From difficult adolescents to the silences of families

Hello Marco, I would like you to comment on the work you have done with families in which child abuse occurs. What has your experience been in this field?

My experience was to have been confronted, at a certain point in my career, with the psychiatry of adolescents who presented a series of very complex and difficult mental and behavioral pathologies: drugs, delinquency, and so on.

In the setting of a psychiatric hospital?

In an institution for difficult adolescents, as the physician in charge of that residential institution. Because of my knowledge of family therapy, I began my work by looking at what the family’s resources were, and I came up against difficulties of understanding, then against a lot of silences. It took me a few months to understand that it was impossible to use the family’s resources before we realized that this same family, which had a duty to protect its adolescents, had seriously failed in that duty through maltreatment or sexual abuse. When I understood that starting with the question of resources, without taking into account the reality of the injustice suffered, was of no use, I became interested in this phenomenon.

Did you think that the systemic model was insufficient to address this problem?

The vision of the circular systemic model, useful for understanding ordinary pathology, was not enough in the field of abuse, or at least had to be complemented by a vision of the precise responsibilities that parents and adults have toward their children; and, at the same time, a therapeutic alliance and a therapeutic truth had to be created, because, to motivate adolescents to take part in treatment, you first have to officially acknowledge to those adolescents that they have suffered injustices, and clearly define who was responsible for the injustice, which is what the parents were asked to collaborate on. In short, all the work I did with those adolescents, what those adolescents and those families taught me, was to be able to go right to the bottom of the narrative construction of their experience. I do not think that defining and precisely determining responsibilities is at odds with an ethic of family reconciliation. But that family reconciliation must start from the acknowledgment that the parents committed acts they should not have committed.

And did you talk about that with the parents? How did you work with the parents?

Naturally, these were multi-problem families, in which the parents were distant, and they were also stepfamilies. The first work I did, from a historical point of view, was work on the practitioners, on the physicians, the nurses and the educators, and it turned out to be very interesting. I carried out a statistical study on about a hundred cases, in which we found that around 60% of these young people had been the object of sexual abuse or sexual touching. 90% had suffered physical violence. Then, when consulting the clinical records and the institution’s documents, this phenomenon had been mentioned and described in those records on only two or three occasions; for all the others, there was a kind of complicity of silence, the same complicity of silence that exists in families.

A radical change of mentality

Were there no professional criteria on how to approach these situations?

What was lacking was a culture, an education in the matter, or rather it was something more complex, because a culture, at least in Switzerland, did indeed exist. But the people who dealt with these questions were, for various reasons, very much hindered by the official bodies. The official institutions, for different reasons, put up many obstacles, and what seemed particularly interesting to me in Switzerland was to have taken part in a radical change of mentality. On the one hand, because in recent years there has been a change of mentalities in the world, and not only in Switzerland. On the other hand, because people like Masson, like me and like other colleagues, at a certain point, opened the way with strength and determination, by organizing a conference on child abuse, by inviting experts who enriched our information on this subject, and by beginning to spread a certain culture that allowed people to report abuse, while maintaining a fundamental respect for both the victims and the perpetrators.

Justice and therapy: two epistemologies facing doubt

Could you say that you have a model of intervention?

The model of intervention we come closest to is that of the Centro per il bambino maltrattato in Milan, whose model, and this is very interesting in that sense, itself refers to Masson’s model. The great difficulty we still have in this field lies fundamentally in the self-referential system of judicial thinking and in the self-referential system of therapeutic thinking; it is a problem that is objectively spoken of in terms of complementarity, but how to put that complementarity into practice is an extremely difficult thing. The dilemma, which you know well, is that it is very difficult to obtain evidence and certain facts. No one can be convicted without the certainty that they are truly guilty. But this epistemology, in which doubt benefits the accused, takes absolutely no account of the fact that this same doubt harms the child. From an ethical point of view, and this is the most interesting part of the book we produced on child abuse, Le silence comme un cri à l’envers, the most important thing we brought to light is that the adult’s word cannot be set against the child’s, because in this position of doubt, the most fragile person is the child. In this sense, we have begun with the magistrates a series of fundamentally interesting collaborations, in which the magistrates agree to remove the children temporarily as long as the facts have not been clarified.

Even if the family was recoverable?

Yes. From the point of view of ideas, basically, the fact of removing the child makes it possible at the same time to prove right the legal epistemology, which says that the person must be protected as long as there is no proof of their guilt, and to prove right a therapeutic epistemology in the broad sense, which says that children are very small, very fragile, that they must be protected and that this is why they are separated, considering that this separation is not harmful to the child. That is a first point. The other point, which we developed in Switzerland, is in a certain sense an intervention of protection through that capillary network that is the medical network. Switzerland has a high density of physicians, so that people go to the doctor frequently. So we did preventive work by raising physicians’ awareness of the fact that domestic violence exists, that family violence against children exists, and that consequently physicians have not only the power but the duty to assess and intervene to protect minors.

Do you think Swiss culture is more on the side of children or on the side of adults?

Swiss culture is changing in two directions: on the one hand, with the aging of the population, the corporatist interests of adults and the elderly are taking precedence over those of children, and there is a series of laws and initiatives that progressively neglect measures for the protection of children. But, on the other hand, the birth rate is falling, which has profoundly transformed the role of the child, who, from being the father’s possession, has become an object of consumption, that is, a very precious object. And it is a change of mentality that is still not very significant in medical intervention, but which is fundamentally of a social kind.

Protecting practitioners: the reference groups

Another subject you have worked on a great deal is that of practitioners: the contact of practitioners with these situations.

What I have tried to pass on to others is something that protects them from the extremely painful experience I was confronted with: having to resolve a series of situations alone, and trying to understand them without having sufficient contacts, put me in serious difficulty.

You wanted to do the work without taking into account the importance of the whole system, taking too much responsibility on yourself?

Yes, I think it is natural, when a practitioner is faced with a complex situation and with an adolescent who has understood that you have understood, for the adolescent then to place on you the whole responsibility for therapy and rescue. In this sense, closenesses are successively created that are not very useful either for the adolescent or for the practitioner, because the child who has suffered violence is faced with this dilemma, which you know well: no longer wanting to be abused, but having established such a strong bond with the abusing parent that he cannot give it up. In this sense, this way of establishing a very close dual relationship becomes harmful for the minor and for the practitioner. So we set up, in Switzerland, reference groups, multidisciplinary groups that meet once a week for a few hours, in the morning, and to which all professionals, whether teachers, psychologists, psychiatrists or physicians, can come to talk about a case and see how to deal with it.

That is, offering technical but also emotional support to all the professionals involved.

Yes. What seemed important to us is that these groups should obtain the approval of the institutions, but at the same time be able to remain outside them. In other words: if I, an educator in an institution, think that this young person has suffered violence and I don’t know what to do, the first person to contact is naturally the director. But if the director says no, the person has little possibility of asserting their opinion. So they go to the reference group, whose function is purely advisory, but which is made up of competent people, which makes it possible to integrate the director’s opinion with the educator’s and with the child’s.

And to come closer to the concept of therapeutic truth you were talking about.

Yes, something of that kind. And now, these reference groups are in fact also used by judges when they are in difficult situations; they are not psychiatric or credibility assessments, but they serve so that the judge can form an idea of a situation, presented only under cover of anonymity, to see what the opinion is of the interdisciplinary majority of the group, made up of lawyers, teachers, adult psychiatrists, child psychiatrists and social workers.