was deemed temporarily more important, so the paediatrician diplomatically withdrew (by design rather than by default) and allowed himself to be replaced for a trial period. (This action raised him again in the nurses; esteem.) Finally, twice-weekly similar team meetings were inaugurated on the ward in order to forestall any further misunderstandings and covert conflicts.

Secondly, it was decided that the mother’s severe psychopathology would sabotage treatment at the outset. Suspending her hospital visits with Tim while at the same time supporting her during twice-weekly office visits (ostensibly to report Tim’s progress) was proposed – and accepted by her. This was a most delicate operation, for we were concerned that she might, if crossed, remove Tim from hospital. As a reserve, the Children’s Aid was discreetly informed of the case by the hospital administration.

The result of this regimen, which lasted one and a half months and which essentially consisted of eradicating two split social fields and one relayer system, was a rapid cessation of Tim’s regurgitation and a gain of 14.2 Kg., that almost doubled his admission weight.

PILOT STUDY

During 1966 I noted several instances of the split social field in families in my clinical child psychiatric practise. Toward the end of that year, it began to dawn on me that structured anxiety in the identified patient seemed to be an uncommonly frequent accompaniment. For the next two years, all such cases were carefully documented and a routine follow-up was done three months after the first interview.

Specific intervention, however, was variable. In some instances, I made active attempts to correct the pathological triangle – that is, the split field conflict was externalized and/or the victim was prevented from relaying. Specific approaches to this treatment are detailed later in the discussion, but, in general, all cases were seen five or fewer times and the second session was timed to follow quickly within a few days of the first. Subsequent sessions were scheduled one or two weeks apart, with final follow-up in three months. In other cases, usual modes of treatment such as family and/or play therapy and/or tranquillizers were used. This was fortunate as it turned out, for when all the accumulated cases of anxiety were later reviewed, it was possible to distinguish therapeutic study and ‘control’ groups of a sort. The cases were originally assigned at a weekly intake conference chaired by a social worker who, like myself, did not know that a study was later to take place. Thus, no one knew beforehand which of the cases would become part of the study or control groups. When a pattern of success in the specific management of the Split Field :: Relayer System was seen to be emerging, the study intake was closed and the accumulated cases were sorted into study and control groups. Bias on my part was thus minimized. What I have to report is by no means a double blind matched experiment, but this preliminary study imbues the clinical observations and impressions with reasonable (if not greater) substantiality.

All of the identified patients in the study were children or adolescents. Everyone was minimally investigated as follows: the referring person, physicians excepted, was interviewed; a family group examination lasting at least one hour was done; the patient was also always interviewed individually or seen alone in the playroom; finally, if two or more front-line caretakers (public health nurses, probation officer, etc.) were involved with the child or family, a conference, frequently including parents and children, was arranged.

A straightforward set of criteria for assigning the label of anxiety was carefully observed. Before citing these criteria, however, it seems appropriate at this point to discuss what is generally meant by anxiety. The term, as with many labels long in general use, has some serious drawbacks. It is a concept somewhat akin to, but not as differentially refined as ‘pain’ in general medicine. With the same word one can variously refer to subjective feelings, certain objective indices, symptom-sign clusters secondary to other disorders and diseases, or finally, patterns of behaviour and feeling that form a recognized neurotic state. Anthony suggests that the terms ‘neurasthenia,’ ‘anxiety state,’ ‘stress reaction,’ and ‘anxiety’ are essentially synonymous. Thus, even though some commonly held ideas are conveyed, the word ‘anxiety’ remains clinically vague. Nevertheless, anxiety has been defined as “a form of fear reaction that is different from normal object fear” (Anthony),vii the latter being appropriate under normal conditions of danger. It is only when the adaptational positions of defence, avoidance, and problem solving fail that it becomes pathological – that is, (1) ‘free-floating’ or diffuse, (2) without causative insight, (3) physically experienced but not so recognized, (4) uncontrolled by any specific defence mechanism, and (5) prompted by anticipated threats that can’t be coped with in the present.

Incorporating these ideas, the criteria for assigning the label of ‘anxiety’ consisted of: (1) physiological autonomic signs such as dilated pupils, tachycardia, sweaty palms, etc., (2) behavioural or motor manifestations such as restless over-activity, clinging, cringing, tremor, stuttering, difficulty getting to sleep or night terrors, and (3) subjective feelings of dread, stated fears, ‘butterflies,’ etc.

Autonomic signs that seemed situational to the clinical examination were discarded. To be considered as a manifestation of anxiety, such signs had to be persistent (either currently or at one time), substantiated either by direct observation or on the basis of reliable history (eg., by a teacher). All hyperactive problems were checked out neurologically or psychologically, and if a diagnosis of hyperkinetic brain syndrome and/or true organicity was made, the case was set aside and discarded from the study. All language problems were investigated by a speech pathologist to rule out other etiological factors. Subjective complaints alone were not accepted as sufficient indicators of anxiety unless accompanied by one or more behavioural and physiological signs.

Of a total of 391 cases of all kinds reviewed, anxiety as above was clinically recognized in 62. There were 39 boys and 27 girls. The age range was from 3 to 17 1/2 years. The bulk of boys in the study were between the ages of 7 and 12, while the girls were distributed fairly evenly over the age range. Except for the excluded diagnosis of organicity, primary diagnoses ranged across the full spectrum of child psychiatric nosology. In 24 cases, anxiety, whether the sole psychiatric manifestation or a symptom accompanying another problem, was judged to be severe in that it displayed itself psychologically, behaviourally, and subjectively. Every case in the study combined at least two of the basic anxiety criteria: physiological and behavioural; physiological and subjective; behavioural and subjective. Thus the study did not involve itself with instances of transient or mild anxiety.

The total number of Split Field :: Relayer Systems observed was 48. Each such triangle system was coextensive with anxiety phenomena. That is, not all instances of anxiety (62) were characterized by the presence of a Split Field :: Relayer System but all such triangles observed (48) were coupled with clinically recognizable anxiety. Thirty-nine triangles involved the parents and identified patient. In 14 of these the patient was also a relayer between one or both parents and an outside person such as a teacher, Children’s Aid worker, probation officer, etc. That is, the patient was involved in multiple split fields. Nine triangles involved only power persons outside the family, the patient acting as relayer between two workers from different agencies who dealt with him while working independently of each other.

The ‘control’ group, those patients in a triangle who underwent traditional modes of treatment – that is, family therapy, play therapy, and/or pharmacotherapy without reference to any pathological communication triangle – consisted of 18 cases. The study group – those triangles that specifically underwent dissolution because treatment was specifically directed toward clarifying and undoing or at least modifying the pathological communication triangle – consisted of 18 cases. The intensity of manifested anxiety, the spectrum of primary diagnoses, and the loci of triangles spread evenly between study and ‘control’ groups. Because of this even dispersal and preliminary nature of the study, cross-matching was not done. This is recognized as an experimental shortcoming to be remedied in future studies.

Results

At three month follow-up, 8 cases or almost 27% of the study group were free of structured anxiety as compared with one case or about 5.5% of the ‘controls.’ Of the remaining cases, 15 of the study group improved markedly, 7 moderately, while of the ‘control’ group 6 remained the same, 10 showed moderate improvement, and one marked improvement. The criterion for marked improvement consisted of alleviation of at least two presenting anxiety sign-symptoms; that for moderate improvement, the elimination of only one. Thus in summary, the overall ‘control’ group response (66.6%) roughly corresponds with the percentage claim of clinical success usually cited in the literature for all treatment modalities of most psychiatric disorders; the study group success rate, even ignoring the moderately improved cases, was considerably higher (76.6%).

The results of this preliminary study of the Split Field :: Relayer System hypothesis indicates two things: First, the Split Field :: Relayer System as one mechanism or cause of anxiety must have some validity. Second, specific intervention directed at such a known etiological factor is more reliable and effective than global, nonspecific, or symptomatic treatment of anxiety.

DISCUSSION

Theories of social causation abound in the cultural lore and literature; however, few distinct mechanisms that actually link interpersonal processes with specific individual outcomes have been described or hypothesized. Such a mechanism, now to be discussed in detail is the Split Field :: Relayer System (or SF:RS).

The Mechanism

(1) This mechanism can occur in any circumstance where a power hierarchy is implicit. It is not imperative that explicit natural or formally structured hierarchical divisions, as in the family or work group, be present. For instance, a group of three peers could develop into a Split Field :: Relayer System on the basis of power in the form of information alone if the information was jointly held by two persons in covert conflict and if it was relevant or essential to the wellbeing of their relayer. The last point is crucial. The split field conflict must in some way be related to the nurturance or control of the relayer.

(2) The predicament, virtually without exception, is a mechanism which specifically sensitizes the relayer to manifest varying degrees of anxiety. It can occur at any age and it is my clinical impression that younger patients caught in the relayer position display either hyperactivity (increasingly so when in more than one split field)viii or apprehensively cowed behaviour; older patients experience the sensation and show signs closely akin to so-called free-floating anxiety. The two patterns of expression of anxiety noted in children are consistent both with Jenkins’ observationsix and the APA Diagnostic and Statistical Manual of Mental Disorders, DSM-II. The DSM-II subdivides children’s behaviour disorders into seven groups including the Hyperkinetic Reaction and the Overanxious Reaction. The latter is characterized by (a) conforming, self-conscious, inhibited, dutiful, approval-seeking behaviour; (b) apprehensiveness in strange situations, undue fears, sleeplessness, and nightmares; and (c) exaggerated autonomic responses. Jenkins states that while overactivity, restlessness, distractibility, and short attention span distinguish the hyperkinetic group, “usually they do not appear anxious except as their hyperactivity may at times be interpreted as evidence of anxiety … intensified in circumstances in which the child is under tension. This implies a functional element, and there is no present justification for assuming that all cases are due to organic brain damage” (p. 1033).x (Recall that organic cases were excluded from this study of the Split Field :: Relayer System.)

(3) Subtle power-dependency changes can occur in the Split Field :: Relayer System. As a result it is possible for the relayer position to oscillate from one angle to another with the development of group anxiety. That is, one person or another could occupy the position of relayer. (The Children’s Aid case hinted at this.) But as a general rule, this possibility is remote because the vested power in most small groups encountered is sufficiently stable to enable the system to fix itself in an equilibrium that focuses anxiety in one victim only.

(4) In order to survive psychologically, at least partially, the anxiety-plagued relayer must learn to omit and disport various elements of the conflicting messages he bears. As a result, and compounding matters, he is frequently identified and vilified as a two-faced gossip and troublemaker. That is, there is a tendency for the older relayer to be the focal point of small-group intrigues. Indeed, sometimes the highly intelligent, well-organized relayer presents as a so-called ‘champion-of-the-cause” (Kazzaz).xi

(5) While compromise at the level of content or pure information is sometimes possible (eg., the head nurse in Tim’s case), even the older, more established, and skillful relayer cannot in his social context resolve the mutually disconfirming relational messages being exchanged through him. In short, apparently there is no fully effective, natural psychological defence against the anxiety arising out of the Split Field :: Relayer System. Comments by Watzlawick about human paradoxes in general apply equally well to this particular pathological triangle:

There is something strangely lethal about this kind of inconsistency … Man is capable of an almost unbelievable degree of flexibility and adaptability as anyone can attest to who has occasion to observe human endurance under the most excruciating circumstances. At the same time, however, man appears to be singularly ill-equipped to deal with those inconsistencies which threaten the validity of, or actually reduce to absurdity, his premises about the nature of the world he lives in. [p. 42]xii

Alone, it is true, the victim of the Split Field :: Relayer System may be truly trapped and quite helpless, unable to recognize or comprehend what is happening or to extricate himself from it. But with rational intervention the outlook changes.

Management

Obviously the first requirement of sensible management is that this specific etiological mechanism, the Split Field :: Relayer System, be recognized for what it is. To be remedied, the SF:RS seems to require a neutral diagnostician from outside the larger system that encompasses it. (For example, it would be unlikely that the Children’s Aid director would pick up and correct split fields in his own agency, or that a busy paediatrician would recognize the pathological import of his failure to confront a resident.)xiii Once diagnosed, the SF:RS theoretically lends itself to straightforward treatment, entailing dissolution by one means or another of either the split field situation or the relayer process.

(1) When communication across the (parental) split field is reestablished or opened up – that is, as the secret, affectively important disagreements are externalized – the relayer is no longer necessary. Get people talking together!

(2) If on the other hand he is an older, compulsive-type relayer, some controls need to be invoked lest he set up new triangles or reactivate old ones. If these controls are successful, not only does his anxiety level drop but his intrigues cease.xiv

(3) Sometimes in emergency cases (exemplified by Tim’s toxic mother), separation of the principle parties concerned is a necessary short-term expedient.

(4) In special instances (eg., Michelle) innovations that may skirt the real issue of covert conflict are possible and may be initially advisable.

In a practical sense, however, treatment isn’t always easy. One should recall that long-standing triangular systems have been deeply ingrained through reinforcement and habit and can be stubbornly resistant to change. The therapist observant enough to perceive such a disturbed system, and with the temerity to intercede, should do so with tact and skill, or he will be replaced. A mere prescription for spouses to be open with each other is inadequate. While some people (eg., the 27 year old nurse) respond and act in an insightful way when the process is interpreted and clarified, fairly persistent coaching is usually needed to effect relearning. The personal style of the therapist undoubtedly has some bearing on the outcome. Although objective neutrality is an essential to diagnosis, it is anathema to treatment. Passivity doesn’t work. The therapist has to be active, involved, and directive. The first session is pretty crucial. During it, the power figures in the triangle, if not the actual victim, must experience some fun and quick relief. Helping them for the first time safely discuss a taboo subject can bring this about, while simultaneously establishing confidence and rapport. I have found that a humorful, enhancing approach is suitable and later helps in cajoling the disturbed trio to do homework on their problem.

iThis is a re-presentation of a seminal concept introduced many years ago in the journal Psychiatry which was dedicated to the study of interpersonal processes. Although the author was professor of child psychiatry at the new McMaster medical school in Canada at the time the SF:RS paper was written, it was declined ‘support’ there, as it “did not conform with current psychoanalytic (intrapsychic) thinking.” Actually, a publication committee member tried to plagiarize it! Theft in high places? But subsequently, the SF:RS was widely acclaimed as a seminal concept with heuristic value. Requests for reprints arrived from across the world, notably from the Max Plank Institute (Leipzig, Germany) and the Karolinska Institute (Stockholm, Sweden) to cite just two. The paper became the stimulus for doctoral theses as far afield as Switzerland.

iiStanton, Alfred H. & Schwartz, Morris S. The Mental Hospital; Basic Books, 1954.

iiiHaley, Jay. “Toward a Theory of Pathological Systems,” in G. H. Zuk and I. Boszormenyi-Nagy (Eds.) Family Therapy and Disturbed Families; Science and Behaviour Books, 1967. (Over the years both words, ‘perverse’ and ‘pathological,’ have given way to the much more preferable term, dysfunctional.)

ivWestley, Wm A. & Epstein, Nathan B. Silent Majority (Families of Emotionally Healthy College Students); Jossey-Bass, 1969. (Of course, such arbitrary assignment of authority to a husband might not be considered so politically correct now in 2011! But, the more things change the more some traditional things might best stay the same. All families require an acknowledged leader, even nowadays.)

vHamilton General Hospital (Barton St.), part of the McMaster University medical school network, Canada.

viIt is ironical that many physicians wont do psychiatry themselves, tending to export (refer) even the simplest of cases off to a psychiatrist, while others keep psychiatry at bay as if with a ten-foot pole, often failing to call for help (consult) until a dire emergency has arisen. The happy conclusion of Tim’s case changed the ways of dealing with both child psychiatry and paediatric psychiatric cases by a goodly number of ‘red-faced’ doctors. They became less red faced as they learned, as Goethe said, “We see only what we know.” In Grand Rounds this wise precept was clarified further: Some intuitively see more than others from the very outset and are labelled scientists.

viiAnthony, E. J. “Psychiatric Disorders of Childhood,” in A. M. Freedman and H. L. Kaplan (Eds.), Comprehensive Textbook of Psychiatry; Williams & Wilkins, 1967.

viiiIn the years following publication of this 1972 paper on the SF:RS and anxiety, research has shown that an IP who is caught at the nexus of multiple split fields (MSF) will develop an ADHD-like disorder called SIH (Socially Induced Hyperactivity).

ixJenkins R. L. “Classification of Behaviour Problems of Children,” Amer. J. Psychiatry (1969) 125:1032-1039.

xIbid Jenkins.

xiKazzaz, David S. “The Champion of the Cause and the Challenge of Supervising His Anti-Leader Role,” Amer. J. Psychiatry (1968) 125: 737-742.

xiiWatzlawick, Paul. An Anthology of Human Communication; Science and Behaviour Books, 1964.

xiiiAs opposed to insight (which refers to inner self-understanding), a particular ability – that of clearly seeing what is actually going on in the human environment outside and around oneself – lent itself to my coining the term ‘outsight.’ One must, in addition to insight, develop clinical outsight in order to properly assess and diagnose the goings on in any marriage or family group.

xivThis old paper is almost embarrassing with its exclusively male referents (pronouns). In 2011 one feels nigh on naked without s/he’s galore.