Not a Can of Peas

Part of my work over the last 30 years has been to highlight the risks of moving young children from one home to another and disrupting their relationships with previous caregivers. Between roughly 5 months and roughly 5 years, but especially for the first two years of this span, children are developing attachments that, if disrupted, may never be rebuilt.

One way to think about attachment is to consider that relating to people is a skill, and we learn to relate to people and to ourselves by generalizing from early relationships. In infancy and toddlerhood, the child has only one or two or maybe three sets of skills, each set being a repertoire of behavior that is reliably reinforced by a caregiver. The child learns first how to make her parents smile, and then generalizes to learning how to make other people smile. The parents’ smiles are reinforcers because they are associated with nurturance, whereas it takes much longer for other people’s smiles to become potentiated as reinforcers. If you lose a set of skills when you only have two or three repertoires, they are hard to replace; on balance, relating to others may become aversive because a large percentage of such relationships led early on to loss. Later, there are other fish in the sea, but in infancy, there are only a few fish in the sea. Losing one of them can make a child give up on fish.

I’ve frequently said, when professionals are considering moving a child out of a home, that a child is not a can of peas. I was gratified once to hear a judge reproach an attorney with this phrase, which meant to me that perhaps I was having an effect on the system. The idea, of course, was that a child is affected by these moves, whereas a can of peas isn’t affected by transportation. A child cannot be put in storage in with no ill effects.

But now, I also see how the phrase stands for the proposition that people won’t protect something if they don’t think there’s anything to protect. Children can be taught to close the door behind them out of obedience, or they can be taught how heat escapes or flies enter. If the former, then they will only close the door when they think someone is watching, and they will feel guilty and anxious about it. If the latter, they will close the door pro-socially, and they’ll feel good about it. But first they have to see that there is something to protect (heat or freedom from insects).

Psychotherapy practitioners and rule-makers make decisions about psychotherapy often without considering whether there is anything to protect. Nowadays, every therapist is legally obligated to call the potential victim in addition to the police if a patient makes a credible violent threat against an identified person. When this incursion on therapy first developed, many therapists were aghast at the intrusion on the therapy space. The same was true of the obligation to report child abuse. All things considered, politicians decided that the potential harm to the psychotherapy process was less pressing than the potential benefits of saving a life or preventing further injuries to children. I generally agree.

Concerns about a slippery slope were, however, well-placed. Colorado politicians recently decided that every patient should be given a mini-lecture on the different kinds of licenses in the state. I doubt this was seriously weighed against the drawbacks of intruding on the therapy process; instead, it has all the earmarks of being thought up by a group that simply did not consider any drawbacks. At the last minute, this requirement was dropped from the statute, but a therapist still has to produce a document that recites the same material, along with a lot of other intrusive information, and the therapist and client have to go through the charade of pretending that the client reads the document.

No one will protect the therapy process unless there is awareness of something to protect.

The therapy process and its ground rules are designed to create a unique kind of relationship in which patients feel like discarding their social masks and in which therapists are authorized to comment on their patients’ behavior. The problem, currently, is that clinical psychology wants to be a health profession, partly to help people and partly to chase the medical dollar. The problem is that, not only is the therapy process not seen as something to protect in a medical setting, it is downright hostile to a medical setting. This is true for two reasons. One, a medical setting is about diagnosis and treatment, not about understanding narratives and changing them. Wondering about narratives makes the medical frame seem arbitrary when it is important to medical treatment that it be seen as real. Two, the kinds of therapy patients best conceptualized medically (those with schizophrenia, some types of bipolar disorder, organic depression, and so on) are the kinds of people who react most intensely and negatively to the kind of closeness promoted by a therapy process. There is less process to protect with these patients, and the process can distract practitioners from the patients’ medical needs.

So, please, treat people in a medical model who can benefit from it and, especially, who cannot currently benefit from the therapy process. But don’t tell me it’s good for everyone to have a public waiting area, a clipboard of pre-visit inquiries, a receptionist to manage payments, and a complete and utter confusion about the difference between legal confidentiality and actual privacy. Don’t tell me that patients are cans of peas.

Author: Michael Karson, Ph.D.

Clinical Psychologist View all posts by Michael Karson, Ph.D.