Warning Signs and Traps: Stuck Cases, Emotional Abuse and Intergenerational Trauma In Child and Adolescent Mental Health Services

BASPCAN CONGRESS 2015

Dr Andrew Dawson

Consultant Child and Adolescent Psychotherapist

Specialist Children’s Services NHS GGC

What is a stuck case?

• Clinical Background to Research

• Midegely and Kam (2006) examined reasons for referrals to psychotherapy

• Professional Symptoms, Britton (1982)

• Systemic Review

• Psychoanalytic Review

• Interview stem

Method

• 12 Intensive Interviews with experienced CAMHS practitioners

• Social Constructivist Grounded Theory• Additional analysis using Glaser’s

(2002) structured approach to the identification of emotional abuse

• Reflexive sensitivity to psychoanalytic and systemic ways of thinking

Results

• Strong connection indicated between stuck cases, emotional abuse and intergenerational trauma.

• Clear evidence of professional symptoms in clinicians

• Warning signs were evident• Cases subject to professional traps that

prevented successful treatment

CHART 1: REPORTS OF PARENTAL ADDICTION

3

0

9

Parental AddictionKnown

Parental AddictionSuspected

No Report of ParentalAddiction

CHART 2: REPORTS OF PARENTAL MENTAL HEALTH PROBLEMS

8

3

1

Known Mental HealthProblems

Suspected Mental HealthProblems

No Report of ParentalMental Health Problems

CHART 3: REPORTS OF TRAUMA IN FAMILIES

9

1

2

TRAUMAREPORTED

TRAUMASUSPECTED

NO REPORT OFTRAUMA

CHART 4: Life and Death Anxieties Present?

7

5

YES

NO

Chart 5: Harmful Parent Child Interaction

10

2

YES

NO

CHART 6: REPORTS OF CHILD PROTECTION CONCERNS

3

3

6

No Action Taken

Action Considered butnot taken

Social Work involved orReferral to Reportermade

Warning Signs

• Taboo

• Life or Death Anxieties

• Blinding Trauma

• Career Shaking Experiences

• Compelled Care

• The Insult

• Crisis of Confidence

Traps

• Benevolence Trap

• Professional Traps

• Loyalty Trap

Potential for Harm

• Vulnerable parents and children• Harmful parent child interactions clearly

observable in some cases• Not addressing the unconscious emotional

relationship leads to harmful family-service relationships

• Use of structured assessment such as FRAMEA is indicated to protect children, clinicians and families

• Need to include psychoanalytic and systemic ways of thinking to support staff

Suggestions

• Anticipate possibility of becoming stuck• Recognise professional symptoms and

use psychoanalytic and systemic interventions to bring about some manoeuvrability in the cases

• Staff training in FRAMEA approach• Support staff with appropriate

supervision and use of FRAMEA

References

Britton, R. (1981) ‘Re-enactment as an unwitting professional response to family dynamics.’ in Box, S. et al (eds) Psychotherapy with families. An analytic approach. London: Routledge & Kegan Paul.

Charmaz, K. (2006) Constructing grounded theory: A practical guide through qualitative analysis. London and California: SAGE.

Glaser, D. (2002) ‘Emotional abuse and neglect (psychological maltreatment): a conceptual framework’. Child Abuse and Neglect, 26:697-714.

Glaser, D. How to deal with emotional abuse and neglect—Further development of aconceptual framework (FRAMEA). Child Abuse & Neglect (2011, in press) doi:10.1016/j.chiabu.2011.08.002

Hindle, D and Boulton, S. (2000) Emotional Abuse: The Work of a Multidisciplinary Consultation Group in a Child Psychiatric Service. Clin Child Psychol Psychiatry July 2000 5: 439-452, doi:10.1177/1359104500005003012

Kam, S. and Midgely, N. (2006) ‘Exploring ‘clinical judgement’: How do child and adolescent mental health professionals decide whether a young person needs individual psychotherapy?’ Clinical Child Psychology and Psychiatry, 11(1):27–44.

Lofland, J. and Lofland. L.H. (1995) Analyzing social settings (3rd ed.). Bekmont, CA: Wadsoworth.

Treacher, A. and Carpenter, J. (1982) ‘“Oh no! Not the Smiths again!” An exploration of how to identify and overcome ‘stuckness’ in family therapy. Part I: ‘Stuckness’ involving the contextual and technical aspects of family therapy’. Journal of family Therapy, 4:285-305.

Van Lawick, J. and Bom, H. (2008) ‘Building bridges: home visits to multi-stressed families where professional help reached a deadlock’. Journal of Family Therapy, 30:504-516.