Family Systems Medicine, Vol. 9, No. 3, 1991
The involuntary client: Avoiding “Pretend therapy”
FRAN ACKERMAN
JORGE A. COLAPINTO
CONSTANCE SCHARF
MARGOT WEINSHEL
HINDA WINAWER
Therapists often find themselves in strange and unworkable situations when they are asked to treat families defined as child abusing. Not uncommonly, this leads to “pretend therapy” in which the untrusting families seem to go through the motions of treatment while baffled therapists struggle with “resistance.” This article discusses the structural base for this configuration and suggestions for effectively transforming it.
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“I used to feel like an adult, that my husband and I could make decisions about our kids. Whatever we decided was the best for them, and whatever we wanted to do, we did. And now I feel like a kid, and I’m told to go places and told to do things; and so sometimes, just like I did when I was a kid, I don’t do them.”
—Cheryl Green
One day Cheryl and Bill’s 6-year-old daughter, Tanya, went to school with a bruised eye and welts on her legs. The teacher noticed them, contacted the child protective agency, and Tanya was taken to a hospital where she was found to have fresh whip marks and scars from pastbeatings. The girl was immediately removed from her parents’ custody and a court hearing was scheduled. The judge supported Tanya’s removal from the Greens’ home and told them that they had to attend family therapy as one of the conditions for regaining custody of their daughter. They were referred to our Family Preservation Project, at the Ackerman Institute.
Tanya was eventually reunited with her parents. This is not, however, an article about their case, nor is it about our, contributions to the outcome. What we want to describe is how we position ourselves vis-à-vis the complex, often adversarial, and at times paradoxical system of forces that wraps itself around each abused or neglected child.
The Impossible Contract
For better or for worse, our society has adopted a formal, institutionalized responsibility for guaranteeing the safety of its children. When a family is deemed abusive or neglectful toward a child, a system of social safeguards and. services is activated; protective agencies, foster families, courts, mental health and drug treatment centers, parental skill courses, housing authorities, and others enter the picture. Their purpose is twofold: on the one hand, to provide a temporary, alternative living environment for the child; on the other hand, tohelp the family become a viable environment to which the child can eventually be returned.
Inherent contradictions are embedded within this dual goal. The designated “helpers” find it hard to promote parental competence when the parents’ right to lead, to set their own parameters for their children’s behavior, to make autonomous decisions has been suspended for the sake of the child. Also for the sake of the child, the helpers must monitor and evaluate the same clients that they are trying to help. Reciprocally, the involuntary clients find it hard to accept help under these conditions, and often feel compelled to defend themselves, legally and psychologically, from the designated helpers.
In rural and small urban areas, the same worker may be in charge of investigating claims of abuse, taking away custody from the parents, finding a place for the child to live, and then helping the family. This worker wears many hats, perhaps too many. In more populated areas with larger systems of delivery of services, it has become customary for child protective agencies to refer the parents for treatment to another agency, one presumably not contaminated in the eyes of the clients with the investigation and removal procedures. Our experience at the receiving end of these referrals, however, suggests that a large part of the original dilemma is carried over to the new service.
Families referred to our project are a far cry from the autonomous, self-contained, self-referred, middle-class family units that are abundantly described in the family therapy literature. Our families have become a fragment of a larger social network, populated by public agencies that monitor and control their functioning. Family treatment is not initiated by these families as an attempted answer to a self-defined problem, but imposed upon them through a court order, or at least through the“strong suggestion” of the protective agency. To agree with the referral source’s portrayal of them, families must see themselves as incompetent or bad; but if they challenge the portrayal, they risk being labeled as “uncooperative” and as alienating the very authorities who have the power to return or not return their child to them. Besides, they did not choose their therapist; he or she was chosen by others, often by the same people who removed the child to begin with—the people, who antagonize, assess, monitor, control, prosecute, and threaten the integrity of the family.
Most people in this predicament will naturally come to treatment angry, suspicious, and/or frightened. They cannot be expected to own up to problems that others have defined for them. They may not see a problem, or be willing to acknowledge and discuss it, not within a context in which acknowledgement and discussion amounts to an admission of guilt, and certainly not in front of a therapist who was chosen by the “enemy.” They may see therapy as part of the punishment for their socially defined bad behavior. Openness may amount to self-incrimination and increased vulnerability; an honest discussion of domestic violence or drug use does not come easy for a parent who fears it will lead to children being removed from the home, or not returned. It should not come as a surprise then—and certainly it should not be thought of as psychological “resistance”—that these families tend to display an abundance of denials, rationalizations, and minimizations; that they create their own descriptions, where the abuse never happened, or was mitigated by external circumstances; or that they claim to have learned their lesson so that they’ll “never do it again.” All these are normal expressions of the dilemma experienced by the family; seen in context, their responses are not psychopathological.
On the other hand, families caught inthis predicament may reason that it is in their best interest to follow the marching orders from the referring autborities —the judge or protective worker who has a hold on the family’s life and would disapprove of noncompliance with the treatment injunction. Accordingly, many of these families go through the motions of therapy, keeping at least some of their appointments, minimally answering questions, maybe even extolling the virtues of 2 weeks of treatment, but not really engaging in a therapeutic relationship. It is not that these families are “manipulative”; rather, the need to deny and the need to comply converge to set up a “pretend therapy” scenario. In any case, without the client’s openness and willingness to change, the traditional therapeutic contract becomes impossible.
Therapy without Trust
Is it possible to draw up a different kind of contract? Is it possible for a therapist to build a real, not phony, therapeutic alliance with a client, when the therapist was chosen by the client’s “enemy”? Is it possible to treat a problem that the client denies having, or at least would rather not discuss with the enemy’s friend? We think the answer to these questions is “yes,” provided careful attention is paid to one’s position vis-à-vis the family and the other agencies involved.
In the Family Preservation Project, our first job is to differentiate ourselves from the family’s “enemy.” The initial emphasis is on correcting whatever expectations the family may bring that cast us as an extension of the “punitive” referring agencies. For instance, while the family may be accustomed to the inquisitive, controlling, safety-focused approach that protective workers need to apply by virtue of their mandate, we adopt a stance of respectful curiosity. The very fact that the protective worker acts as a watchdog frees us, the therapists, to be more interested in gettingto know the parents as people than in getting to know them as abusive parents.
We further differentiate ourselves from the referring agency by not taking the terms of the referral for granted. For instance, we do not assume that the family is here for needed treatment, and that we are here to identify and •cure areas of pathology. Rather, we convey our understanding that they may not be terribly interested in what we have to offer, or know what they are here for, or even trust us. By adopting the position that commitment to therapy and trust are difficult or even impossible, we keep those potentially frustrating issues out of the way; since our relationship cannot be based on such premises, we do not need to nag about noncompliance or demand more honest disclosures.
At the same time, we do recognize that the clients are compelled to attend sessions and, more generally, that they have temporarily lost some decision power. We may then point out to the family members that they are indeed experiencing a problem, although not necessarily the same one that the referral source has identified. Typically, the first problem to be pointed out is located in the interface between the family and the protective system. It may be something as obvious as the fact that the parents are dealing poorly with agencies that have become important in their lives:they cannot persuade these agencies that they are good parents and should be allowed to raise their own children. Parents may challenge the labels of “abusive” or “neglectful,” but they can hardly question that their public relations skills might be improved.
The discussion of problems in the interface between families and agencies leadsrather naturally to an exploration of areas of family dysfunction. A “public relations” problem, for example, may indicate that the parental couple’s teamwork is lacking. Perhaps they have chosen the wrong spokesperson—perhaps it is the husband, who happens to antagonize people in authority such as protective workers. In one possible scenario, this might sequentially lead to the finding that both husband and wife consider him to be the “smarter” partner; to an exploration of the couple’s complementary rules; to looking into their ways of managing power struggles and expressing hidden resentments; and ultimately to placing the vulnerability of the family to violence and abuse in context. In the case of Cheryl and Bill, the “public relations” theme resulted in a renegotiation of the couple’s rules for dialogue and eventually to Bill’s getting a more stable job, which in turn increased the sense of competence within the parental couple and improved the relationship of the family with the agencies that were monitoring their functioning.
There is a pitfall inherent in this approach. The effort to differentiate from the referring agency may drag the therapist into joining the clients in their denial and unwittingly turning into their ardent champion. There is always a risk that the therapist will get caught in the adversarial rules of the child protection game, passionately advocating for the family against a system that is perceived as misinformed and arbitrarily punitive. Just as family problems can be detoured by selecting one scapegoat, the complexities of the child protection game can be artificially simplified by staging interagency fights, wherein each agency—including one’s own—claims possession of the truth and casts the others in the roles of villain or dunce. The price is usually high: if the therapist takes an unconditional “pro family” position, he or she may end up ignoring or sidestepping real neglect or abuse of a child or, at the very least, provoke a backlash by complementarily raising the level of concern of aprotective agency worker.
Cooperation without Agreement: The Forum
Chances of falling into the “champion” pitfall are greatest when the therapist’s experience is limited to meeting with the family, and excludes contacts with the other agencies. To listen to a family without listening to the rest of the system produces the same selective effect on the therapist’s perception as hearing about a family from one of its individual members:the therapist gets a limited perspective of the total system involved in the problem and of the potential solution. In one of our cases, a protective worker brought to a session close-up photographs of the abused child, taken at the hospital. Both the therapist and the parents, who for the past few sessions had been focusing on the couple relationship, were forcibly jolted to consider the abuse anew.
In our Family Preservation Project, we maintain conversations with the agencies that hold positions of power and responsibility over the child and the families, typically the child protective agency and, if the child has been placed, the foster care agency that supervises the placement. To avoid partial coalitions, we position ourselves as consultants to the various parts of the system. At times we are interviewers, gathering information about the various perspectives and concerns, and clarifying goals; at other times we are interpreters, of the family to the agencies and of the agencies to the family. To the agencies, we explain what is needed from them in order to help the family change; to the family, we explain how it needs to change in order to satisfy the concerns of the agencies.
Finally, there are times when we become conveners. In what we call the “Forum,” we meet with the family and workers from the relevant agencies to discuss goals, progress, and plans. Here we play several roles. We may track the various views of the problems and the potential solutions.We may offer constructive reframing of conflicting views. We may operate as moderators of the dialogue between family and agencies, helping them listen to each other. We may become listeners ourselves, for instance, joining the family in learning more about what the protective agency expects from therapy.
Our forum provides opportunities for collaboration, unity of purpose, and conjoint treatment planning, but also for open enactment of differences and realistic goal setting. It gives participants an opportunity to acknowledge and respect the heterogeneity of their agendas, roles, and concerns, and then to recognize how their often conflicting positions are interconnected. For instance, a father may find out how his proud and angry defense of his family’s integrity is spreading fears of domestic violence throughout the system of helpers; a worker may appreciate that her well-intended insistence that the parents should apply for food stamps has led to a stubborn power struggle. The forum also contributes to mobilize the families’ strengths by changing their experience from reluctant recipients of treatment in an adversarial context to constructive participants in their own treatment plan. Often the forum helps integrate perceptions of strengths and weaknesses that had been fragmented because of the dynamics of the larger system.
Acase in point is that of Maria Cintron. A single parent of five children, Maria related to workers as a child herself. Whenever one of her children appeared to be out of control, she called on one or more of the many agencies with which she was involved (the child protective agency, the children’s schools, a court diversion service, a couple of community preventive programs) and asked for the child to be placed, or talked to, or straightened up in some way. When the agencies respondedand took over control, Maria adopted a dependent/rebellious position as a client (demanding the agencies’ help and at the same time protesting their intrusion), and became increasingly powerless as a mother. So, the more help Maria demanded and was given, the more incompetent she appeared to both the agencies and her children. Addressing this phenomenon in family sessions yielded no change; but when we convened the Forum, a shift in collective perception took place. It became clear, for instance, that Maria presented a more competent side of herself to some of the agencies than she presented to others, that all of the agencies felt frustrated with themselves and each other for their failed attempts at helping the family, and that they all felt at least as helpless as Maria when it came to exercising control over the children. A new collective picture emerged, in which Maria was seen as the person best able to bring about order in the family.
Throughout our interventions, we are particularly careful to avoid passing judgment on whether it is safe to return a child to her or his home. In fact, we are explicit with both the families and the agencies that such a judgment is a function of the child protective agency; it should be neither assumed by us nor delegated to us. We know that the dynamics of the multi- agency system organizes each agency to develop different views of the family; our own vantage point, which encourages a more positive opinion of the family, is also the least amenable to monitoring risk. It is the family then—and not the therapist as advocate—that has to persuade the protective worker that the child will be safe.