Joined-up Psychotherapy
The place of individual psychotherapy in residential provision for children.
Diana Cant.
‘Joined-up psychotherapy’ – what is this? Although the phase is somewhat redolent as the phrase is of Blairite ‘joined-up government’, (with perhaps more than a whiff of paternalism), it does, it seems to me, convey an idea of ordinary common-sense. If government departments were to learn to speak to each other, operate in conjunction with each other, and towards the same ends, who could deny this would be sane, sensible, and probably for the general good? Yet how hard this seems to be to achieve in practice. Similarly with psychotherapy. If we as psychotherapists were able to speak to each other clearly, work together with other professionals, towards the same ends, surely our patients could only benefit? Yet this too, can be surprisingly difficult..
I would like to share some attempts to ‘join-up’ therapeutic experience around young children resident in a therapeutic community. I will describe the community, and talk in some detail about the work with two of the children. What I particularly want to focus on is the way that individual psychotherapy is truly only a part of a more total therapeutic experience, and how vital it is for the child that all the adults involved in their care to talk, think and act with a common understanding and a shared purpose. This means that residential staff must talk to teachers, teachers to psychotherapists, psychotherapists to administrative staff – and in all permutations, if the child is to be held in mind and in body securely, reliably and consistently. Because of the degree of disturbance and damage that children in residential care so often exhibit, this level of communication can be exhausting. And the communication and thinking needs to be extra ordinarily detailed. A seemingly unimportant comment from a child can often, when placed in a wider context, together with other peoples’ information and insights, make sense in a way it could never do when it was only an isolated utterance. This attention to detail in its’ every form, and ‘piecing of things together’ needs a staff group who are really interested and curious – curious to understand how the child feels inside, and why and how they have come to feel like that. It requires a staff group who, in the manner of some psychotherapeutic ‘detective’, are engaged in the business of gathering the clues, and piecing them together until things begin to make sense, and the truth can be known.
Like ‘joined-up government’, ‘joined-up psychotherapy’ in such a setting seems an obvious idea, but can be very hard to achieve.
Individual psycho-analytic psychotherapy has sometimes occupied a rather uneasy position within the therapeutic community movement. The early pioneer communities, such as Dingleton, in Scotland, and the Social Rehabilitation Unit at Belmont (then Henderson) Hospital, were centred very much on group treatment, arising out of the experience of treating patients suffering from trauma following the Second World War. In addition, there grew an increasing emphasis on the therapeutic potential of the whole community, staff and residents alike, and the idea of the “therapeutic milieu” was born. This is a tradition which has had a powerful influence on much of the philosophy and principles governing the therapeutic community of today. (Rapoport, R, 1960). In essence, these early communities paid a great deal of attention to the dynamics of the community as a whole, and regarded the patients/residents as playing an important part in the therapeutic process. The group was seen as a central plank of treatment and individual work was either discouraged, or split-off in a rather uncertain way from the main thrust of the community. I remember, as a young “social therapist” at the Henderson Hospital in the 1970’s, being puzzled and intrigued by the individual work that did occur, but was held in private; whilst everything else, all day every day, was fed into an infinite permutation of community groups. Some therapeutic communities had (and have) no individual work, often frowning on the idea of “private practise” as being anathema to the philosophy of the community. Others have harnessed the consultative skills of the psychotherapist, using them to consult to and supervise the staff, who then work directly with the residents (Sprince, 2002).
This has often been particularly effective in work with adolescents, where the drive towards autonomy is an important part of the developmental process, and can be very usefully harnessed in treatment models. Thus the work in groups, similar to the original adult therapeutic community model, becomes an invaluable tool that speaks to the adolescents natural progression from parents to peers.
In working with younger children, however, there may be something to be said for a rather different model, and one that incorporates the primacy of the parental relationship. It may be that the individual psychotherapeutic relationship has a developmental ‘appropriateness’ for this age-group, all of whom have had very damaging early parental experiences.
I work as a child psychotherapist in a small therapeutic community for young children that is part of the Peper Harow Foundation, an organisation that has a long and respected history in the therapeutic community world. Here I both see the children for individual psychotherapy, and I consult to the staff group, and supervise individual staff members. This raises all sorts of issues about confidentiality, boundaries, and the quality of the transference that are potentially fraught with difficulties and confusion. However, it seems, in the main, to work, and work well.
The community is based in a big house with quite extensive grounds. The community has only recently moved into this house, and all rooms have been refurbished to a high standard with each child involved in choosing their own bedroom colour, curtains and bed linen. There is a large Aga in the kitchen (it’s warmth considered an essential by the children who had had one in the previous house), a dining room, sitting room, and a playroom. On the other side of the building are the office and administrative facilities. In an extension at the back are the utility room, bedrooms for some older children, staff sleeping-in room, and at the end of the corridor, a therapy room. The later two rooms have a door separating them from the rest of the house. On the first floor are more bedrooms and another staff room and on the top floor is the Directors’ office, and a large meeting room. The garden has a large play-shed, with table-tennis, sand-pit, and full sized trampoline. All the children have bikes, and other outdoor toys. There is a “wild area” to the garden, used mainly for beating nettles ferociously with sticks; and scaling muddy mounds.
The community is the home for a maximum of 10 children, aged between five and thirteen years, who live there all year round. Most children stay between two and four years and, where possible, move into carefully sought and supported foster placements. The children are referred with difficulties and histories that are distressingly familiar to us all: emotional, physical and sexual abuse, severe neglect and deprivation, and multiple placement and educational breakdowns. These are children who have suffered “multiple traumatic loss” (Lanyado, 2001), and who often arrive at the community when other options have been tried, and failed.
There are 10 residential staff, with varying levels of experience and expertise. These residential staff work long and exhausting hours. There are three senior staff, a deputy director, and a director. All staff are very committed to a psychodynamic, psycho-analytic way of working, and are appointed via a vigorous application and interview procedure, whereby their preparedness to think about their own life experiences and the effect these might have on their relationships with the children is carefully assessed. There is an ‘in-house’ training for all residential workers. It comprises theoretical, experiential and supervisory modules. Two external tutors run the first two modules, and myself and my colleague and predecessor, are responsible for the latter. There is an external consultant child psychotherapist who consults to the Director, and occasionally to the staff group – for example, she met with the residential staff group on a number of occasions to help manage the recent house move.
The community also has its own school, provisionally registered with the Department of Education, which provides primary age special education. Almost all the children from the community attend this school initially, but may then go onto gradually re-integrate into local mainstream schools, or to other special education facilities when they reach secondary school age. In a recent development, the school has started to admit day pupils. These are children requiring special education, who may still be with their families, or who are placed in specialist foster care, with the organisations own foster carers. The school also has a strong psychodynamic base, and there is a great deal of shared communication and understanding passed between school and the home. The school has it’s own consultant educational psychologist, and I consult to the staff team regularly. School staff also attend community staff meetings, and regular case discussion groups, and house staff join children and school staff every day at lunch time. A joint community meeting is held in school at least once a term.
In addition to providing therapeutic daily child care and education, the third plank of provision is that of specialist foster care. Two specialist social workers offer a service to the placing authority that includes finding, training and supporting foster families for those children leaving the community and needing long term foster care. This is a project that is run jointly with another nearby community. The aim is to provide as smooth a transition for the child from the community to the outside world as is possible. The social workers provide a bridge between the foster-carers and the residential and teaching staff throughout that transition. They also provide regular and on-going support once the child has moved home. It has also been possible for individual psychotherapy to bridge this transitional time, as will be seen later in this paper.
The philosophy of the community is firmly rooted in the psychodynamic tradition, drawing particularly on the work of Winnicott and Docker-Drysdale. It aims to create a secure environment which can hold, contain and nurture very damaged children. The bedrock of the work is the understanding that children within the community will be unconsciously driven to recreate distressing and abusive relationships with each other and with the staff, and that their lack of self-worth, their sense of guilt and shame, will inevitably be enacted time and time again. It is the job of the staff not only to provide consistent, clear and reliable parenting, but also to withstand the sometimes virulent attacks, not just on their person, but on their capacity to think. By providing such containment, the child comes to experience, often for the first time, a degree of maternal pre-occupation that helps them feel less persecuted and more understood. (Bion,1962). Great emphasis is placed on the children’s physical environment. Food is often home made and the children are always encouraged to try unfamiliar foods. Fresh food is used wherever possible, and it is striking that, when children leave the community they often can allow themselves to talk of missing the food, even though they may not be able to acknowledge missing the community in other ways. Attention is paid to small, practical details, on the understanding that if you do pay attention to detail, the whole of the children’s living experience can be brought together coherently, with less possibility of destructive splitting and denial. For example, one boy, although often outwardly compliant, was extremely good at secretly attempting to undermine the therapeutic structure of the community, and involving the other children in these attempts. When the staff checked his bedroom minutely, they discovered that he had painstakingly unscrewed the cover of his radiator and hidden a variety of articles (including soiled pants!) in a gap in the woodwork. Thus he was demonstrating, in a very clear way, how he was determined to find any gap in the system, and use it to split off the more destructive and attacking aspects of himself. But it needed the staff to constantly check in the most rigorous of ways all possible hiding places for this aspect of himself to be held, and ultimately to be thought about.
The concepts of loss and change are very active currency within the work, but so too are the excitement of growth and discovery. Hence children are encouraged to swim, ride horses, run, sing, paint – wherever they seem to have an interest or an aptitude.
There is a conscious attempt within the community to provide an experience of “seamless care” for a child coming to the house, moving into school, and eventually making the transition to a long term placement. This is a deliberate attempt to provide a different experience from the numerous placement breakdowns most children have endured, often without the opportunity to say goodbye, or to begin to understand what is happening, or why. What these children thus have inevitably internalised is a compacted sense of rejection, failure and unacceptability, often together with an unconscious fear of their own destructiveness and power.
All children have a full psychotherapy assessment once they have been living in the community for some time, usually 3 to 4 months. Often they have been referred with a recommendation for individual psychotherapy, which may have been unavailable in their previous placement, or thought to have been inappropriate until they were more settled. Most (but not all) children are subsequently seen in either once or twice-weekly psychotherapy, usually over a period of at least two years. It is the role of individual psychotherapy within a community such as this that I would like now to consider, and the ways in which the individual work can mesh with and compliment the overall therapeutic concern that is the community. What I particularly want to think about is the idea of “joined-up therapy”, where the insights from individual psychotherapy are shared with the rest of the staff team in the service of a more profound understanding of the child’s internal world. The converse is also true, of course. Insights from teaching and residential staff are extremely valuable to the psychotherapist. The concept of the confidential, private space of the psychotherapy session, is thus altered, with confidentiality being held by the whole staff team, rather than solely by the psychotherapist.
Toby
Toby was five years old when he came to live in the community. He had lived initially with his father and mother, where there had been early concerns about the quality of his care. He suffered breathing difficulties at birth and was separated from his mother in a specialist hospital for the first ten days of his life. By the time he was nine months old, he had had eleven hospital admissions for minor illnesses. Sometimes no physical ailment could be found. His mother, herself with a history of numerous hospital admissions, was clearly very anxious about him, and unsure of her ability to care for him adequately. Toby was taken to hospital with blood unaccountably in his nappy, and, on analysis, the blood was found to be his mothers. A diagnosis of ‘Munchausen’s Syndrome by Proxy’ was made, and the case referred to Social Services. There followed a great deal of professional intervention, a residential assessment and treatment programme at a London Hospital, and increasingly erratic care for Toby, who was passed around various family members, nurseries and child-minders in a bewildering cycle. His parents then separated. Inevitably, his behaviour deteriorated, as the professionals were divided in their opinions of whether Toby could be cared for by either or both parents. Toby was unpredictable, angry and aggressive. He had massive temper tantrums that could last for over an hour. He would kick and scream, bite and hit, damage objects, and wet and soil himself. His headteacher described him, at age five, as the most difficult child he had come across in 30 years of teaching and he was excluded from primary school. Following a public assault on Toby by his father, Toby was eventually taken into care, and moved to the community.
There he proved to be an imperious and highly demanding little boy, who could protest with sound and fury for many hours of the day. He was eneuretic and encopretic, and could wet and soil at will. He was significantly overweight, and could also make himself sick. He bit and spat and hyperventilated – in short, he used every bodily means at his disposal to attack and protest. He had a mild form of cerebral palsy, which meant he had to wear leg braces and do orthopaedic exercises each day, which he hated – these were a prime source of contention. Indeed, even the most simple of every day requests, such as cleaning teeth, could elicit a massive tantrum, during which Toby was largely unreachable. After a great deal of patience and fortitude, the residential staff set about the business of parenting Toby in a predictable, reliable and non-persecuting way. They met his temper with firmness and enterprise, variously holding him, putting him in his bedroom, and taking him for walks in the surrounding country lanes. Most importantly they gradually evolved a humorousness, a form of gentle teasing, that Toby could respond to with a smile, a giggle, and later, a full blown laugh. The teachers offered very much the same approach, and Toby began to feel held, both in the house, and at school. He knew the teachers and the residential staff talked regularly to each other about him, and felt contained by this. He started to attend a local play-group for a couple of mornings a week, together with the community’s own school, with the aim of him transferring to the reception class of the local primary school, again for just two mornings a week initially.
It was at this point, after he had been in the community for a year, that I was asked to see Toby for psychotherapy. From the outset Toby was absolutely clear how we should use the therapy time – we should use it to play “darlings”. This, it transpired, was a game in which I was invariably the son, and he the mother. The mother was bossy and domineering, and bombarded her son with instructions. No sooner would I, as the son, carry out one instruction, than it would be followed by a second and then a third, until my experience in the counter-transference was one of being harried from pillar to post with no opportunity to draw breath. Each command was appended by the word “darling”, delivered in a controlling and rather sadistic way, for example – “sit down, darling”, “get up, darling”. The net effect was that I, as the child, was bombarded with commands that had nothing to do with me, and everything to do with my mother. I ended up emotionally deadened in an effort to protect myself from the onslaught and intrusion, and with no time or space for thought. Toby was unwilling to think about this play in relation to his external experience, and indeed, remained reluctant to do this throughout. It fell to me, I think, to be the one to make the link and put it into words on his behalf.
This game persisted throughout the two years in which I saw Toby, although its ferocity and the quality of intrusiveness waxed and waned. At times I was literally hauled around the therapy room, pushed and shoved into position, and shouted at mercilessly. At those times I talked about the little boy having a mother who couldn’t seem to stop to listen to her son, but pushed and pulled him about in a way that could feel frightening and cruel. But at other times I might be tucked up in bed and left in peace for a few moments, or Toby, as mother, might go to great lengths to prepare a birthday “feast” for me. I took these moments as indications that he was slowly internalising the possibility of a more benign maternal object, a mother that was capable of putting her child first, and showing him care, concern and generosity.
After nine months in therapy, Toby began to talk to staff both in the house and at school about being frightened of his mother, saying that she used to hurt him and had “done other things” to him. He was very worried that she might come and take him back to live with her. Although these admissions never amounted to a formal disclosure of any kind, there was very much the feeling that Toby had enacted much of this in therapy, and had felt it received and understood (although its connectedness to his outside world was always denied). He was able to acknowledge some of the reality of his fears with his immediate carers. As so often in working with these children, therapy is used as a sort of “rehearsal” for disclosure, where the dynamics are enacted but the reality denied. It often falls to the residential worker to receive the disclosures or allegations that are consciously connected to the external world.
Not only were there significant changes going on in Toby’s internal world, there were moves afoot in his external world too. He had recently made the transition from the community’s school to the local primary school and was attending there full-time. This transition was very carefully managed with a classroom assistant from the community’s school accompanying Toby and staying with him for a significant proportion of time. This role was smoothly transferred to a full-time learning support assistant employed by the school. Additionally, the foster placement project linked to Community had found prospective foster-parents for Toby. This couple had already successfully fostered two older boys and were currently involved in the project’s training programme for foster-carers.
Toby’s general behaviour although still, at times, extremely testing was not nearly so difficult. The staff had learnt to anticipate the sort of situations that would provoke anxiety in Toby, hence avoiding an escalation of his violence and aggression. He had learnt that the staff were basically trustworthy and dependable and able to survive his attacks. He had also learnt to laugh at himself and the growth in his sense of humour was a delight to observe. He was now seven years old and had been in the community for two years.
Toby was introduced to his foster-carers, John and Pat. The introductions went very well and a date was fixed for his move. It was decided that I would continue to see Toby after his move and that he would be brought back to the community each week for therapy. I met with John and Pat to talk about Toby and about his therapy. Although already clearly very committed to Toby they were unfamiliar with psychotherapy and felt, in the way that many foster-carers do, that once Toby was living in an ordinary family his difficulties would largely disappear. It was hard for them to understand the degree of emotional damage that Toby had suffered and they understandably wanted to feel that they could put that right.
In the run-up to Toby’s move, his play in therapy sessions became more regressed. He had previously been playing a game of “schools” in which the boy was sometimes naughty in school and appropriately punished by the teacher; but was sometimes good, produced excellent work and was praised. On hearing about his move the cruel mother play made a resurgence and he again began to wet and soil. In the last session before he moved, Toby became the mother who fed her son “nasty food for his own good”. She dragged her son around the room and tied him up with a skipping rope. She then instructed a policeman to arrest her son and take him to prison, saying “you’ll never see me again”. It felt very poignant but absolutely right.
Toby moved home over the Easter holiday. His first therapy session after the move was also his first visit back to Community. He did not want to talk about the move at all in therapy. Instead he played “darlings” again, in a game in which the mother oscillated between good and bad, well and ill. There was a lot of very messy play with the sand and water and he only just managed to get to the toilet in time. It felt that he was struggling very hard to manage some very messy and difficult feelings and to avoid them spilling out all over the place. I had the sense of his distress spilling over in the therapy session, in an effort to preserve the placement. This was confirmed in a brief conversation with John and Pat when they said they had hardly had any problems so far. The only difficulty had been a re-emergence of Toby’s enuresis in the last few days, which they linked to the return of therapy and the coming back to Community. Maybe it might be better, they wondered, to make a clean break.
I was concerned by this and discussed it at length with the manager of the fostering project who was offering a great deal of support to John and Pat. She could share my view of the dynamics and could well understand the foster-parents desire to “go it alone”, whilst sharing my anxiety that this would not be helpful to Toby. It was enormously useful to be able to call upon her as a go-between – she could be an advocate for the therapy whilst also supporting the couple. In the event, Toby had a very traumatic night the following week, in which he experienced a flash-back (this had happened on a couple of occasions whilst he was at the community) and was inconsolable and unreachable for hours. John and Pat were shocked and frightened and felt helpless. As we all talked it through, they were able to let themselves see the degree of internal damage and distress that could overtake Toby at times. They could see that he still needed therapy.
Toby continued to come to sessions in the community for six months after he moved out of the community. Not only did he have the continuity of the therapy but he also had the contact with the physical building, the staff who were working when he arrived and the other children, who were back from school themselves when he finished therapy sessions. They all would greet him with great enthusiasm, although he only ever stayed for a matter of minutes. But it was enough to reassure him that everyone had survived and remembered him. It also gave the other children the opportunity to see that he had left the community successfully, but without forgetting them. He used his therapy as a place to bring his chaos and his fears that the placement would breakdown. Session after session ended with sloppy wet sand all over the floor. Any identification with a good maternal figure was rather fleeting and liable to be quickly submerged. But there was also a sense of hopefulness – the mother in his play did a great deal of cleaning and cooking healthy meals. He occasionally talked enthusiastically about “when I was at the community”, and remembered a particularly happy birthday party there when he had “laughed and laughed”. This conveyed a sense of good experience internalised and available to be remembered. It also felt that Toby had moved on.
After six months I stopped seeing Toby at the community and started seeing him in the consulting room at my private practice. This was a move discussed with Toby beforehand (in fact, he had already visited this therapy room, as I had initially been asked to provide an assessment for court before seeing him in therapy.) He was pleased to return and John and Pat felt pleased that they could move on from the Community. For them, it was one more step in “taking possession” of their foster-child. They had been focusing for some time on Toby’s cerebral palsy and putting a great deal of effort into getting him to do his exercises. They felt that many of his difficulties would be over if he no longer needed to wear his leg-braces. There came the great day when Toby had been told by the hospital that he could leave them off. Toby and Pat arrived very proudly and displayed his brace-less legs. “Look”, said Pat, “he’s like a normal boy now”. Toby immediately corrected her “no, I’m not normal yet, I still need some help.” Thus he was able to make it clear that he knew he still had to some way to go and could not collude with his foster-parents rather magical hope that this important external change had healed the internal damage.
I saw Toby in this setting for six more months, a time in which some important consolidation took place. Gradually, the kind and solicitous mother became more of a regular character in his play. In one session, the son was ill and his mother cared for him with great kindness. Even the mother’s touch was gentle and she did not mind when her son was sick on the floor and even over her. Instead, she was sympathetic and cleared it up. A favourite game became “sports day”, in which Toby would build a series of obstacles all around the room and proceed to surmount them all in record time. He was thrilled with his new-found physical ability. In the last couple of months before therapy ended, Toby created a game in which he was being chased by a witch. He was very brave and was rescued at the last minute by his mother. He was a doughty fighter, undaunted by the witch, and finally he and his mother joined forces to vanquish ten witches. This was an enormously important shift – Toby had found inside himself a mother who could be relied upon to defeat evil and who could overcome the “witch mother” he had carried around inside for so long. There was some evidence of the fragility of this resolution, however, in his wetting of himself in this session, something he had not done for some time. In the final few sessions he revisited all the games we had played over the two years of therapy and denied any sadness about ending; he was pleased, he said, to know he would be like all the other children at school. John and Pat had meanwhile continued to meet regularly with the fostering project manager and were able to rethink their desire to move Toby to a school near them. They were able to see that Toby’s school was as committed to his success as they were. At the time of writing they continue to meet with the fostering worker and Toby is thriving.
Although the foregoing is written from the perspective of the psychotherapist, I think it is evident that what I have described is the end result of a lot of work by a lot of different people.
This work has to be carefully planned, even choreographed, so that one intervention leads to, and is overlapped by another. At its best, this demands shared goals and ways of working, considerable inter-professional trust and respect, and great attention to emotional and practical detail. As a team we by no means got it right all of the time, but perhaps we got it right enough of the time in order to offer Toby the experience of being held, understood and helped. This case is additionally interesting in the use made of psychotherapy, almost as a transitional object. Toby’s therapy went with him from the Community to foster-care, providing a consistency as he managed some mammoth changes in his life. It provided a link between residential care and school life. It meant that he could be helped to hold on to and remember the past and begin to integrate it into the present. At times he was not at all sure that he wanted to do this – the impulse to split and deny was very strong. At times his foster-carers were not sure they wanted his past to come with him either, and who can blame them. But there was a commitment to Toby and to a psycho-dynamic way of working, that meant that everyone involved in Toby’s care tried to remain thoughtful and alive to his history and to the implications of all the external changes in his life. These changes were broken down into “bite-sized pieces”, that could be taken-in and digested gradually. His therapy became something of a link between those pieces, a bridge that could enable him to move into a new phase of his life.
Holly
In preceding material I have tried to look at the way individual psychotherapy contributed to the whole treatment offered to Toby, and to illustrate some of the ways the service can ‘join-up’ around the child. In a sense, it is a description of a process. I would now like to look at another case, but in finer detail, in order to think about some of the real technical dilemmas involved in providing psychotherapy in a residential setting.
Holly was seven years old when she came to the community. Both her parents were drug-dependant at the time of her birth, and had been heavy drug users for some years. A brother, two years older than Holly, had died at two months old of Sudden Infant Death Syndrome. Holly had an extremely chaotic early life, being looked after by a variety of people whilst her parents were in and out of prison or drug rehabilitation units. Holly’s father was replaced by another man, who was also a drug user. There were numerous interventions by Social Services, and Holly was placed on the ‘at risk’ register. Once she started school, there was escalating concern, not only about her emotional neglect and abuse, but also about her highly sexualised behaviour. However, it was not until Holly was six and a half years old that she was finally removed from her family. In the next year, prior to her move to the community, Holly was placed in six different foster placements. I was asked to see her for an assessment after she had been at the community for a year, by which time she was just eight.
The Holly I met at assessment was pretty and determinedly self possessed. She unerringly made for pencil and paper and started to do ‘maths’. She said she was very clever, and could do lots of sums with big numbers. I suggested that she wanted to show me how clever she was. Her sums gradually became more grandiose and fantastical, and her attempts to write these numbers bore less and less resemblance to reality. She showed me some ‘tricks’ to get her tables right, but these tricks were applied indiscriminately, and the tables ended in chaos, a chaos that Holly averred was correct. It was clear that, for Holly, the ‘trick’ was all, not the mathematical principle behind it, and I wondered about her over riding need to be in control, in an attempt to manage internal chaos. She seemed to do this by a superficial trickery, rather than a deeper understanding. She then wanted to show me her skill in writing. It was soon clear that this was rather limited, although she was quick to copy any writing she could see, and claim it as her own. Her words became longer, and a jumble of letters. Sometimes there were no letters, just ‘pretend’ writing. When I commented on her made-up words, she said she had her own private language that no-one else could understand. I suggested this might be a way of keeping secrets, but also of keeping people out, so they could not hurt her. She responded to this by telling me an involved story about searching for, and finding, everybody’s Christmas presents, so that they were no longer a secret. I wondered if she was telling me about a part of her that kept her ears and eyes open, that was on the look-out all the time, so that she could feel clever and safe. She had a cold, and at this point sneezed richly, so that her face was covered in mucous. Her response to this was unusual – she froze, and seemed momentarily as if she might cry. However, she recovered her self-possession, and attempted to continue as if nothing had happened, until I handed her a tissue. It was as if, very briefly, her vulnerability had broken through her defences, and let me see the Holly who needed care and concern. Right at the end of the assessment, she drew a Christmas tree, and cut it out. She asked me if I thought it was a tree or a decoration. I said that I thought this was a really difficult question, because it could be either, and so whatever I said might be the wrong answer, and Holly would have tricked me. She smiled and agreed, and this felt an important acknowledgement of the way she could work very hard to stay one step ahead of anyone attempting to come near her emotionally.
From the assessment, the themes of trickery and trust were paramount. As therapy began, Holly was uncertain about how to fill the time. She spent numerous sessions showing me her dancing, which was extremely provocative, seductive and ‘sexy’ beyond her years. She so much wanted to be admired, and indeed, she was extremely good. But there was that shocking dissonance between her sexual awareness and seductiveness, and her eight-year-old body. In the transference there was great pressure to admire her, but to admire her as a sexual woman, rather than a little girl. This dynamic was coupled with an omnipotent triumph – “I bet you can’t do this”, “you’re an old granny, and granny’s can’t dance”. Holly desperately wanted me to try and prove that I could, and collude with her in a competition for sexual potency, (and, of course, there was a part of me that bridled under the appellation of “old granny”!) Therapy with Holly has proved to be enormously challenging, not least in terms of managing the sadistic feelings that are aroused as a result of her constant denigration. She was obsessed by what other children did in their therapy sessions, and made many attempts to trick me into letting the smallest piece of information slip, once she realised that other children’s sessions really were private. She set ‘traps’ in the room for the next child, or tried to leave hidden messages. These sorts of ‘skirmishes on the boundaries’ were very common, and often designed to spoil something for someone else. I came to see them as envious attacks on a good object, especially if that good object might belong to someone else. But Holly also attacked the possibility of her receiving anything good. Time and time again, any moments of hopefulness, once they were recognised, were destroyed, and destroyed with glee.
Holly’s play became more obviously perverse as she allowed herself more freedom to play symbolically. For example, a ‘witch’ mother appeared in the sessions, who often behaved like a wild animal, clawing and spitting. She would chase her daughter, changing from a ‘proper mother’ to a tiger or a snake. The tiger mother ate from the rubbish bin, and threw good, wholesome food away, so that her daughter never knew what sort of a mother she would encounter. Although Holly would absolutely deny the external validity of any interpretation, saying “it’s only a game”, it seemed clear that she was showing me something of an internal mother who could not be relied upon to be trustworthy, but who might turn the world upside-down at any moment in a very frightening way, until bad was good, and good was bad. I wondered privately about a little girls experience of being with a heavily-drugged mother – that she may have easily seemed to Holly at those times to be like a wild and unpredictable animal, and almost unrecognisable as a mother.
The feelings of perversity moved from the symbolic material directly into the transference. Holly spent session after session attempting to attack me and the room. She would refuse to come to her session, and then she would refuse to leave. She would break the shared toys in the room, seemingly by accident. She would wipe paint on the furniture and on me. She would trample clay and soggy sand all round the room. She attacked my jewellery, sometimes damaging it, and made numerous attempts to take small objects from the room. She seemed to circumvent all my attempts to limit her mess, and to delight in the vexation she caused. She posed me endless technical dilemmas about the boundaries of the work, as I struggled to keep up with her attacks on the therapy. Many of the attacks were around privacy, and confidentiality, and Holly’s stated desire to know all about the other children’s sessions. For example, on one occasion, Holly found a small glass bead belonging to another child on the therapy room floor. She had an unerring instinct for the smallest of changes or mistakes. When I asked her for it, she immediately put it in her mouth, and leapt in triumph around the room. I had, in her mind, become an unreliable mother who could not protect her child from intrusions from outside. Neither could I protect the possessions of another child. But the level of anxiety about this breach in boundaries meant that she attempted to use it as proof that I was useless, and to put herself at risk, whilst also threatening to destroy the loved object belonging to someone else. Sometimes she would climb onto the top shelf in the therapy room, and refuse to come down. From there, she could reach and dismantle the light bulb and fitting, but I could not reach her sufficiently well to get her down safely. She knew the therapy room was sacrosanct, and that no other adults came in. She literally looked down with scorn and triumph on my helplessness. In all these instances, and many others, I found that my guiding principle had to be Holly’s safety, even if that meant compromising, for example, the privacy of the therapy room by asking another member of staff to get her down from the shelving. In many ways, this felt as if it went against the grain of psychotherapeutic confidentiality. The therapy room could be seen to be no longer a protected and private space. Everything a child had been doing could be thus exposed to the gaze of another, who might use the information thus gleaned for their own purposes. The important point however, is that the other person is also a therapeutic worker, for whom the child’s safety is also paramount. They also respect the child’s privacy, and are well aware of the dangers of splitting and denigration so readily available in a situation such as this. When I sometimes belatedly realised that Holly had taken an object from the room after a session, I would let the residential staff know so that when it re-appeared, (as it always did eventually), we would all know what had happened, and could think about it with Holly as appropriate. Thus the boundary was held by the whole staff, and not just by myself. Holly had concrete proof that we shared information that would help us be consistent and coherent in our provision of her therapeutic care.
Holly’s attacks intensified, and an additional dimension emerged. She was genuinely drawn to certain objects of beauty – sea-shells, jewellery, bright painted colours. She built up a collection of shells over several weeks, and other staff, appreciating this genuine response to something beautiful, helped her to add to her collection. She brought some of her ‘best’ shells into therapy, and identified them in books. But gradually these shells became weapons – they were used in competition with other children, as envy-inducing objects. Staff who had been eager to gratify Holly’s move towards appreciation of beauty were made to feel foolish for their hopefulness. Holly derided them for it. In her therapy she did the same to me. She would start a session, for example, making ‘make-up’ with the paints. This would initially be in rather beautiful pastel colours, painstakingly put together. I would find myself thinking (hoping) that this would be the session in which something good could survive. As soon as I allowed myself to be conscious of that thought (not even to voice it) Holly would spoil whatever she was making. She would add black paint, or she would tip the mixture all over herself and the room. Her timing was immaculate. And I would feel crushed, hopeless and desperately disappointed – again. At one level I understood Holly’s transference communication of her own despair and disappointment. I was aware that she was needing me to feel the intensity of her hope, and the pain of its’ being repeatedly crushed. But what made this so hard to bear was her delight in my despair.
This degree of perversity was extra-ordinarily demanding, and, after about 6 months of relentless attack I became unsure about the validity of continuing. I had discussions with the consultant child psychotherapist attached to the community about the danger of the therapy being used to inflame the perversity in the transference. I talked to the teachers and the residential staff about the therapy sharing my misgivings, and my sense of hopelessness and doubt about the psychotherapeutic endeavour. What they recounted was fascinating. The teaching staff had seen great strides in Holly’s ability to learn, and especially in her ability to read and write. They had devised an individual learning programme that addressed Holly’s dyslexic difficulties, and she was no longer using the ‘pretend’ writing I had seen at the assessment, but was now using a sort of ‘emergent writing’ that was decipherable. The residential staff felt that was a much more ‘ordinary’ and unpersecuted Holly available more of the time, and especially in the evenings, when she could be relaxed and genuinely affectionate. This was a very different Holly to the one I saw in the therapy room, session after session. Perhaps this was the beginning of a more healthy splitting, in which Holly could bring the perversity and attack to therapy, thus leaving her more free to be affectionate, creative and relaxed elsewhere. It also seemed as if she was beginning to be able to learn. The staff were unanimous in their feeling that I should continue to see Holly. This was helpful and heartening for me as it was clear that she was using the total therapeutic provision of the community. She was able to bring her sadistic attacks and her despair to her therapy, forcefully enact them, and make sure I experienced their intensity. But she was also able to feel that those parts of herself could be safely left in the therapy room when she left the session; and that, temporarily unburdened, she could enjoy life in a more ‘ordinary’ and less persecuted way. As a staff team, we could understand the various roles we all played in containing Holly’s distress and despair, and in allowing her the opportunity to feel connected to her object in a different way, however fleetingly. We could see that it needed us all to be able to share the intensity of the work to offer a sense of true, thoughtful containment. I think that Holly was highly attuned to the receptivity of the staff body as a whole. I think she also had an extremely accurate unconscious awareness of when the staff group was particularly cohesive and well-contained, and that she ‘chose’ those times to let us see more and more of the internal terror with which she had been living for so long.
This coming together of the staff heralded a change in the therapy. Holly’s play became more perverse in a sexualised and sadistic way. In one session, she pretended to have a penis, that was graphically cut off. She said that she had weed on it, and that now “it glistened like a gem” . The play became full of part objects – breasts, penises and bottoms that were cut from the rest of the body, and kissed and eaten, variously with relish or revulsion. The mother in the play was made to say “I had a bite (of the penis) once and it was very nice”. The child in the play was held down, and forced to put the penis in her mouth until she choked. Then the child seized the penis, and forced it on someone else, saying “it’s got my mother’s autograph on it”. I attempted to relate this to Holly’s external world. She would scream at me that it was “only a game”, and maniacally continue the excruciating abuse. In the transference I felt paralysed and despoiled.
Weaving throughout this sexualised play, a different game emerged. This involved the tricking and sadistic treatment of a well meaning, but rather ineffectual grandmother. This granny was duped, deprived, poisoned and shut away for long periods in darkened rooms. She was denied food and water, or was cruelly tantalised with believing she would be well-treated, only to have that hope snatched from her at the last moment, once she had allowed herself to feel hopeful. It felt as if a calculated emotional torture was being enacted.
In the midst of this, real external change was on the horizon. The community was to physically move to new premises about a mile down the road. The children were all told about this, and the staff group met regularly with the external consultant child psychotherapist to think about the implications of this, both for their practise, and for the children.
A few days after the announcement of the move was made to the children, Holly announced that her periods had started. In her session later that day, she talked about how upset and scared she felt. The sanitary pads felt uncomfortable, and she felt dirty and sick. She was unusually calm and insightful. However, towards the end of the session she retreated behind a chair, and emerged with bloody fingers and a small pointed sea-shell. She then poked at her nose with the shell, and made it bleed. She dowsed her face with water and then tipped water “all over my minny”, soaking her trousers. I talked to her about the bleeding, and how upsetting it was for her. But I said that she had showed me how she could make her nose bleed, by scratching at it with the shell. Perhaps she had also made her ‘minny’ bleed in the same sort of way? She denied this, but I noticed, after the session ended, that she had left the shell behind. This presented me with a dilemma – how much of the details of the session, and my anxieties about Holly’s potential self harm to share with other workers? I decided that I needed to let other staff know about my concerns, and that also, as Holly had left the shell behind, that there was a part of her that wanted others to know about this detail. (She had other, similar shells in her collection in her bedroom which would need to be removed if she was self-harming). I went from this session to a staff meeting. In one of those fascinating conjunctions of parallel process, I discovered that whilst I had been seeing Holly, the staff group had been discussing her behaviour with the external consultant, who had wondered about some sort of attacking masturbation, exacerbated by the news of the move. I later discovered that the teaching staff had, that morning, been having exactly the same discussion. It therefore became clear to all of us simultaneously in three separate professional spaces that Holly was abusing herself, and drawing attention to her internal injuries in a very concrete way. My concern within the individual work was to try and help Holly make the connection between her anxieties raised by the house move, and her deep-seated anxieties about loss of stability and security. This loss of external security heralded, in Holly’s mind, an attack of the most intrusive kind. It also seemed to highlight Holly’s great ambivalence about growing-up and becoming a woman. On one hand she welcomed this – even encouraged it by creating a pseudo-menstruation. This, she felt, would make her the object of envy of others, and she could triumph in her sexual potency. On the other hand, the onset of puberty filled her with dread, and a conviction that her internal damage would be made manifest. Her bleeding then represented to her not only her received damage, but also the virulence of her retaliatory fantasies. These fantasies further depleted her internal objects. It was, of course, no coincidence that the instrument of Holly’s attack on herself was also something that she had previously treasured, and thought to be beautiful. It was a further illustration of that perverse dynamic that dictated that nothing beautiful could be allowed to survive, but was inevitably transmuted from gold to base metal – from hope to perverse attack.
In a healthy functioning therapeutic community, the work does not, of course, only go on in individual therapy sessions, but throughout the day. The fact that insight into Holly’s behaviour happened, in this instance, simultaneously at school, in both the staff meeting and in the therapy session is no co-incidence either. It bears witness to the degree of ‘whole community pre-occupation’ needed in order to hold the child emotionally. The sort of children who find themselves in residential provision need more than individual maternal pre-occupation. They need the joint, joined-up pre-occupation of all the staff who work with them. They need to feel held by the whole community, and to know that the community is more than the sum of its’ parts; that it cannot be weakened and split, but that it can withstand attacks and survive, and help them to survive. Only then can they begin to feel held and contained enough to take the enormous risk of making relationships founded on trust rather than mistrust.
But to return for a moment to Holly’s shell, left behind in the therapy room. I gave the shell to the Director – very much a firm but caring maternal figure for Holly. She showed it to Holly, explaining that I had given it to her, and that we were both concerned that Holly was hurting herself with it. The other shells were removed from her bedroom, and the bleeding stopped. Holly’s fears about her internal damage were addressed directly by residential staff, and also within the therapy. What we, as a whole staff group, aimed to do was to clearly demonstrate to Holly that her safety was our priority, and that we would work together to ensure that the community kept her safe – that we would talk and share information when we felt we needed to, in her best interests. Of course, the work does not stop with the active demonstration of containment, but needs to be extended to working with the underlying conscious and unconscious fantasies. Everyone attempted to show Holly that they could understand her terror of internal damage, and her drive to enact it rather than think about it. In essence, we all attempted to think about it on her behalf.
The work with Holly is ongoing. She has been able to make a number of disclosures of abuse – unsurprisingly, in view of the material – of a very severe and perverse kind. Her behaviour has deteriorated, as she lives with the conscious and shared knowledge of that which she has experienced. As a community, we continue to feel enormously challenged by her assaults on our capacity to remain thoughtful, non-persecutory, and hopeful.
Conclusion
It is my hope that, in describing in some detail the work with these two children, it has gradually become clear the extent to which individual psychotherapy in this setting is a joint, and joined-up endeavour. I think it will also be apparent that such an endeavour absolutely depends on the willingness and commitment of all the staff to be preoccupied with the child, and with all the smallest details of the child’s life, both at a practical and at an emotional level.
The final point I want to make, however, is a rather different one, and concerns the children’s view of their psychotherapy. All the children seen within the community, both by myself and by my predecessor, value their therapy very highly. Not only do they value it highly, but they use it extremely well. They seem to have what many of us would consider to be a rather sophisticated understanding – albeit perhaps unconscious – of the purpose of therapy, and of the boundaries involved. They may test those boundaries, but they respect them. The children want their therapy time; they feel it is important, and that it is there to help them. Undoubtedly, this positive attitude is a reflection of the value placed on psychotherapy by the whole of the team, and of their sophisticated understanding of what it involves, conveyed consciously and unconsciously to the child. But I also wonder whether there is something more: that for children of this age, who have already suffered the most appalling degree of deprivation and emotional damage to warrant them being placed in a residential setting, the opportunity of individual psychotherapy, on top of excellent therapeutic primary care, begins to offer the enormous preoccupation that these children need.. As we all know, love is not enough, but neither is ordinary ‘good enough’ maternal preoccupation. These children need more than that; they need an extra-ordinary degree of preoccupation, joined-up around them in a safe and containing way. When the child can feel this is in place, then it becomes possible to harness the internal hopefulness, and the wish for change. Individual psychotherapy can perhaps come to symbolise, not just adult pre-occupation, but also a sense of hopefulness, held by the adults, on behalf of the child.
Diana Cant M.A.C.P.
Child and Adolescent Psychotherapist
March 2002