Review by: Peter Moore, MD, FRCPC
When professional helpers damage their clients, it is often a personal agenda—conscious or unconscious—that has sabotaged sensitive management. In this book, the Caplans focus particularly on harm perpetrated by those who work with children of divorcing parents. Taking as their model the guidelines of the British Medical Council, the concerns they discuss are as relevant to doctors as they are to child care workers.
Daughter and father, the Caplans collaborated 40 years ago in pioneering preventive psychiatry at Harvard Medical School. Shalom bayit—peace in the home—was their ultimate goal. For the past 15 years, they have worked to refine this goal by building a community service in Jerusalem. Readers will note that their case material reflects a heavily burdened and multiethnic society for which stabilizing structures are struggling to emerge in the midst of highly destabilizing conflicts. That said, even in less beleaguered countries, awareness of the social cost of multiform neglect and abuse is calling for new kinds of helpers; regrettably, helpers of scant expertise may be given powers that they abuse through lack of judgement. Abuse, however is not confined to the poorly trained. Many experienced professionals have caused harm by mismanaging certain of their clients, either through carelessness or through personal bias.
As stressed in the book’s introduction, therapeutic initiatives sometimes worsen psychiatric and social disorders instead of improving them. Often, people need support rather than change. Support, of course, must be tailored to fit a particular crisis. If offered careful guidance, family members themselves may find ways to increase their own efficacy, either by ameliorating problems or by learning to live with what cannot be changed. In such cases, no aggressive intervention may be needed.
Yet, the book reminds us that sensitive understanding of clients’ unique situations requires more background than many helpers possess: many helpers lack the skill to carefully analyze the possible causes of a crisis and often make decisions they fail to revise, even when their theories fall apart in the face of contrary evidence. “Theme interference” is suggested as the force behind many inappropriate interventions. Seen as a subconscious problem of the helper, theme interference occurs when the problem gets displaced onto the client: “the abuses you’re suffering are what I, too, have suffered.”
The Caplans enlarge on this idea in their second chapter and then proceed in the next 4 chapters to describe cases wherein “a major, if not the major and recurring factor in creating iatrogenic damage is a failure on the part of professionals to examine evidence.” Two crises make up the content of the following chapter. Both crises were precipitated by school teachers who created far-ranging damage by taking hasty positions and then enlisting support from child protection workers. They held rigidly to their faulty judgments, with tragic results. Another chapter tells of “a healthy, academically and socially successful [girl] from a cultivated and well-endowed home” whose paranoid mother roused such lurid suspicion of her innocent husband that the girl was taken into custody. This is a disturbing tale of a caseworker so dogged and vigilant in her crusade to take ownership of a child that she intentionally falsified facts to gain her ends.
Two subsequent chapters tell of further malfeasance. In one, the goal of social engineering was used to justify flimsy pretexts for taking a bright, attractive girl from her humble family and having her adopted into the upper middle class. In another, a pathologically lying girl charmed a welfare officer into a folie à deux that made rescuing the girl a desperate mission, causing great damage to both the girl and her family.
“Kafka’s World” is a chapter telling of a type of case so one-sidedly documented that, although challenged many times in court, it can never be won. From age 7 years, a boy is hostage to a child protection worker who appears to be hostage to the boy’s charming and psychopathic father. Isolated from his mother and extended family, he is held in institutional settings until, after several years, his father wins the fight for him. Despite his unwavering aversion to his father, the boy is not free to make his own choices until he is 18 years old.
Various approaches to reducing iatrogenic harm are explored in the final 5 chapters (one of which gives the Caplans’ critics a platform). Goals vary according to the situation. Victims, despite losses and feelings of helplessness, may be encouraged to develop self-efficacy and to sidestep stressors that might otherwise defeat them. Caregivers, agencies, and judges are all urged to take roles as both consultant and consultee in dyads or groups of mutual surveillance. It is asserted that the human penchant to copy behaviour modelled by respected consultants, along with a willingness to learn, will create helpful change. Entrenched systems must abandon secrecy and stop falsifying records; they must allow fresh values to replace stale protocols and unmerited influence.
Idealistic as these goals may sound, the Caplans repeatedly stress that attaining them is possible, even if progress is slow. Tactful and noncoercive approaches may gradually influence helpers at all levels. Many cases are so complex that only open-minded and diligent reviews of all the evidence can turn problem making into problem solving.
This book rambles. It abounds with repetitions, anecdotes, and woolly sentences. (For a crisp and tightly organized contrast, I suggest Pat Denning’s excellent Practicing Harm Reduction Psychotherapy . Although aimed at substance abusers, this book uses the Caplans’ public health model with very workable clarity.) Notwithstanding these criticisms, readers turning the final page are likely to feel that they have visited 2 wise and kindly teachers—teachers dedicated for many decades to helping all of us who have caused harm, or may yet cause harm, to work toward giving better care.
1. Denning P. Practicing harm reduction psychotherapy. New York: Guilford; 2000
Rating Scale/ Échelle dévaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé