PSYCHOTHERAPY - Psychoanalysis - Systemics - Pnl - EMDR

Diagnostic and therapeutic levels in psychosocial intervention. The psychosocial interview

Extended version of the lecture I gave at DIXIT, Social Services Documentation Centre, Department of Social Action and Citizenship. Barcelona, November 24, 2008. In this version I add the subject of psychological explorations in children, which the lack of time prevented me of mentioning it although it was contained in my script and other points suggested by the interventions of the audience.

I’d like to start quoting something whose author I thought was Plato, but I wasn’t able to confirm today the authorship when I searched for it.  I had found it in a novel by William Gaddis, and in a humble support of my trembling memory I can only say that at least it has clear Platonic echoes.

The sentence reads:

¿Justice? Maybe in the next world, in this one we only have the law.

In the world of psychosocial intervention we are always, in some way or other, working with the law, not only within the law as in any activity, but by appealing to the law as a tool, a resource that all too often we spell out in support of our proceeding with users. When doing this we are not only acting as psychologists or social workers but playing also a bit of the lawyer, the cop or the detective.

This is especially true in the field we are going to talk about tonight, in which I move, that of abused children. In this field we are expected to promote changes in family interactions, changes that may abide by the law, which wants us to exhaust the possibilities of a child to remain in or return to his family before thinking of other measures. And so we set out through very complicated processes, like dealing with reluctant parents on “improvement plans” or broadly stimulating all those dynamics towards change that we call “therapy in context of coercion”.

Some will say, and often say, that therapy is not our assignment, but that’s exactly the point I want to talk about today. On diagnostic and therapeutic, or, as stated in a language closer to social services, on “assessment and treatment”.

The law not only aims to justice, it also aims to ethics and optimal. When working in child protection we feel ethical stings in our conscience each time we are tempted to engage in subtle abuses of power during interviews with parents whose child has been taken in charge by the administration. It’s really hard not overdoing it when you need to provoke them in order to assess their potential for change. We’d rather cope with an outraged father than a frozen one and, on the other hand, some people can’t think unless they are incensed, so here we go.  We often hear that a professional does not have to tolerate disrespect of these parents, but perhaps such outbursts are the only means available to the father to regain some of the dignity he needs to step up and try to change.

In the field of the optimal, we are also in an imbroglio when doubts loom upon us on proposing a foster family, we know how hard it is to find such a resource, and so we somehow force a temporary residence in a children home, accompanied by an improvement plan slightly optimistic.

According to our plan we have to talk about the psychosocial interview. In Psychosocial Intervention the interview plays a privileged role. We deem it as one of the three most important tools, being the other two the reports and the coordination meetings between teams even though we have to accept that the latter is also somehow an interview, but of a different kind. We could almost say that we live permanently in an interview context, except and luckily when we are between our colleagues in the same team.

What now follow are some notes relating to interviews with users. Between several possible ways of classifying them, perhaps the most expanded in our country is to differentiate between

– First ones, interviews of reception and appraisal of the case.

– Second ones, follow-up or treatment of the case.

There are two main options. Sometimes we discuss if a specialized team must perform the first ones and solely these, without doing second ones, being the alternative that the same team may do both. In the line of what I am developing this evening, this second option is much better, for the benefit of both parties, protecting the first team from making diagnoses and proposals so good that they are impossible to solve for the second one, and protecting the latter from feeling frequently forced to counteratack re-diagnosing the case to boil it down into their operating possibilities.

In a parallel dialogue I must say that along several clinical and psychosocial contexts I have often taken part in a debate on who has to perform the first, reception interview. On one side there are those who argue that the initial interview is purely informative and therefore any professional can do it, even the most novice, as a step of his apprenticeship, or even better, the social worker (usually better informed about the resources’ catalogue in order to inform the user). On the other side we have those who think that the first interview may be the most important of all them and therefore the interviewer should be a very experienced professional. Put this way, these are extreme positions of course, but with the advantage of showing the ideologies underlying each position.

For the flag-bearers of the first position, the reception interview was meant mainly to inform, that is basically to contextualize (apparently easy but misleading concept) the user, tell him where he is and what resources we may offer him, depending on the needs he had. For the defenders of the second position it is much more important to listen very carefully to the user, not so much to find out his needs but his attitude in front of them, specifically what he had done before coming here to ask for help and what his expectations were, even his fantasies about the institution he is now in, and what does he deem as help. As my old teacher Pichon Rivière used to say, elicit his fantasy of illness and his fantasy of healing, conveniently translated these concepts into the psychosocial field.

Roughly speaking, as in a caricature, for the “informational”  team the issue was not so much listening as speaking, something like “first listen to me, I’ll show you everything we have and if we don’t find  what you need in our catalogue, then we’ll try to direct you where you may find it”,   while the message of the second “clinical” team could be paraphrased as “tell me what you need  in your own words and feelings so we can discover or invent together what may be the best resource for your  problem. ”

Any reader will already have noticed the models that support each position. For the first option the model is the management interview, the allocation of resources, in the background the sales interview, for the second option, the model is utterly the clinical interview.

There are important differences of course; the professional in psychosocial intervention does not “sell” anything to the user, although sometimes it may seem so, seeing his efforts to convince him, in spite of what the user seems to think, that the resource he has offered will do the trick,.  The same professional does not adopt either a strictly “clinical” position before the user, when he subtly points out some exaggeration in his idealizing the expected help or some overly dependent attitude in the relationship with the interviewer.

Let’s come closer to our subject. When a child recently withdrawn from his parents (out of having seen indicators of abuse) steps through the door of a children’s shelter centre we face a kind of dilemma similar to the one raised on how to make a first interview. We may include him as quickly as possible in the normal dynamics of the centre’s daily life of, tour it, introduce him to other children, in short we can contextualize him, or we can take more time to stay with him,  empathizing, listening without questioning and taking good note of all his first utterances, words, faces, looks…  In the first case the child will get in all likelihood rapidly integrated, the presence of other children does wonders and generates reassuring affective channels, in the second case we can find out in the first place what he thinks, his feelings, fears, grasp his separation anxiety and in short where does he think he’s been brought and why. Because what never fails, statistically speaking, is that the next day this child will be repeating in a parrot-like singsong the familiar refrain that “he must remain in the centre because his parents have some problems to fix before he can return with them …”

And thus we enter more specifically in the field of diagnosis and treatment of ill treated and neglected children. We soon see that all teams involved in this area, without exception, diagnose. All or nearly all teams produce assessments, appraise risk factors or ill-treatment indicators, and depict abusing family dynamics or parenting skills.

The most obvious question immediately pops up, who deals with these cases? Who resolves them, if everybody is diagnosing and writing diagnostic reports?

The answer is not easy, because the question is somewhat oblique.
Actually every professional involved does something to improve or change the circumstances in all cases of children maltreating, but then if you ask any of them if he is treating this case, usually the answer will be by no means, that is not my task, which consists entirely in diagnosing either the possible abusive situation or the family remaining competences to get back their child.

We all know, of course that to assess is also to operate but this acknowledgment is not always the case (especially in contexts in which coercive interventions can have undesirable results), and in any case sounds more like professional consolation to the unsatisfactory situation of not being able to carry out completely their job.

The therapeutic, to call things by their own name, dimension is repressed in the child protection system.

A few days ago, reading a commentary on the economic crisis (I think it was Krugman’s, I’m not very lucky tonight in quoting) I found another phrase of those that make you think. It said “politicians who boast of being men of action and immune to theories are unconsciously ideological slaves of an already surpassed economic theory”

Now, I think we can pretty well apply this idea to the situation in our children protection system. Those who think they can neatly separate therapeutic from diagnosis, beyond other political or budgetary considerations (the ones which they are possibly taking into account) ignore that from the technical point of view, the line between one thing and another has been fading since decades, and  believe me I’m not just talking about psychoanalysis, where it never existed, I’m also talking of systemic or strategic family therapy, so blooming in our job, and also of the generally called brief therapies, or focal, as NLP or EMDR, which for 30 years or more have revolutionized the psychotherapy world, especially in regard to the treatment of trauma. Actually the model behind this alleged (and basically impossible separation) is more like outpatient medical model, where diagnosis comes first and treatment comes behind.  In fact, if we look for medical analogies, a much more appropriate example would be to compare to the Intensive Care Unit, where observation, diagnosis and intervention constitute a single movement from the very arrival of the patient.

In support of this statement I want to dwell in some detail on two concrete examples.

The first is the psychological examination, namely the psychodiagnostic (psychometric, projective and relational) study of the children carried out during his stay in the centre. The psychologist in charge passes tests, asks for projective drawings, performs some playing sessions and in short, takes several interviews to that purpose. Later on, in addition to making his report, provides advice and technical support to the child’s tutor, who will have more contact with the child, who puts represents the voice of the child and is in charge of accompanying and being attentive to his needs during the process in the centre.

All well and good, this is perfectly adequate for a good majority of children. The problem begins when some children have behaviours that we classify as clinically symptomatic, as anxieties, signs of PTSD, and other disruptive behaviour, clearly indicating a mental disorder. With “pathological” I mean manifestations of the child that aiming at been defensive against any conflict, become in the end detrimental to the healthy child development. Pathology in this case means exaggerated, anachronistic or invalidating defenses.

In this case, the centre often requests help from an external resource, and refers the child to a specialised service, except that they are usually quite collapsed of demands and will be able to see the child to the extent permitted by their agendas.

Question: Why don’t we take care of the child’s condition in the centre? We have psychologists and we have the child 24 hours a day. The centre gives enough emotional holding and the only thing we need is to assign a psychotherapist to this particular child, so they can meet with any frequency, which will always exceed the capabilities of the external centre.

Symptomatic behaviours of a child can rise very high, as anyone who has worked in a centre can witness. Sometimes we mistake the healthy child for the one that gives no trouble, even though we all know the difference the daily bustle naturally leads us to prefer the less annoying, and not always we grasp that this silence is a very bad clinical prognostic indicator, and if we see it we often put the blind eye, as we have enough problems dealing with children noisily expressing their discomfort.

It sure takes specific and ongoing training, and specific technical updating. But the cost of this training is lower than the costs in future treatments, and without departing from the present, let’s mentally calculate how many hours of training or supervision of cases can be covered with the monthly cost of one residential place.

And above every economic consideration, if we can do it in the centre, in the present context of the child, and do it before and with an intensive frequency, why delegate it? The first beneficiary will be the child and next to him the centre and its staff, who may feel better doing a more complete job. And of course we’ll always keep if becomes necessary the external specialized centre.

The second example I want to put out concerns the referral of cases from our centre to the following-up territorial team, in three specific cases, that is when the chosen protective measures are a) Return of the child to his own family b) the child is fostered within his expanded family and c) the child is temporarily interned in a residential centre with a positive prognostic of being returned to his own family.

The referral of a case entails the referring of three very important elements, two of them relationships: a) the relationship with the child, b) the relationship with the child grownups and c) the centre’s written report with proposed measure and its clinical and technical reasons.

The transfer of the child is particularly relevant in the case of going to another centre, even for a predetermined time. Invariably these movements cause pain, the child loses binds with adults who have cared for him and other children with whom he has shared his daily life in the centre. These losses are accumulated with retrospective posttraumatic effect on children who already know a lot of losses, and although farewell rituals and progressive transfer plans are carried out to minimize these effects, these may be heavy upon his development.  If the chosen measure is that the child returns to his home none of these risks take place, but the situation is naturally fraught fears and uncertainties, though not as painful.

The transfer of the report takes a while to reach the territory. Administrative or communication delays and backlogs of the recipients take time until the following-up team can read it, take in the case and finally make contact with the family. Coordination meetings are held and emails sent, but invariably and inevitably this process takes many weeks.

And now the referral of the family, where we have the biggest problem, let’s look at it in steps:

–    The rapport between the family and the professionals of the centre gets truncated. If the case is to be followed by the same team that exposed the case of ill treatment the family resentment will be for sure keyed up, reactivated (which would not be bad if the encounter could be conveniently prepared). If it was not we need to create a new link between this family and the professionals who will do the follow-up. While the child has been “kidnapped” by the centre the rapport between the family and the professionals has been of a fruitful tension, that typical ambiguity (useful and provocative) accompanying coercive treatment. This relationship usually has a therapeutic coloratura which is surgically cut when the family is referred to the territory. Here is another source of pain and feelings of loss, now in the adults, all too often old abused children. In the best case, that is if we can start over a therapeutically useful relationship between the family and the new team will have lost precious time to test the proposed measure.

–    The current system of several coordination meetings between the centre and territorial teams generates a useful and necessary exchange of information, but does not solve or alleviate the mourning for the loss and replacement of the bond with the family.

So we come to the end of this lecture, with examples meant to illustrate some unintended consequences of separating the diagnostic and therapeutic steps in the process. In the first case the solution may be that the same professional team, the one who does the child’s psychological exploration could perform the psychotherapeutic treatment if it is necessary. And obviously the same solution comes to mind if we were to solve the second case, that is that the same professional team (the centre’s) may take over  the following-up of the case in the territory, without breaking up the rapport with the child and his grownups, and wasting no time in sending reports and holding coordination meetings.  According to this point of view I deem as an institutional abuse the splitting of the case by halves between two different teams.

Just to end up allow me a general comment. Psychosocial interventions are a recent and growing working field. Transferred into professional practice, and in the way it is usually described in their training programs, their goal is to increase the quality of life and welfare of people in different areas of development, aims to improve the relationship between people, their contexts and social system, and this is intended by promoting changes in the services of social welfare and law enforcement systems.

Their current subjects are: children in risk, domestic violence, aging and dependence, disabilities, immigration, family reunification, crises and emergencies, women and gender relations, sustainability and environment, legal and prison systems, marketing and costumers. Etc.

That is, all its areas of activity are or may become a symptom of a social malaise.

I say symptom on purpose. For those like me, who come from the clinical field, the notion of symptom is very familiar and if I may, I will risk an intuitive comparison between our symptom and the task that society, through its institutions, usually asks to a psychosocial professional team to solve or alleviate.

By symptom we mean a discomfort, emotional pain, which appears apparently without motive, sometimes accompanied by some inhibition or foolish behaviour. Irrational fears, phobias of some animal, horror before elevators, persistent ideas heavily laden with anticipatory scenes of horrific situations not apparently related to any semblance of reality, current difficulties on activities of daily life we’ve always done easily, repeated inconvenient but uncontrollable behaviours, etc. The list can be very long, but the formula is very simple: a mysterious pain that we do not understand how it has seized our mind, which makes us ask ourselves constantly, even with a guilty tone, as if deep down we fear to deserve this torture. And if we come up with hypotheses, no one does the click and thus we keep wondering.

The commission put out, asking for the psychosocial intervention shares some of these characteristics, but instead of coming from the dark side of our mind comes from society, especially from the government, when the administration decides to do something to relieve this discomfort and instructs some institution to develop a planned action.

This commission expresses a current unrest weighing heavily in everyday social life and therefore asks for regulation, intervention and even full paragraphs of political programs. It’s a call to action, and then volunteers, NGOs or firms turn up, looking for contracts with the administration. Like the symptom it generates hypothesis and intervention plans, all of them unsatisfactory and incomplete. Finally as well as with the symptom, this commission may be an old solution that has now become an issue, as in the case of immigration or family reunification or eventually becomes something of a problem it was high time to confront to, something that was glaringly hidden, as sex violence or child abuse.

Anyway, I just wanted to end up with this analogy that aspires to nothing concrete but only to be entertaining and suggestive.

Thank you very much for your attention.

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