Book Review: Helping the Helpers Not to Harm

This book by the Caplans is something of a challenge. Following in the path of other writers, most notably Ivan Illich, the authors set out to catalogue the ways in which health professionals can cause damage to vulnerable individuals. Drawing heavily on their work with child and adolescent welfare services in Israel the authors explore the ways in which those involved with professional services can get caught up in what they term "Kafka's World". In Kafka's world in this context is characterised by 'an atmosphere of absurdity and blocked exits.' Such features are, according to the Caplans, major features of 'institution-sanctioned malfunctioning by damaging caregivers' (p. 117). It may be instructive here to actually mention what Kafka says in regard to psychology:

Psychology is impatience. All human errors are impatience, the premature breaking off of what is methodical, an apparent fencing in of the apparent thing.

(Kafka, 1991, p. 15).

Thus, at the level of the individual practitioner, what the Caplans are talking about is a type of 'premature focus' and 'theme interference' whereby a loss of objectivity occurs. Where suspicion of sexual abuse occurs such theme interference appears to become magnified and subject in some instances to distortions and projections from the unconscious. Another way of putting this is to recognise that what is happening is a closing down of possible explanations in favour of that which most readily fits what is already being looked for. This is obviously a trap to which all therapists can succumb, but what the Caplans are identifying is a more institutional form of closure. Blocked exits exist not simply within the minds of individual practitioners, but within their professional systems as well. Thus, the Caplans are clear that the instances of iatrogenic damage that are of concern to them are not the result of 'honest mistakes', but of 'well disciplined workers acting in accordance with the apparent standards of their agencies and enjoying the support of their superiors' (p.205).

The book is divided into thirteen chapters that cover four elements of iatrogenic behaviour: causation, typical features, difficulties and suggested solutions. Built around a series of case studies, primarily involving child welfare social workers, the book is more descriptive than theoretical. Yet, despite social workers bearing the brunt of the Caplans' critique, there remains a while social workers bear the brunt of the Caplans critique, there remains a theoretical silence as to the motivations of these workers not least because the Caplans were unable to engage with social workers either at the level of individual cases or at a more strategic/theoretical level. Inevitably then this is a one sided book. As the Caplans note 'by the very nature of the subject examined, this book accentuates the negative (p.23). They also note the difficulty of using material without 'readers concluding that we are thereby implying a condemnation of entire professional groups' (p.23). Thus, while the Caplans are clear that they do not really know the motivations behind the protagonists, they do recognise that 'in various iatrogenic damage cases we have studied, fear is a major factor, distorting professional behaviour. It may have irrational roots, but it can also be based on an all too realistic perception of the public's intolerance for mistakes coupled with the tendency of society to find scapegoats wherever tragedy strikes.' (p. 67). The authors go on to note 'This can thereby inhibit even the best trained and balanced caregivers when they face a boundary between the acceptable and the forbidden that has been moved in response to suddenly changing societal concerns.' If opposing voices are silent within this text, the Caplans, to their credit, attempt to examine and answer what they consider to be the most obvious types of critique that can be levelled at their work. Thus, in a chapter entitled 'Our response to some critics' the authors respond to some key questions, including whether they are prejudiced against social workers, whether they are prejudiced because of being excluded for example or are pro-parents or pro-children.

Is this a book that has any relevance to those engaged in existential therapy and those interested in existential ideas? While there is a clear sense that what is occurring is a result of the blinkering of the unconscious, this is also a book about bad faith and the consequences of autonomy when applied to the human condition:

If all responsibility is imposed on you, then you may want to exploit the moment and want to be overwhelmed by the responsibility; yet if you try, you will notice that nothing was imposed upon you, but that you are yourself this responsibility.

(Kafka, 1991, p.41)

In many ways the material highlighted in the book is testament to the power that professionals wield over us and perhaps more crucially how we assist in the creation of such power. The Caplans in a slightly rueful concluding chapter note the ways in which they sponsored the very system that they critique. Thus, this is a book that fits into the political existential tradition of Sartre more than existential therapy per se.

While this theoretical material undoubtedly has a wide remit, there is an undeniable parochial quality to the material. Interestingly, this resulted in a degree of ambivalence on the part of the reviewer, a nod of recognition co-existing with the cognition 'this couldn't happen here'. There are probably a number of reasons for this, but in the main, the cases the Caplans cited seemed too refined, and just a little too conspiratorial to be washing over our own shores. While health and social services departments in Great Britain may have scandals, Israel, judging by this material, has conspiracies. Yet secrecy which is the sine qua non of any decent conspiracy, is actually uncharacteristic of Israeli culture as the Caplans point out. Moreover the Caplans would also point to Britain dispatching 'children from British slums to a "new-life" in the Antipodes,' as an example of why the issue of iatrogenic damage is not confined to geographical places, but rather to specific groups of professionals:

Therefore, when we describe system-supported iatrogenic damage perpetrated by disciplined workers, as opposed to idiosyncratic aberrant behaviour of individual workers, we are sensitized to the possibility of its existence. Such behaviour appears to be less a product of a particular place, as much as a set of customary views and practices that is shared by certain types of people in a variety of professions and countries who, like cultists, cooperate with each other to serve what they identify as a paramount good, and in that service appear to feel that they are entitled to circumvent the inconveniently created checks and balances that were erected precisely to safeguard the public against being damaged

(p. 211)

Kafka's world then is perhaps too mystical an explanation for what is occurring in such situations. Bad faith may have been a more apposite term, for as the Caplans state:

Among the cases we have cited, there is a progression not only in the severity of outcome and the amount of damage generated, but also in the degree of culpability of the damaging caregivers. That progression ranges from those who are doing their job badly because of poor understanding, skill, or objectivity, to those who are being forced into malfunction by unconscious drives, to those who are acting with conscious intent, using their position to distort the principles of humane, professional functioning. The latter category of damaging caregivers is in many ways the most troublesome, since they are often determined and skilled in achieving the goals of their hidden agenda whether because of ideology or because of narcissistic needs. Moreover, we must not assume that such damaging workers are always examples of eccentric individual behaviour. On the contrary they may be following normative standards and guidelines

(p.135).

R.G. Hill

Clinical Psychologist – South London and Maudsley NHS Trust and Senior Lecturer - Middlesex University

References

Kafka, F. (1991). The Blue Octavo Notebooks. Cambridge, MA: Exact Change.