Two experiences that are not studied: fighting, escaping

Among the formative experiences of the family therapist, those that consist in fighting with one’s colleagues or in escaping from a case remain among the least studied. Training centres, with a few exceptions, prefer to assume that there is not much benefit in examining that experience very closely; they consider that devoting oneself to the study of well-conducted cases produces more obvious benefits, in terms of motivation and know-how, than the painstaking study of interrupted cases. Those that have broken off do not fit the implicit aesthetic notions that dictate what good teaching material should be. There is even a fear that, by devoting time to a forensic attitude, by seeking to understand in detail the particular difficulties that led to the case being abandoned, the therapist in training will become discouraged.

Although training centres prefer to study the case that succeeds, many therapists dispute this. They consider that, in order to train – especially with a view to working in the frustrating environment of public mental health –, there is a great deal to be learned precisely from interrupted cases. After all, these make up, even on the most cautious estimates, more than half the cases the therapist faces when working with the most deprived, with questions of drug addiction among the poor, with delinquency and violence¹. Such cases arrive loaded with multiple problems and emerge from varied contexts of cultural diversity. With them, it is impossible not to come up against the fragmentation and the shortage of services. When benefits have to be obtained from hospitals, schools and courts, this population always runs into frustrating inter-institutional tangles. In this environment of complex exchanges, the therapist cannot harbour many illusions about the limits of the problem or about his own, and quickly discovers that many of the obstacles he encounters do not arise mainly from the patient’s mind or conduct, but from the lack of coordination and collaboration on the part of those who are supposed to be his resources and his allies. What is more, disagreements of mood between the therapist and the family abound, resulting from the interruption of the therapy.

The fantasy that the therapist moves in a broadly harmonious professional field, peopled with cooperative colleagues who allow him to navigate like an imperturbable Buddha, dissolves. Other associated romantic ideas disappear as well. One learns that, in his moment of vulnerability, the therapist cannot always be directed towards a milieu of therapists of therapists, politically disconnected from the training centre, where swift and discreet repairs would be carried out. In short, interrupted cases bring an enormous dose of reality to the therapist’s training. They teach, among other things, that the hidden art of knowing how to disengage from certain cases in a responsible way is necessary, and that it requires taking seriously the process of learning to become the adversary of one’s colleagues.

Interrupted cases contribute above all to the therapist adjusting, or abandoning altogether, the metaphors of the day that claim to guide therapy. The idea that life is like a book of which you are the author and the narrator quickly proves useless and disposable. The same goes for the poetic flight according to which your soul is a ship and you are its captain. If the therapist and the family end up seeing that they look more like a paper boat drifting with a tiny sail while the sea lashes them with ferocious waves, the chances increase that they may adjust their goals and help one another. They increase still more when the therapist behaves creatively in the face of the powerful background forces that Pakman brings to light: globalisation and postmodernism². As these forces steal from him and devalue the conceptual truths that until then lent him support and direction in his journey with the family, the therapist quickly looks for others. He no longer finds the usual footholds he used to count on and has to situate himself in the new inescapable truths. I can count for certain on the fact that some of my own will block me or betray me. I can count for certain on the fact that some cases will make me lose my equanimity. A few of the ways in which these new overwhelming truths, ancient in the heart of man, allow themselves to be glimpsed can be observed in the improvisation demanded by the two cases that follow.

Case no. 1: the confrontation

A woman was referred to a therapist because her two-year-old daughter had had to be hospitalised as an emergency. According to the paediatrician, the child was severely dehydrated. The mother’s sisters had noticed that the little girl looked very unwell and had called the child protection service. The mother, a chronic drug user, had a long history of severe emotional trauma. She was using drugs when she left her daughter in the hands of irresponsible neighbours. The paediatrician was alarmed: in his view, the child should have been hospitalised much earlier. Over the previous two years, the mother and her daughter had moved from one state of the country to another. She was driven by the idea that hospital records were altered by doctors in order to take her child away from her.

The therapist to whom the case was entrusted noticed that, shortly after the child protection service had taken over the file and brought it before the court, the mother stopped being friendly. She developed an attitude of annoyance as soon as the court had appointed a psychiatrist and a lawyer for her. The mother explained to the therapist that these new resources – the lawyer and the psychiatrist – had told her: “you may lose the child, because your therapist does not fully support you”. On hearing this, the therapist shuddered, but she considered that it could not be a matter of an ethical failing on the part of her colleagues. Surely it was a misinterpretation on the mother’s part. The therapist immediately got in touch with the psychiatrist and the lawyer, who replied with one voice: “your report casts doubt on whether this child’s safety and care can be ensured independently by this mother. You say that she is still in recovery, that she remains unstable and that she cannot look after the child without being supervised.” A solemn and arrogant alliance had been formed between the psychiatrist and the lawyer against the therapist. They insisted at all costs that the mother should get her daughter back immediately and without any supervision.

The therapist felt betrayed and disqualified. She felt that her professional reputation, as much as her very self, was threatened by two powerful and respected figures of the court. She took concrete steps to resist them. She repeated to her patient that she could no longer recommend, without going against her conscience, that the court return the child to her without being sure that this time there would be a responsible adult to support and supervise her. She made clear once again that the continuity of the child’s care had been dangerously unstable over the previous two years. She then wrote to the court setting out the reasons why she was separating her opinion from that of the psychiatrist and the lawyer. She anticipated that the psychiatrist and the lawyer would give the court to understand that any recommendation of supervised care in fact amounted to recommending the termination of parental rights. She stated that she meant nothing of the kind and added that putting an end to the mother’s rights would leave this woman with no motivation whatsoever to recover from her addiction. She warned the court that the mother’s sister, the first candidate to take in the child, had always sought to push her patient aside. If the court were to consider the aunt as a substitute mother, it should do so only as an absolute last resort. To do justice not only to the mother’s needs, but also to those of the child, who was in great danger, the court should put supervised care in place. Such a measure could repair and prevent the instability of care.

The case is ongoing. The therapist, although uncertain in the face of the possibility that the court will favour the recommendation of the two most highly esteemed figures in judicial circles, feels that she has responded to the ethical pressures by doing what was right.

Case no. 2: the escape

A woman comes to see a therapist because she is very sad after deciding to end the relationship with her partner. She explains that he never finds work and that, lately, he has been behaving strangely. This woman’s mother told her that she had found him at the foot of her bed, late at night, and that she did not know for certain whether he was trying to pull off her pyjama bottoms. Following this information, the woman confronted her partner, who replied coldly that this accusation was a good example of her mother’s senility and that he had done nothing of the sort. Whatever the case, the woman asked him to leave the house, which he did.

At the second session, the therapist discovered that this woman worked as a prison officer. That was where she had met this man. He was an inmate when she became friends with him and became his advocate. She had managed to present his file before the parole board and, through her intercession, had obtained a reduction of his sentence.

Between two sessions, the therapist notices a coincidence. She had been following the news on television about a serial rapist at large, and it turns out that he was operating in the neighbourhood where her patient lived. The therapist questioned her patient about the type of offences committed by her partner and learned that on more than one occasion he had been suspected of rape. The therapist went on exploring how effectively her patient had broken off with her partner. She discovered that the woman remained very involved in this man’s life, that she spoke to him frequently and without restraint. They had long conversations over coffee every time he came to collect his things. The more the therapist questioned the extent to which this man had left this woman’s life, the more the latter insisted on talking about the hardness of this “poor man’s” life. The therapist concluded, in silence, that this woman remained entirely willing to find excuses for her partner’s conduct. She maintained an open-door policy with him.

It so happened that the therapist, whose husband was temporarily away from the city, began to feel insecure and vulnerable. She thought that, despite all her efforts, it would be pointless for her to offer this woman treatment as long as she herself felt very frightened. She decided that she had to find a way to help this woman obtain help without continuing the follow-up herself. Reflecting on the unbridled way this woman talked, she wondered whether the man had not already learned where she lived. She enquired about it and, indeed, the man was already informed, through the frequent conversations he had with this woman over coffee. Even after learning what had happened to her mother, this woman had remained incapable of holding boundaries and disclosed everything to him.

The therapist got in touch with a consultant and shared her concern with him. Could it be that my patient’s partner is the serial rapist the news is talking about? Reacting to the therapist’s anguish, the consultant immediately asked her whether she wanted to go on working with this patient. “No, in any case I am already on my way out. My aim in this consultation is to see how I can hand over responsibly to another therapist.” After this exchange, the therapist confronted her patient: “I do not see you closing the door on this relationship completely. Make sure your mother stays away from this man and, as for you, take care of yourself.”

The therapist went on: “You must start immediately trying to understand how you choose your men, but it will not be able to be with me. Right now, I am not ready for that task. I recommend you consult Dr X.” The therapist disengaged as best she could, making sure that this woman found another therapist before she herself abandoned the follow-up completely. At a review session, the consultant, taking the ethical pressures into account, intervened by asking the therapist: “could this patient alert the community to the possibility that her ex-partner is the rapist being sought?” The therapist replied immediately: “No, that is unlikely. It is unlikely, but it is on the other hand possible that, in one way or another, she will warn this individual that there is a rapist in the neighbourhood and that the police are looking for him. Remember that she is the one who pleaded for him when he was incarcerated and that she even obtained a reduction of his parole term.” Then she added: “you see, I feel safer, and perhaps this woman and her mother are more watchful and even less in danger, but the community has been left without protection”.

Immediately after the consultation, the therapist made an anonymous call to Crime Stoppers³ and insisted that this man be put on the list of suspects.

Conclusion

Training in family therapy can be improved if it more deliberately includes the study of the clinical decisions and the ethical pressures that govern interrupted cases. Such cases abound, and they offer the advantage that their ambiguities deflate the tradition of omnipotence and triumphalism that frequently slips into case presentations at conferences and in the literature.

We recommend that training emphasise the development of specific skills aimed at improving the therapist’s communication with the family. This craft-based perspective receives indirect support from recent research conducted in medical training⁴. A series of experiences can be organised that improve the therapist’s communication skills with the family, and these skills can be made to reduce the number of interrupted cases. They could prove effective despite differences in the institutional context in which they are taught. There have no doubt been constructive consequences to admiring the image of the therapist immune to being startled; but, for better and for worse, this has at the same time accelerated his suffering. The lack of well-being can become intolerable when the therapist discovers, again and again, that precise skills are lacking in him, that he is a disturbable and imperfect being in an imperfect field. When he accepts that the unpleasantness of doing battle with colleagues or of fleeing responsibly is an integral and natural part of what there is to learn, the professional task becomes more bearable for him.

Encouraging this step of acceptance to be taken early in the training path would perhaps relieve the dissatisfaction and the insidious demoralisation that tends to take hold of public mental health services. Any step likely to relieve this situation deserves to be considered, alongside the encouraging words with which Dr Luis Polo consoles those who complain about the heaviness of the working climate in public mental health institutions: “This field would be most delightful if it were not for the patients and the colleagues.”