When the obvious solution may not be as simple as it seems

Harriet Winstanley, 2013. When the obvious solution may not be as simple as it seems. Reformulation, Summer, p.15,16,17.

Ethical dilemmas are common and can be extremely diffi cult to negotiate within psychotherapeutic interventions. Given the importance of the therapeutic relationship in cognitive analytic therapy (CAT) and the use of the client-therapist relationship as a vehicle to explore the client’s internal and external world (Ryle & Kerr 2002), ethical dilemmas can be paralysing and debilitating for both parties during the therapeutic process. This is a refl ective account exploring an ethical dilemma from my own experience and how this may have impacted on the therapeutic process and my ability to deliver an intervention using CAT.

Reflections on a Case Vignette

The case involved a middle-aged gentleman named Andy who had been living in 24-hour supported accommodation for a number of years due to physical health problems. Andy was referred to me as he was experiencing episodes of anger, which were having an impact on his relationships with others. During my fi rst meeting with the staff team who supported Andy I was informed of a number of issues, one of which I found particularly concerning. Andy was seemingly unaware that his father had passed away when he was younger; instead Andy had been informed that his father had moved abroad, leaving his mother to bring him up as a single parent. In my experience this type of ethical dilemma is not uncommon when working with vulnerable adults. However, in Andy’s case I became interested in the reasoning behind the decision to withhold this information. Furthermore, I became increasingly concerned by the situation as Andy continually discussed his father and the abandonment and distress he still felt in relation to his father walking out on the family.

On the surface there seemed an obvious solution, to tell Andy the truth about his father’s death. However, when I probed the staff about this they explained that Andy and his mother had an extremely strong relationship and she was the only family fi gure left in his life. The staff were extremely concerned that Andy would not be able to forgive his mother if he found out the extent of her falsifi cation and their relational bond would consequently be broken. I wondered at the time if the staff team were worried that their bond with Andy might also be affected if he were to be told the truth. I noticed that they seemed particularly protective towards Andy and I certainly experienced similar feelings towards him as our relationship grew through therapy.

As I thought about the dilemma more I was struck by some of the intricate details that would need to be taken into account before the truth was revealed to Andy, including the possible consequences to his relationships with those who had kept this secret for so many years. I began to wonder whether the obvious solution was in fact the correct solution or whether there might be distressing implications and consequences. I questioned whether there was a better solution to my concerns. However, I also had concerns that the situation could be conceived as a Human Rights issue. Did Andy not have the right to know that his father had died and had therefore not abandoned him when he was younger?

At a follow-up meeting, which I arranged to explore the situation further, the staff conveyed a picture of Andy’s mother that was characterised by control and power. They provided me with a further example of how she had blocked contact from a sibling of Andy’s (a child of Andy’s father from another marriage) without him realising. At the time this angered me and I recall feeling compelled to fi ght on Andy’s behalf for the truth to be heard. Andy’s support network was limited to his mother and some members of staff but he could potentially be missing out on developing a positive relationship with a sibling, who would also provide him with a connection to his father.

I began to see that the staff team too were under the control of Andy’s mother and I became aware of the powerful nature of the controlled- controlling reciprocal role being played out between Andy’s mother and the staff; a reciprocal role which had infl uenced the staff’s decision to collude with a lie that Andy’s mother had been telling for so many years. It made me incredibly sad to think that everyone in Andy’s support system knew this piece of information and yet no-one was prepared to share this with him. I think that the overwhelming sense of helplessness that I felt also transferred into our therapeutic work together. There were times during our therapy sessions when Andy brought up the abandonment of his father and how this had impacted on him. I then felt even more helpless, silenced and even trapped, feeling unable to support Andy in a meaningful way. I recognised that the abandoning- abandoned reciprocal role was commonly being repeated in his everyday interactions with others, so the impact of the lie was continuing to have a detrimental impact on Andy’s current functioning. I wondered whether this was a chronically endured position for Andy, which may have infl uenced the vicious circle or trap he appeared to be caught in, a trap that continues to negatively affect his relationship with others.

During our therapeutic work together I made an active decision to avoid making contact with Andy’s mother as I was aware of how controlling she might try to be and I had concerns about this entering our sessions subconsciously. I felt strongly that Andy deserved some space where he could talk openly and confi dentially without any infl uence or interference from his mother. Perhaps this desire was naïve of me as, on refl ection, I suppose that Andy’s mother’s control had already been imposed on me indirectly via the staff team and the restrictions I felt during our session were exerted via this controlling – controlled reciprocal role. This dichotomy was interesting as on the one hand I was in control of the therapeutic content and could have disclosed this information during our sessions. On the other hand, I was being controlled via the staff team and indirectly through Andy’s mother, thus showing the power of the reciprocal roles and the duality of their nature. This procedure repeatedly occurred as the staff were silencing me, just as they were being silenced by Andy’s mother, and it felt as though I were caught in a dilemma whereby all of my options would result in some form of distress on Andy’s behalf. I also felt a great deal of empathy towards Andy as reciprocal roles are thought to refl ect a stable relational pattern that most likely develops in the context of how our primary caregiver relates to us. It made me wonder how this controlling – controlled reciprocal role had played out during Andy’s upbringing, in the absence of any family members except his mother.

During our therapeutic journey I felt stifl ed by the piece of information that had been disclosed to me. I repeatedly wanted to say something and I sometimes fantasised about what might happen if I were to tell Andy during one of our sessions. I had dreams, or rather nightmares, about disclosing the truth by mistake during a therapy session. I recall a time where I had managed to convince myself that I would blurt the truth out if there were a silence during our session; the dilemma certainly played on my mind and I remember feeling on edge throughout our appointment. I became increasingly distressed because, without realising it, I had slipped into the same role as that of the staff team and Andy’s mother; namely I was colluding with a lie. It made me feel terrible.

I wonder if I had such an extreme response due to my passion for the fi eld of Clinical Psychology. People often follow a career into psychology as they want to play a part in helping to support people and alleviate their distress. Indeed the metaphor of the hero-innovator being eaten by the dragon for breakfast springs to mind (Georgiades & Phillimore, 1975). I felt that I had been limited by the knowledge that was provided about Andy’s father and in this way the staff team had set me up for failure, perhaps without realising it. They expected me to be able to ‘fi x’ Andy’s diffi culties using some magical powers which I had accrued from my training so far, even though Andy regularly described the abandonment and anger he felt in relation to his father, implying that there were unresolved issues that were impacting on his current presentation. I certainly did not feel like a hero or rescuer when I had to inform the staff team that my concerns had been such that I felt it appropriate to follow the Trust policy and escalate the situation further in order to explore whether other professionals felt that Andy should be told the truth. Indeed my concerns resulted in the decision to anonymously present Andy’s case to an ethics committee who felt that the situation was an example of emotional abuse. So, I subsequently found myself having to hold the staff disappointment in two separate forms. Firstly, their disappointment with me, ‘the whistle-blower’ who was ‘intentionally’ trying to break a bond between mother and son. Secondly, I felt their disappointment in relation to the limited progress which Andy had made during our therapeutic journey. I found both of these situations very un-containing, perhaps due to the incongruence between the distress that my decision could potentially cause, which was at odds with the reason I pursued a career in this profession; namely to support people and alleviate psychological distress.

In fact I delayed telling the staff my concerns at an earlier stage in the therapeutic contract and initially I thought that this was rather cowardly of me. However, I realised that I was actually concerned that the staff might then be uncooperative. I was reliant on staff bringing Andy to his therapeutic sessions and as such felt at their mercy; another pressure that most likely contributed to the stifl ed feelings I encountered during my time spent working with him. They certainly held a substantial amount of power in relation to Andy’s attendance at therapy. Is it really fair that I should have had to contend with such feelings and at times self-loathing due to concerns about the negative impact my actions could have on Andy? I think that this further highlights the complexity of the ethical case surrounding Andy and exposes another ethical dimension. When I see clients who live independently, they often bring themselves to therapy and as such can make their own decision on whether to attend. In the case of Andy and other clients who live in supported accommodation, I wonder if this choice is unavailable, perhaps due to pressure from staff to attend.

Despite the sometimes strained relationship between myself and the staff team I did feel sympathetic towards them. This was in the context of the power and control that Andy’s mother had over them. Although they had presumably been provided the information about Andy’s father under a cloak of confi dentiality, they seemed extremely keen to share the information with me, even after I expressed my concerns. I wondered whether the concept of projective identifi cation, which Ryle (1994) described as a way of understanding reciprocal role procedures, would help here. William Stiles (1997) suggests that projective identifi cation is a “means of expression for otherwise suppressed voices” (pp. 174). He goes on to talk about the position of both parties in a dialogue evolving into an extension of the other. Thus expressions, intentions, feelings and physical acts conveyed by one person could in fact be an extension of the other member of the dialogue, even though it is a subconscious act. Perhaps this explains the level of distress and self-loathing I experienced during my time working with Andy. These intense feelings could have been a consequence of the staff feelings of disgust in addition to my own, hence why they continued to divulge confi dential information to me even when I informed them of my plans to escalate the situation. Indeed the reciprocal role of suppressing – suppressed seems appropriate in this scenario too and perhaps subconsciously the staff disclosed this confi dential information as they felt unable to break the confi dential pact between themselves and Andy’s mother. My position as an outsider could have been interpreted as a way around this confi dentiality issue so they could therefore use me as the messenger in order to get their voice heard; I was acting as the voice that they could not be.

But where is Andy’s voice in all of this? Whilst his mother should, and certainly does, have a say in the care provided to him, it feels as though Andy’s voice in all this rigmarole is too quiet. This brings me back to the primary objective of writing this article. What can you do in a situation like this where one outcome is potentially just as devastating as another? Yes, Andy has a right to know that his father has died and somewhere out there he has a sibling who may want to develop a relationship with him. On the other hand, the expression of this information could fatally damage Andy’s relationship with everyone in his support system, not excluding me, who have until this point been a part of the collusion. This seems to be the biggest dilemma of all. I have thought long and hard about what a positive outcome might look like. I suppose that the only way to tackle this situation is to weigh up what would be the least damaging solution for Andy. Perhaps this might entail educating his mother as to the negative implications that her lie will continue to have on Andy’s relationships with others. Only this way might she see the error of her ways and be able to work collaboratively with staff to provide Andy with the information about his father, which he has a right to know, in as containing and gentle a way as possible.

Full Reference

Harriet Winstanley, 2013. When the obvious solution may not be as simple as it seems. Reformulation, Summer, p.15,16,17.

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