Clarifying an ethical dilemma with CAT in work with children and adolescents

Marie-Anne Bernardy-Arbuz, 2013. Clarifying an ethical dilemma with CAT in work with children and adolescents. Reformulation, Summer, p.28,29,30,31.


Adult patients bring into therapy a suitcase fi lled with different life events relating to members of their family circle, friends and enemies In adult practice, patient and therapist work together, side by side in a ‘one to one’ relationship, relating to ‘others’ in the sessions and making sense of different forms of relationships whereas in therapeutic work with children and adolescents these ‘others’ come into the therapeutic space as persons and sometimes as ‘co-therapists’.

Winnicott said “there is no such thing as a baby” and even in therapy with older children and adolescents we need to consider this statement: Very often, we need to take into account the relationship with the parent and work with it, if we want to help the child. But this can face us with a dilemma when we perceive that the parents’ interests or even the child’s relationship with the parents is in confl ict with the child’s interests in other respects.

Consequently therapeutic work in child and adolescent setting, forces us to engage with complex ethical issues in our work on a daily basis. The fi rst issue is about the sharing or not of information: ‘ Do we tell the parents ? How do we tell them ? What do we tell them ? What if we do not tell them? What information could help the parent to help his child and what information could be ineffective and even harmful for the child? A second major issue is: Are the parents using us? How are they doing this? And how are we, as therapists, going to respond ?

Sometimes the parents’ help will be positive, as they have come to seek help for their child, aware of his/her problem. In general, these parents will be willing to collaborate with the therapist. Other parents push the child to see a therapist, we call them “symptom children”, but it is the parents who really need help. Normally we will be able to talk about this and offer the help where it is most effective and needed. In most situations, parents will help the therapeutic work and the psychological well-being of their child. But in some cases, and this will be the focus of our article, parents act consciously or unconsciously in a way that will make therapy fail. Sometimes these parents suffer from psychiatric illness and are unable to collaborate positively. For others, their psychiatric disorder makes them act in a way that will block the therapeutic work. The toxic relationship between the parent and the child cannot be addressed and we know that as soon as we try to touch it, therapeutic work will fail.

The process of events that brings us to the heart of our ethical dilemma

A child is referred for psychotherapy for example by social services, or by accident and emergency services mostly after an attempt of suicide, or by the judge for children and family affairs or sometimes by the schools.

The parent accompanying the child might have agreed to seek help and show a willingness to collaborate (see diagram). But very quickly, often due to a psychiatric illness, this same parent will fi rst try to interfere with the work we are doing and if they cannot succeed, they will oppose and sabotage what we are trying to do.

We have noticed several signs occurring regularly in these situations and we now describe a situation taken as a composite from many cases:

  • mostly the parent is suffering from a diagnosed psychiatric illness ( psychotic depression, bipolar disorder, schizophrenia,)
  • the child lives with a single parent, often the mother – the relationship with the other parent is non existent or very poor
  • the child can clearly be seen to be suffering in this parent-child relationship and is willing to engage in therapeutic work
  • the parent is willing to let their child engage in this work, but has, right from the beginning, a story of their own, explaining why their child is not well
  • work begins, the child confides in the therapists and transference is established
  • the child starts moving away from the parent and tries to escape from the ‘spider’s web’ that is imprisoning them
  • the parent tries to interfere with the work in different ways: trying to seduce the therapist, trying to play a victim role, then trying to control the therapist and the therapeutic work
  • the therapist resists and continues to work with the child, trying to keep the parent out of the room
  • the child acknowledges his/ her suffering and decides to leave his/her parent, asking the therapist for help
  • the parent realises that they might ‘lose’ their child, as the child starts expressing a wish to move away from his/her parent
  • if the parent does not succeed in controlling the therapist, they may criticise and start sabotaging all the work that is being done
  • the child believes their parent and changes his/ her mind, they no longer not want to leave their parent
  • the child then comes to believe that all the social and psychological services want to harm their parent and that they have to protect them from this harm.

Our ethical dilemma is situated at this point:

We cannot go on helping children in situations like this where they are completely dominated by their parents ; so we consider taking the case to court and asking for help from the family court; (In France, the family court carries out some of the investigative functions which, in Britain, are carried out by Social Services). If we do this, we will loose the patient and therapy will stop. However, if we do not refer to the court, we cannot go on and work as we are caught in the parent’s ‘spider’s web’ and we become accomplices with the parent’s psychological abuse of their child. However, if the judge orders a foster home, the child might find other adults to identify with and form healthier relationships with, but there is no guarantee that this will work out well for the child.

Often at this stage, we are able to confirm a diagnosis we had on our minds for sometime but lacked evidence earlier; either a “folie à deux1”, or a case of “Munchhausen’s syndrome by proxy”.

An example of the ethical issues encountered when working in a CAT informed therapy

The case described below is fictional but stereotypical of my experience of working in these situations. The child was referred for therapy following an incident of self-harm when in a state of great anxiety.

He is an only child, who lives with his mother. His father left the family when he was a baby. His mother has a chronic psychiatric disorder and has been in and out of active treatment including several hospital admissions. She has become, at least partly, dependant on her son as a carer.

As in similar situations, I was very conscious that I needed to preserve the confidentiality of the therapeutic space and consequently tell parents that if they have any questions they want to ask, they would be seen by another member of the team.

The boy had been warned by his mother “not to tell me everything”, as I was according to the mother “working with social services” and they would separate him from her. It therefore took him some time to trust me and allow us to start working on his major difficulties.

Although I had tried to keep the mother out of our therapeutic relationship, she seemed to invite herself into the sessions through her son, a situation typical of a “folie à deux”.

Naming several times, the triangular relationship in which we were engaged, I told him that while I wanted to hear more from himself, I felt that his mother was constantly with us in the room.

This allowed us to shift gradually to his relationship to his mother, the way he suffered in this ambivalent, unstable and insecure relationship. The diagrams helped a lot to clarify his diffi culties and understand the process underneath. The boy dreaded his mother’s quickly shifting states and gradually expressed the wish to join a home for young people or live with a foster family.

Although this mother had seemed willing to work with us at fi rst, it took us a few months to realise that it was impossible for her to separate from her son and that she invented constantly new pretexts in order to prevent the separation.

As the mother seemed to grow more and more opposed to the project of separating from her son, the son started to change his mind, saying he did not want to go away any more, as all the problems he had told us about were no longer existing.

It was only at this moment, that we realised that the mother had been sabotaging all our efforts in a very sly and subtle way. The question was then “do we carry on therapy, knowing that nothing will come out of it as the boy is imprisoned in a what became more and more obvious as being a ‘folie à deux’ or do we take legal action on his behalf?

Did he feel guilty about his disclosures and his mother’s warning “if you tell them too much, they will call the social services” which became true?

It was the invitation by the editors of Reformulation to write on ethics in CAT that made me want to illustrate, with an example, the diffi cult questions raised when working with children and adolescents in therapy. It stands for many situations we encounter in our practice.

The questions are then:

Were we right in our decision to report to the family court our concerns in order to help us “separating this child from his parent” ?

Were we right to interfere, as at his majority he would be entitled to make his own choices ?

We thought that he was feeling very guilty, felt that he was imprisoned in his mother’s delusion, could not choose for himself and was in danger.

As a result, if we did not interfere, we made ourselves a party to the mother’s folly, abandoning the mother-son couple in their “folie à deux”.In Summary

In reference to “Hamlet “ to call or not to call for the court:

Such parents often feel persecuted by health and social services, family and other people in their environment. Their children may be “ the only trustworthy object in their dangerous world”. Such parental children are essential for their parents, as without these children, the fragile parent looses the only object relating them to reality and the only object that prevents them from being attacked by the “outside world and its persecutors”.

These parental children are engaged in a protective mission. They feel a powerful sense of guilt and in their opinion they never do enough and should do more. The result is that they become the guardian of their fragile parents, their nurse and carer and can often end up refusing to go out and socialise with their peers. They make every possible effort to satisfy their needy parents and try to repair the wrongs that has been done to them. This means the parental child has to defend their parents against every possible critic and try to convince everyone that their parents are suffering from the attacks of “mean” people around them. If we were outside the ‘mean, persecutary group’ for some time, we now surely joined it by reporting the family situation to the court.

In calling on the judge we enter into resonance with the parental child and needy parent’s ambivalent position:

Parental children express their difficulties in relation to their needy parent’s illness and situation in life, but they cannot receive help themselves if it would mean leaving their parents. Abandoning such a needy parent means the parental child is faced with unbearable guilt.

If we, as a psychiatric health service accept this situation– and decide not to involve the family court it means that we agree to act as an accomplice. We accept how these parents are behaving towards their children in how they treat them, use them and prevent them from separating from them and developing a healthy personality structure. Therapy becomes useless. We are enchained by these needy parents and imprisoned in their pathology.

But if we as a psychiatric health service decide to report to the court, the therapeutic bond will be split. The parental child’s trust is lost and it will confirm their belief that their parents were right to warn them to be careful about what they tell us. We will then be unable to help them in the future and they might live forever in this “folie à deux”, unable to separate.

But on the other hand, we also have to consider the prospect that being separated from the demands of managing such a needy parent , means that they may be able to cope and develop a more stable personality structure themselves, with the help of professionals..

In Conclusions

To the question “What right did we have to interfere?”

I would answer firstly that I acted according to my personal ethical convictions and according to the deontological and ethical codes of my profession as a clinical psychologist and psychotherapist.

Secondly, as a team, we spend a lot of time discussing these cases and we often end up sharing the same convictions and do report our concerns to the family court.

Nevertheless these questions open up another field of questions, which are:

What are the limits of psychotherapy?

Psychotherapy for whom?

Could we “know” in advance how things can turn out in these situations?

Do we need to rethink how we collaborate with social and legal services? There has been, on several occasions, many different professionals intervening and a difficulty to coordinate, speak the same language and act in the same direction.

CAT informed work with patients in such complicated situations helps the therapist to map the reciprocal roles gradually and understand how he/she is drawn into the parent’s trap and unable to touch the parent- child/adolescent relationship without referring to the judge.

Analysing the situation with the reciprocal roles puts the ethical problem in a clearer context, showing that we needed to try and break up this type of ‘folie à deux’ , especially when the therapy is completely blocked.

But we will only know in months or years whether our decisions in these cases help our young patients and whether we were respecting a major ethical and deontological principle “do no harm”.

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Full Reference

Marie-Anne Bernardy-Arbuz, 2013. Clarifying an ethical dilemma with CAT in work with children and adolescents. Reformulation, Summer, p.28,29,30,31.

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