"Whomsoever I've cured I've sickened now, and whomsoever I've cradled, I've put you down.  I'm a search light soul they say, but I can't see it in the night.  I'm only faking when I get it right." ~ Soundgarden, Fell on Black Days
"We are kings and pawns, emperors and fools." ~ The Count of Monte Cristo

For a brief period in my career I worked as a school-based therapist.  Meaning, I was employed by a community mental health agency and contractually housed (had an office) in a school in one of the areas of service.  Through a substantial state grant and collaborative efforts from both the school system and the agency, I had worked with both school and clinical systems to build an elaborate play therapy room conjoined to my office.  Effectively, this was a full-sized classroom that had been partitioned into an office / waiting area and then a space for play therapy.

Franz was enrolled in the second grade when I met him.  His mother met me after school one day to request an assessment consultation after being referred to me by Franz's teacher.  During the assessment Franz's mother describes autism-like symptoms in conjunction with increased anxiety.  

I proceeded, as was common, to conduct a trauma assessment (THQ) as Franz's anxiety and catatonia were quite notable and an anomaly considering the reported health and appropriate family dynamics between Franz and his mother / father as well as between the mother and father themselves.  There had been no reported incidents of neglect or abuse.  Spankings were extremely rare in the household.

For our first session, I went to Franz's classroom to bring him back to my office.  It was early in the morning and other students were still getting settled in the classroom.  Franz stiffened and became frozen in his chair.  After extensive persuasive efforts from the teacher and her aide (while I waited at the doorway), they left Franz to me and went about tending to the rest of the class.

Franz began to cry softly while still rigidly stuck to his chair.  I don't recall if I was actually able to persuade him back to my office for that first session or not.  Later, I collaborated with the teacher and we devised a plan.  Since my office was near the cafeteria, while returning the class from lunch, the teacher could walk the students past my office so that I could "intercept" Franz -- or at least have the opportunity for a more smooth transition.

All went according to plan until the planning came to an end.  Once inside my office, Franz stood silently frozen in terror.  My common response to this, especially given the facility and resources I had available, was to present a few varied play materials in front of the child (for example:  crayons and paper, a beanbag chair, or action figures) and proceed to "mill around" or appear to be disinterested in the child while working at my desk or writing on the whiteboard; allowing the child to proceed at their own pace without the pressure of my direct observation.

To my frustration this was to no avail.  Several sessions passed in this manner.  However, I had managed to "steer" Franz a little further into the room and he eventually sat down on the bare floor -- though certainly in any way but relaxed.  I decided to hedge my bets.  I left an assortment of supplies in front of Franz and left the room.  As with many classrooms, there was a narrow window in the door which allowed me to peer in intermittently to make sure there weren't any safety concerns.  Incidentally, Franz's teacher happened to walk by at that moment and remarked that I "had the patience of Job."

I saw that Franz was writing on the paper I provided and after he had finished I re-entered the room.  It was my intention to end the session there, but my curiosity got the better of me and I probed about Franz's drawing.  Of course, the barrage of questions was overstimulating and my own frustration grew and my clinical tact was traded for stubbornness.

I wanted to "get to the bottom of this" and "figure out the reason" for Franz's behavior.  I began reviewing the questions from the trauma assessment, inquiring whether anyone had hurt Franz on purpose or if anyone had touched his private parts when he didn't want them to.  Through a series of questions it was disclosed that a school teacher had touched Franz's crotch.  I thanked Franz for working hard on his drawing and walked him back to his classroom.

Franz is only the beginning of this story.  As we'll soon be reminded, every day in the practice of psychotherapy is rife with layer upon layer of ethical dilemmas.  Given the nature of the reported incident I immediately sought consultation with the school counselor, social worker, and principal.  The school had their own internal reporting protocol in addition to my legal mandate to report the disclosed abuse.

The school officials and myself made our respective reports.  Within one week I was contacted by the clinical supervisor of the agency I was working for.  She informed me that effective immediately (same day notice) that I was no longer allowed on school property as the principal had contacted the supervisor regarding concerns about "the efficacy of my interventions and overall ethical soundness."

Resistance was futile.  There was no revoking the decision.  My employer had sided with their stakeholder (the school) and immediately (and indefinitely) stripped me of my case load and suspended me without pay.

There were so many things wrong with this.  I begged and pleaded to even be allowed to return to the school to retrieve my personal possessions and supplies from my office.  What kind of decision making process was this?  What was going to happen to the other patients I was seeing?  What were they and their families being told about my sudden  disappearance?  Nevermind, how this process is going to affect the children themselves!

The only answer that I got from my supervisor was that the principal felt my questions to Franz were both "leading and inappropriate to ask an eight year old."  I protested that the questions were identical to the ones I had asked on dozens of other trauma assessments with similarly aged children including the initial assessment I conducted with Franz in his mother's presence.  My pleas fell on deaf ears.

I was, however, allowed to return to the school to retrieve my belongings.  As I was packing up my office Franz's teacher stopped by and asked what was going on, why was I packing up my things?  I briefly stated that the principal had decided that I had acted unprofessionally with Franz and that I had been asked to not return to the school.  The teacher was shocked and appalled.  She assured me that if I ever needed a reference, to contact her immediately.

I never spoke to anyone from the school again; not the teacher, not the social worker, not the school counselor, not the principal, none of the patients, none of their parents.  My agency offered to "allow" me to return to community-based, but not school-based work.  I declined the offer and resigned.

In retrospect, I do not think that any sexual misconduct had taken place with Franz.  Perhaps my questions were leading and he sensed that the "right" answers would lead to a quick exit and alleviate the anxiety of our interaction.  Nevertheless, passion can be fatal.

We have far more to contend with in this profession than our clinical execution.  We live in a world of insurance companies, reimbursement, diagnostic codes, hospitals, pharmaceuticals, agencies, and private practices alike.  They all have their agendas and allegiances which inevitably become known one way or another.

On the door to my office at the school hung a small white board that I wrote a "thought for the day" on -- more for myself than anyone else.  As I was packing up my things to leave for the last time I noticed that I hadn't changed the quotes since the last day I saw Franz.  It read:

"Analytic interpretation isn't for understanding, it's for making waves." ~ Lacan
"Some people feel the rain.  Others just get wet." ~ Bob Marley

Afterward:

As with the Abandon All Hope story, the thematic lesson here is to not be attached to outcomes.  In part, that seems cruel or disconnected.  In reality, it's to ensure self-preservation.  As if contending with the complexities of clients wasn't enough of an ethical dilemma, there is the added amplitude of the systems we operate in (families, schools, agencies, etc.).

Looking back on this story, there is the obvious note to caution oneself and ask if you're acting in the service of your client's betterment or your own?  Either may or may not be "right", but it certainly is a reflective bearing in any light.

Of his 60+ year marriage, my late grandfather said the key to success was; "You have to decide just how right you want to be."  Professionally, we call it practicing psychotherapy for a reason, which I suppose implies we never quite get it right.  Maybe therapy is not about "how right you want to be", but "how much of yourself do you want to remain at the end of the day?"

There is a perpetual tension then between best practices and minimum standards if you will.  The crux is that there is no question of if you will make compromises (on your ethical standards, personal and professional practices), but when?  And to the expense or benefit of who?