Report on ‘A conversation about unintegration,disintegration and integration’ with papers by Anne Alvarez and Edna O'Shaughnessy,chaired by Margot Waddell, 25 february 2005 1

This paper attempts to explore the nature and consequences of trauma in infancy by an exploration of a prototype of trauma when babies are born addicted to heroin. The trauma not only involves a painful withdrawal from the drug and invasive medical procedures carried out in isolation in a special care baby unit, but often also an ongoing cumulative trauma of the lack of availability of a receptive containing parent. The paper raises specific issues about these babies as well as about trauma in general. It examines current psychoanalytic, attachment and other theories about trauma and resilience, and includes an infant observation of a baby in a special care baby unit who was born addicted. A detailed case is presented, illustrated by sequences of drawings by an 11-year-old boy who had been born addicted. These show how the lack of containment of any sort in infancy had profound effects on the child's ability to process his emotional experience in any meaningful way. An attempt is made to evaluate the effectiveness of the psychotherapy using criteria derived from Mary Main's work on disordered/chaotic infants. This involves a shift from disintegration and a lack of resolution of any crisis towards the emergence of the possibility of a hopeful outcome.     

Clinical Commentary

This paper describes a lengthy period of psychotherapy with a child. This treatment began only after a prolonged contact with other child and adolescent mental health services during which the child's difficulties, which had initially seemed to be ordinary behavioural problems, had proved puzzlingly intractable to a variety of interventions. Subsequent psychotherapy revealed a profound disorder of development which lay bath the Surface presentation. In a climate where Asperger's syndrome is often felt to be untreatable, this paper argues that some children, at least, can benefit from psychotherapy and can be helped towards real mental growth. Asperger's syndrome in children bears some striking similarities to narcissistic personality disorder as described in the adult psychoanalytic literature and this paper discusses some of the theoretical and clinical implications of the innate origins of Asperger's syndrome.     

Frustration and disappointment

The paper describes research on children’s responses to failures of gratification. Although this has always been an important area of consideration in psychoanalytic thinking, arguments are put forward for the child’s actual feelings of disappointment being significant in ways that have yet to be fully realised theoretically and clinically within Kleinian object relations. Since Freud first used the term ‘frustration’, it has been applied in psychoanalysis as a means by which to describe in an undifferentiated way all those responses to failures of gratification that have an aggressive content. It will be argued that, in a context of the historical shift in thinking from drive to relational models, there is now perhaps scope to posit the existence instead of two discrete object relational positions towards such failures of aim – that frustrated responses can be differentiated in important structural and developmental ways from disappointed ones, by suggesting that the former are schizoid, whilst the latter are depressive in quality. To try and begin to test the hypothesis that there might be an object relational distinction between feelings of frustration and feelings of disappointment, selected process notes from two training cases became the subject of a combined piece of clinical and theoretical research. I will outline how this research was undertaken and present the findings that arose from the clinical part of it. With the use of a content analysis, a method for gathering interesting quantitative data about the children’s various responses to the failures of gratification was arrived at.     

‘I don't want to be the mother of a paedophile’: the perspectives of mothers whose adolescent sons with learning disabilities sexually offend

The subject of sexual abuse is a major focus of professional and public concern. Sexual abuse of (and by) people with learning disabilities evokes even greater disquieting emotions, and makes severe demands on the social services, and the criminal justice system. The aims of the project were: 1) to determine whether group psychotherapy produced effective outcomes for adolescent boys with learning disabilities who exhibit sexually abusive behaviour, 2) to explore the perspectives of parents and other care-givers, and 3) to document the nature and extent of service support to families. This paper focuses solely on the mothers' perspectives. This was a three-year project with six boys (under 16) receiving group psychotherapy, using both quantitative and qualitative methods. Clinical measures were used to track changes throughout the course of psychotherapy. Semi-structured interviews (taped and transcribed) were held (separately) with the boys, their parents, paid care-givers and the therapists. The mothers tried hard to make sense of, and come to terms with, what was happening to their sons and to themselves, they struggled to reconcile their own confused and often conflicting emotions, and to maintain their own sense of identity. They felt almost totally unsupported by the services, both in the past and present, and could see little hope for the future. There is an urgent need for development of effective and sympathetic services for the parents of boys with learning disabilities who have been abused, and who are now showing abusive behaviour.     

‘And when you were a child?’: how therapists working with parents alongside individual child psychotherapy bring the past into their work

When a child is offered psychotherapy, it is common that regular meetings will be offered to the parents. However, there are debates in the literature about the degree to which such parent work should include a focus on the parents’ own childhood experiences. This study aimed to examine the way that those offering parent work as part of a study evaluating the treatment of adolescent depression dealt with this issue in their work with parents, both in the study and in routine clinical practice. Design: five therapists were interviewed on the subject of working with parents’ childhood experiences within parent work parallel to child psychotherapy. Data were analysed qualitatively, using Interpretative Phenomenological Analysis. Findings: participants described the need to consider the different parameters of this work to individual adult therapy; in addition, participants felt that it was necessary to negotiate permission to work on the parents’ childhood experiences. They also spoke of making use of insight into the repetition of the parents’ history, the analysis of parental projections and offering containment within the relationship; this varies from the ‘transference work’ of individual therapy and a different style of interpretation was described. Conclusions: there is a need to give more attention to the neglected field of working with parents alongside individual child psychotherapy, especially at a time when such work is under threat within many public services. There are particular technical issues related to work with parents’ own childhood histories that are different to how one might work in individual therapy with a parent.     

An individual approach to psychotherapy with psychotic patients

In this paper I attempt to explore particular aspects of the therapeutic process, especially the unusual way in which the therapy of this 11-year-old girl, referred for possible or potential anorexia nervosa, came to a sudden end. The oedipal configuration provides a useful theoretical framework in which to consider the course and vicissitudes of treatment. The restoration of a link between the child and her father allowed a distance to be created between mother and daughter. The meaning of this is considered both in terms of external events and clinically within the transference relationship.     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.     

Assessment for psychotherapy

This paper explores some issues that might arise when one considers having a table hockey game in the therapy room, and describes how an autistic boy, aged four-and-a-half when starting treatment, used that game. The unfolding process from withdrawal to separateness, intersubjectivity and playfulness is illustrated by the progress of two years of twice-weekly psychoanalytic psychotherapy. Special attention is paid to how the play progressed through the intermediate area that the therapist provided.     

To know or not to know: an application of Bion’s K and –K to child treatment1

The authors discuss an application of Bion’s conceptualisation of thinking and non-thinking states (K and –K links) to the treatment of a nine-year-old girl. The authors consider Bion’s interrelated concepts such as K and –K, container/contained, maternal reverie, and the development of thinking through alpha function to be highly applicable to child treatment. The afore-mentioned conceptual elements are used to elucidate case material over two consecutive hours. A K link is established between therapist and patient, the fragility of which link is then demonstrated by its deterioration into a –K link. Complex issues about knowing and not knowing are central in this girl’s clinical presentation. She was conceived through in vitro fertilisation (IVF), and subsequently diagnosed with cerebral palsy. The authors consider the emotional impact of this origin story and how the parents relate to it. The authors discuss how parents sometimes cope with perceived losses by wishing to shield or protect their children. This can have repercussions for children’s efforts to know (K) and not to know (?K). The fear that emotional knowledge will be too painful to bear can interfere with ‘learning from experience’. Bion’s premise that the purpose of analysis is the growth of the mind is synonymous with the child analyst’s goal of fostering development and understanding impediments to development.     

Counselling,autism and the problem of empathy

The experiences of disabled people suggest that ableism insidiously and invasively impacts upon the practice of counselling and related therapies. This article critiques a particular account of psychotherapy with a child with the label of autism to illustrate how ableism can disrupt the process of empathy and negate the therapeutic experience. In so doing the article highlights the inherent difficulties in traversing different epistemic positions to make sufficiently informed readings of counternormative expressions of being. General principles of counselling practice are then proposed to support practitioners with providing effective therapy for all clients.