Stuck cases: understanding the experience of children, families and clinicians in a child and adolescent mental health setting when the helping relationship becomes stuck.

Abstract

Stuck cases in multi-disciplinary Child and Adolescent Mental Health Services occur when families attend for help but something in the helping process becomes a problem in itself, to the detriment of the child and the distress of parents and professionals alike. This research reviews the psychoanalytic literature in relation to stuckness and impasse and then samples the systemic literature, drawing comparison between them both. The literature review reveals that the study of stuckness has lead to theoretical and technical developments in both fields. The thesis goes into detail to consider the appropriate methodology for studying stuck cases in a way that is robust and allows for the interviewer to use their psychoanalytic training in a reflexive way as a strength in the process and details the reasons for choosing constructivist grounded theory. The research itself is based on twelve intensive interviews with CAMHS staff from a range of disciplines in the Greater Glasgow and Clyde area. The research aimed to interview families too and there is a detailed discussion of ethical reasons which meant this was not viable in this study. The interviews with clinicians highlighted the close links between stuck cases and trauma, addiction, parental mental health problems, and psychological maltreatment of the child. The analysis of the interviews demonstrated that in every case there was a great deal of unconscious or unprocessed communication from the family that impacted on the progress of the treatment. Further study of the nature of the cases allowed for warning signs to be identified that can be used to alert clinicians that they should proceed cautiously. The warning signs are Taboo Subjects, Life and Death Anxieties, Blinding Trauma, Career Shaking Experiences, Compelled Care, The Insult, and a Crisis of Confidence in relation to child protection. Following on from the warning signs the research suggests that stuck situations can be conceptualized as a series of traps which follow a particular pattern. Some of these traps are possible because the clinicians want to maintain a view of themselves as helpful and benevolent, making experiences where they are dismissed or seen as malevolent particularly difficult to reflect upon. The benevolence traps are Hero to Zero, Zero, and Pandora’ box where the clinician’s curiosity and linking the child’s problems to other family factors is seen as catastrophic. Other traps are described as professional traps as they involve services, teams or belief systems and these include Evidence Based Traps, Logic Traps, Professional Isolation, and the Parent Trap. The final trap is described as a Loyalty Trap and explores the anxious nature of the relationships in the families of stuck cases and how the child may be put in a cruel position of having to choose between the clinician’s view of the problem and the family’s view of the problem. Although the family view may be causing and prolonging the distress of the child, it is argued that the child will invariably choose the family view. This is conceptualized as Loyalty to the Toxic Breast. The research ends by recommending developments in CAMHS and across agencies in relation to training, support, team work, supervision, consultation and the management of psychological maltreatment of children in stuck cases.