Helping the Helpers Not to Harm

Gerald Caplan, Ruth B. Caplan

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134944934
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The authors of this controversial volume have collected case studies and observational accounts of caregivers for over 15 years. Iatrogenic harm is a serious and widespread problem that many have been reluctant to speak out about for fear of being blacklisted by their colleagues. In writing this book the authors hope to establish guidelines that will help caregivers to recognize and deal with potentially harmful behavior thereby improving the standards of care for all patients.

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CHAPTER

Introduction

Iatrogenic harm is a term that originated in medical practice to denote the damage induced in a patient as a by-product of a therapeutic intervention, such as undesirable side effects of medication or secondary infections caused by invasive procedures. We are extending the word here to refer to the harm that is caused to a patient or client by any caregiver, whether physician, teacher, psychiatrist, school guidance counselor, social worker, or judge, in the course of a professional intervention such as that which has the declared intention of curing or preventing psychosocial disorders.

In reviewing cases that have been referred to our clinic in Jerusalem after passing through local religious and secular courts, the adoption service, the welfare-child protection office, and other agencies, we have been struck by the irony that community services ostensibly dedicated to preventing psychiatric and social disorders are prone to generating them. Such damage to individuals and families can be so severe as to dwarf the client’s original problem, and may lead to more psychological suffering and social maladjustment than could have been expected to emerge from the predicament that first brought the client to the notice of caregivers.

Colleagues in a number of countries have privately agreed that harm caused by the caregiving system is a serious and widespread problem, but one on which they have been reluctant to speak out for fear of spoiling relations with fellow professionals and of being blacklisted by key agencies. As the head of a British social agency told us, “After I raised questions about the harmful handling of a case by another agency, I was treated as a pariah.” Efforts to combat these abuses have been hindered by an absence of criteria for delineating the problem and for identifying patterns of factors involved that would allow us to devise programs to prevent and counteract the suffering of vulnerable individuals.

We had never planned to study iatrogenic damage, nor were we particularly aware that the phenomenon existed on any scale that made it noteworthy. The subject obtruded itself gradually on our attention during 15 years of efforts to organize a community service in Jerusalem to reduce the incidence of mental disorders in the population of children of divorcing parents. In this primary prevention mission, we were basing ourselves on a conceptual framework that we have developed over the last 50 years, and that we have explicated in a series of publications.¹

Our interest in children of divorce led us to study a variety of harmful patterns of professional interventions in their lives by community caregivers in various fields. Gradually, the phenomenon of iatrogenic damage emerged as a subject of research in its own right whose noxious effects on mental and social well-being, we found, were not confined to children of divorcing parents. These effects could be seen to pose a potential hazard in any situation where professionals and lay people of good will intervene, often with the best of intentions, in the lives of others, ostensibly in order to help them. Therefore, while this introductory chapter will focus on the conceptual and historical background of our interest in professional malfunctioning which was rooted in our efforts to study and establish a primary preventive community psychiatric program for the children of divorcing parents, this book as a whole will not dwell exclusively on the effects of damaging behavior on this particular subpopulation. Instead, it will also draw on the experience of individuals from other high-risk categories whose weaknesses and needs rendered them vulnerable to mismanagement by caregivers.

Before we discuss the issues associated with iatrogenic damage, it may be useful to briefly describe the theoretical framework on which our work is based, which also colors our assumptions, analyses, and definitions of professional malfunctioning, and to describe the setting in Jerusalem in which we have been working.

Primary Prevention

At the core of our activities lies the concept of primary prevention, a concept borrowed from public health (G. Caplan, 1964a). This refers to organizing programs for reducing the incidence—or the rate of new cases—of a disorder in a particular population. In our community mental health work, this means attempting to reduce the incidence of psychosocial disorders that we have reason to believe occur in identifiable subpopulations in reaction to particular stress or misfortunes. We base ourselves on studies that we and colleagues have conducted which have identified certain circumstances of loss, actual or threatened, or sudden life changes, as precipitating a rate of psychosocial disorder in an exposed group that is higher than the rate of mental breakdown found in a similar population that has not been exposed to such stressors. Put most simply, the focus of our work involves identifying particular subpopulations that are vulnerable because they have experienced certain potentially damaging events, and then working out ways to help and support those people so that they do not develop pathology.

This goal, beneficent in theory, involves inherent dangers in practice. In the course of our work, we have been forced to confront the unwelcome fact that when one moves from traditional therapeutic intervention in situations of present illness to intervening in the lives of people who are currently healthy with the purpose of preventing future pathology, we confront ethical and procedural problems for whose ramifications we may not be sufficiently prepared. Proactive intervention is a basic feature of programs of primary prevention, whether in public health campaigns of mass inoculation or of adding antibacterial substances to the public water supply, for example, or engaging in the community mental health equivalents. We thereby intervene, often uninvited, in the lives of healthy people because, based on the evidence at hand, we have decided that they have been exposed to circumstances that pose a statistical risk of their incurring future disorder. Usually, however, the individuals concerned are not aware of this danger. They may feel, in fact, that they are coping adequately in their own way and time, and they may object to our reaching out to change their lives by trespassing on their privacy and autonomy and by intervening in their relationships. Here we see one possible factor among many that may predispose to iatrogenic damage and which, in consequence, should make us very cautious about how and under what circumstances we move from a preventive program that is oriented towards an entire at-risk population, to a qualitatively different type of intervention in the lives of particular individuals.

A primary preventive program for a population involves an educational approach—the dissemination of information whose contents are based on research findings about the expected hazard, and on possible ways of avoiding or lessening the intensity of ensuing stressors. It may also involve attempts to change public policy so that those institutions that may be mobilized to act in circumstances associated with the particular hazard do so in ways that reduce, rather than exacerbate harmful forces. Preventive style intervention in the lives of named individuals, however, should be confined to those people who manifest symptoms of strain that show that they are having difficulties in coping. Those who are free of symptoms of strain, on the other hand, should not suffer direct professional intrusion in their lives just because they belong to an identifiable population known to be at statistical risk. We will return to this subject in later chapters in relation to concrete examples, since the confusion of some caregivers about when and how to move from primary preventive intervention in a population to an individual case orientation can cause iatrogenic damage.

Let us continue, then, with the theoretical models on which we have based our Jerusalem program for the children of divorce.

Psychosocial Support

People in communities are rarely exposed to adverse circumstances entirely on their own. They are usually helped in times of stress by interaction with other individuals and groups, as well as by the values and problem-solving traditions of their culture. We refer to these forces as psychosocial support systems. They act as a buffer between the individual and the full impact of the short-term crisis situations.

Empirical researches have consistently found that individuals exposed to high levels of stress who, at the same time, receive adequate psychosocial support are usually able to master the stressful situation without any reduction in their level of mental health. Similar individuals exposed to similar levels of that stress, but without psychosocial support, subsequently have about two or three times the rate of mental disorder of the general population (Brown, Bhrolchain, & Harris, 1975; G. Caplan, 1981a, 1989; Cobb, 1976; DeAraujo et al., 1973; Kalter, 1977; Kalter & Rembar, 1981; McDermott, 1970; Nichols, Cassel, & Kaplan, 1972; Rutter, 1985; Wadsworth, 1979; Wadsworth & Maclean, 1987; Wadsworth, Peckham, & Taylor, 1985; Wadsworth et al., 1990; Wallerstein & Kelly, 1980; Weiss, 1975). These support systems that have been found to lower the risk to mental health are characterized by providing a solicitous group that helps stressed individuals to lower their emotional upset marked by anger, anxiety, depression, shame, and the like. Supporters instill hope, and they help sufferers deal with the cognitive burdens of the stressful situation by guiding them to collect essential information so as to overcome possible confusion and to work out effective ways of solving the problems raised by the adversity. They also help with the concrete tasks involved in coping with the predicament, and they may provide extra material and financial resources and services, so that an organized life can continue despite the upsetting and preoccupying circumstances of the stress (Antonovsky, 1974; G. Caplan, 1989; Cassel, 1974; Garmezy et al., 1978; Halpern, 1978; Tayal, 1972; Wallerstein & Kelly, 1980).

Most studies have found that raised levels of anxiety and other negative emotions are associated with a lowered capacity for effective problem solving. The essential core of the kind of support that protects against mental disorder is help in making up for this cognitive deterioration. That help may be supplied by providing guidance and by sharing the tasks of overcoming the difficulties involved in the situation, or else by encouraging the individual to resign himself or herself to the realities of nonfulfillment of previously satisfied needs and of finding alternative sources of satisfaction (Beck, 1970; Blaufarb & Levine, 1972; G. Caplan, 1982, 1989; Crawshaw, 1963; Hansell, 1976; Hiroto, 1974; Janis, 1951; Seligman, 1975, 1976; Shader & Shwartz, 1966; Tayal, 1972; Tyhurst, 1951, 1957). The harmful effect of short or long-term exposure to stressful circumstances results from the negative pressures of the adversity interacting with the individual’s existing capacity to cope with difficult circumstances. These, in turn, are linked with his or her inborn personality characteristics and with what that individual has learned from previous experience. The main factor in determining whether the nature of the outcome will be healthy or pathological will be the type and level of the buffering offered by the psychosocial support system operating at that time.

These ideas have led to the development of our conceptual model of primary preventive psychiatry: To monitor the reactions of a population exposed to types of adversity that have been shown to be pathogenic; and to ensure that people are receiving effective psychosocial support that is helping to reduce the level of their negative emotional tension, that offers guidance about the hazardous situation and how to master it, that provides helpers who intervene personally to deal with the current difficulties, and that also assists by providing money and concrete goods and services to foster a positive outcome.

A number of studies of “vulnerable but invincible high-risk children”—highly resilient children who spontaneously master high levels of stress—show that these youngsters elicit from helpful adults nurturing attention that replaces the psychosocial and socioeconomic supplies of which they are deprived by the absence or malfunctioning of their parents (Werner, 1989, 1997). These temperamentally gifted young people actively reach out and make the contacts which allow them to create the supportive environment that enables them to overcome their adversity no matter how pathogenic this may be for most children. We may copy the way these resilient children operate in order to achieve similar results for ordinary children involved in such stressful situations. In other words, our primary preventive psychiatry mission calls on us to study the psychosocial and the socioeconomic hazards involved in a stressful life situation that empirical research has shown to be associated with high rates of mental disorder in a particular population. Then it calls for us to introduce measures that increase the likelihood that more children will be enabled to overcome these difficulties in ways similar to those used by the invincible children.

From both stress researches and the studies of vulnerable but invincible high risk children, we have learned that we need to guide community leaders, strategically positioned care givers, parents, and other family members to reduce the impact of the stressors, and to provide emotional support and cognitive guidance to the children and to their parents or guardians. Such support and guidance will enable them to evade or overcome the burdens, or to find ways of putting up with the pain and discomfort of the irreducible elements of the adversity and to focus on more rewarding aspects of their life.

Crisis Theory

While we believe that most mental disorders occur as a result of the operation of factors of adversity over a prolonged period, the course of pathological development is not smooth but occurs in a series of steps, each of which is preceded by a short period of upset to which we have given the term crisis. These are temporary periods of cognitive and emotional upset precipitated by sudden changes in life circumstances when threats or challenges to essential psychological supplies confront the individual with novel problems that he or she is not able to solve quickly (G. Caplan, 1963, 1970; Hansell, 1976; Lindemann, 1944; Parkes, 1970; Rutter, 1985). It appears that these crisis periods are way stations when the trajectory of the mental health of individuals may change and lead them in the direction of improved mental health or of mental disorder.

We have studied the short-term developments that characterize such crisis periods, which are not only periods of change, but also turn out to be periods when individuals, because of their temporary dis-equilibria, become more open to being swayed by outside influence and more amenable to being modified by it than they are during a stable state. During the crisis, individuals may change their level of mental health significantly. They may be influenced by those around them to try novel ways of managing which then become incorporated into their ongoing coping repertoire, or they may use ineffective ways of problem solving, or may evade the presenting problems, thereby failing to deal adequately with the current crisis. They may also integrate these weakening tactics into their ongoing pattern of coping.

From this, it follows that the intervention by support and guidance that is at the core of primary prevention must be organized to operate during the period of crisis which will occur as the hazardous factors impinge on the members of the population at risk. We have found that, by harnessing such crises, we can achieve profound psychological changes that would have required...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• Foreword
• Acknowledgments—For Our Critics
• 1 Introduction
• 2 An Overview of Some Causative Factors
• 3 Some Typical Features of latrogenically Damaging Behavior
• 4 Professionals’ Stereotypes, Premature Closure, and a Preplanned Outcome
• 5 Adoption, Secrecy, and the Hidden Agenda
• 6 A Loss of Professional Objectivity
• 7 Kafka’s World
• 8 The Difficulties of Preventing Iatrogenic Damage
• 9 Some Suggested Solutions
• 10 Adapting Techniques of Mental Health Consultation to Influence Unwelcoming Agencies
• 11 Involvement of Judges
• 12 Our Response to Some Critics
• 13 Helping the Victims of Iatrogenic Damage
• Bibliography
• Index