Some Aspects Of The Psychotherapeutic Treatment Of A Child



My aim in this work is to discuss some aspects of the treatment of George, a boy who has been in care since the age of two and who has not had any continuous mothering or family relationships since that time.

Till fairly recently, children who were so emotionally damaged at such an early age were very often considered unreachable through psychotherapy, because of their difficulties in accepting any relationships offered to them and the hostility with which they reacted to it. My experience with George is in line with Boston's view when she states that "interpretative work along psycho-analytic lines is possible with these children, but there are considerable difficulties in coping with the violent feelings which are aroused." Typically, in severely deprived children, these feelings are used to create a hard shell which is used defensively as a protection from further emotional pain.

One of the most difficult aspects of the treatment of these children is the struggle to establish a therapeutic alliance and to gain their trust. This trust has been broken many times by the time they reach treatment.

Before discussing George's background and his therapy, I would like to reflect briefly on the setting in which treatment took place. I treated George in a day school for maladjusted children which he was attending at the time and to which I was attached as the child psychotherapist. I saw him three times a week for two and a half years, and during that time I became acquainted with a number of problems peculiar to treating a child intensively in a school setting.

The first point to consider here is the quality of the relationship between the therapist and the teaching staff. Without close co-operation, no treatment stands any chance of success, on two counts, (a) in these schools teachers fulfill the supportive role that parents or substitute parents would play in the child guidance clinic, and (b) this setting gives a child many opportunities to try to manipulate and divide the adults involved.

Another aspect to consider is the difficulty of keeping the transference within boundaries. Contrary to what occurs in a clinic, where one sees a child only during his session time, working in a school setting makes meeting the child outside the Therapy Room almost unavoidable. The therapist is seen talking to teachers, having tea in the staff room, walking around the building, etc. I found, as Jackson does, that such unclear boundaries arouse jealousy and envy, and these feelings can sabotage the therapeutic alliance and weaken the child's trust.

In addition, feelings of jealousy and rivalry are stirred up in children who share the same therapist and are in daily contact with each other, and further, there is the division between them and those not in treatment.

The issue of how a child arrives for his session is not clear cut either. The question of responsibility for the child in transit from different locations in the school (i.e. the playground, the classroom, the dining room, etc.) implies delicate negotiations in each case, as it imposes an extra burden on teachers and auxiliary staff already working under stress. Initially, I experimented with collecting children myself, but found this counterproductive because it increased the patient's scope for acting out and contributed to stirring up the children who were not involved.

The question of confidentiality requires discernment of conflicting needs: if the therapist is perceived to be too secretive, the team may feel demeaned and can become envious and hostile. The balance must be maintained between the need to keep the psychotherapeutic relation a private one, thereby safeguarding the child's trust, and the need to give the staff enough feedback to provide them with an adequate understanding of the process and to secure their support for the treatment. It is important for teachers to be able to feel that they are gaining something from the treatment, either improvement in the overall behaviour of the child, or a deeper understanding of his difficulties.

Finally, the effect that six breaks a year (including half-term holidays) has on deprived children, who are particularly sensitive to separations, should be considered. Each separation reawakens the original pain caused by rejection and abandonment. The therapist must be able to hold this dimension constantly in mind.

Early History

George was born in London of West Indian parents. He is his mother's second illegitimate child. He was placed in care by her at the age of two with his older sister Sharon, who returned to the maternal home some years later. Mother has had two more girls since then and they all live together.

George has never returned to his mother's home and she has never shown any interest in, or awareness of, his needs. Her contact with him has been very sporadic and unreliable. Long periods of time have elapsed without her seeing him, and without anyone concerned with George knowing of her whereabouts. She has said she does not want to see her son because she is reminded of the very unhappy relation she had with his father. She will occasionally visit and try to compensate by giving George material things.

We know nothing of George's birth and early history. Mother does take an interest in her three girls and seems to cope well with them. Whatever relationship there is with George has to be insisted upon and developed through the efforts of the social worker. Despite this persistence, contact has been negligible. George's father is not known.

By the time I met George he had already had six placements and two failed fostering situations. The first fostering attempt occurred when he was five and it came to an end a month later. There was a second attempt when he was seven and this also broke down very quickly. The reason is not known. In each case, he returned to the children's home he has been living in since the age of five, to which he is strongly attached. He has a particularly strong relationship with the superintendent and his wife, who have always shown a marked preference for him.

He was referred to us at the school because he was extremely difficult to manage in ordinary school. He was often aggressive and disruptive, and absconded persistently. As a result, he was suspended from his primary school. From the time he joined that school he rarely completed a day. When asked to work or do anything, he would run from the classroom and out of the school. Within a few days he was taking groups of children out, often arriving early and collecting them before school started. This led to mounting problems with the parents of the children concerned.

Despite his difficult history, he was liked by those who cared for him and related positively to the staff. He is of average intelligence and usually very lively.

Physical symptoms which appeared early on, and have persisted, are asthma and bed-wetting.

Initial Phases of Treatment

George was almost nine years old when he was referred for treatment. He came to my attention months before he was referred to me. He tried several times to force his way into my room, either by trying to force the door, or by slipping past me as I was entering or leaving. He would stop me in the corridors and ask with enormous curiosity what there was inside the room, whether I saw other children, and if so, why I could not see him. He insisted he wanted to come. I would have to hold him physically to prevent him from getting into the room, and would have to pick him up and carry him out in my arms like a baby. He gained great pleasure from these situations.

I will describe the first and second assessment interviews, the first session and the after session before the first holiday, as some of the most important themes of his therapy were enunciated at this early stage. I have left out the interpretations I made at the time in order to preserve the flow, and I have added my comments at the end of each session.

First assessment interview: George was brought in by the headmistress, who introduced us and then left the room. I invited him into the inner room. He came in eagerly and stopped by a table where I had some toys lined up (a lorry with a crane, a car, a cow, a bull, three calves, a family of pigs and a few crayons). He looked at them and then sat down in a chair opposite the table.

1 asked him if he knew why he was here and he said he did. The headmistress had told him that I was going to help him to get back to ordinary school. He said that he wanted to come very much, and smiled when reminded of the times he had tried to force his way into the consulting room.

We agreed to meet a few times and see how he felt about it. Then I pointed out that the toys were for him and would be kept in the locker at the end of the session for the next time. He smiled and asked me if I did the same with J (another boy I was seeing) and whether he had his own place too?

When asked what he thought, he became very shy and did not answer. Then he leaped out of his chair and started touching all the toys. He put all the wagons together and tied them to the lorry, and put a family of animals in each wagon. In the front wagon he put the pig family, in the second the cows, and in the third the lions. Then he made the lion from the last wagon go to the first one, pick up a little pig and come back. He said the little pig had been wounded by the lion and dropped him. The car behind the lorry and wagons was watching, he said, and he picked the little pig up, put him in the boot and took him to the vet.

Then there was a fight between the bull and the lion with all the animals watching, and the bull was wounded.

He put all the toys in order in his locker and started pacing up and down the room, and looking out of the window. Turning to me, he said he did not know what else to talk about.

He sat on a chair and started drumming a beat. Then he told me he knew how to play the drums. He went up to the desk and started drumming another beat.

The time was up and we agreed to meet again the following week. At the end, he asked if he could go to the toilet. I took him there and then took him back to the headmistress.

Comments: From the beginning a strong element of idealization can be detected. It manifests in the readiness with which he comes into the room, the high expectation he has placed upon the therapy and his eagerness to continue coming.

There was also an intense feeling of insecurity present which seemed to be related to the fact that this was an assessment, and to his worries about whether I would accept him and take him in. He tried to conceal this behind a facade of seductiveness; he had to show himself at his most attractive. Just being himself did not seem to be good enough - after all, it did not get him in with his mother.

Very soon after that, the first signs of rivalry and jealousy towards my other patients (his analytic siblings) started appearing, and also his feelings of greed. So the questions of who is included, who is excluded, and who gets what, appear already.

Looking at the next sequence from this angle, the lorry would represent me and the wagons my different patients (he being represented by the wagon with the lions, the last one in the row, my last patient). Very quickly this situation becomes unbearable and the lion (a part of him) has to intrude into the other two wagons, wounding the pig and the bull. He seems to be expressing how, when he feels left out, he can become an angry, intrusive, wounding lion.

These feelings also get projected into me and therefore, this angry, intrusive, wounding lion also represents his fears of me and of the therapy that might intrude and wound his vulnerable parts.

In addition, there is also a hopeful aspect present in the sequence where the wounded pig is seen, picked up, taken to the vet and cured.

Second assessment interview: He came in smiling, with a pair of shoes hidden under his sweater, saying that he had taken them from a boy and asking me if he should give them back. I put the question back to him. He went out, returned the shoes and came straight back. He asked me for water and started drinking from the tap.

He looked at some things which were on the table and I explained it was the rest of his material (a family:- grandpa, grandma, father, mother, brother, sister and baby, and some plasticine). He said he had to collect the toys from the locker. He wanted to open the locker with the key but I said I would do it.

He started by taking out the lorry and the small car. Then he took the family out of the bag and put them all on the back of the lorry. He brought the animals out and said the family was going for an outing to the zoo.

He called the little boy Kiddo, and he said that Kiddo was driving, but he put the man in the driving seat and Kiddo next to him, with the rest of the family in the back of the lorry. When they reached the zoo, Kiddo came out of the car and sat on the lion's back, while the rest of the family were placed under the table; he said they had gone to the vet. Kiddo and the lion went off to America, and Kiddo was taking £1,000 with him.

Once they crossed the sea they both got out onto the lorry. After travelling for a while the lion said that he wanted to go and look for the lioness, "but as he didn't see her, he forgot her and never thought about her again".

Kiddo had stolen the £1,000 for the journey from the family, who had to sell the car and leave the house to try to raise the money to pay it back, but they managed to get back into the house. In the meantime, Kiddo and the lion were continuing their journey and he said they were good friends.

After this there was a scene in which there was a big fight between all the women, "and they all died". Kiddo got into the middle of it and rescued the baby, and took it away with him. He explained that Kiddo and the baby were the same because the baby was Kiddo when he was small. Here the session ended.

We agreed that we would meet regularly (once weekly). He was very pleased. He put all his things away and asked me for the key to close his locker. I gave it to him and he started using it to try to open the other lockers.

Comments: The beginning of this session can be thought of as an attempt by him to clarify the therapy situation in his mind by trying to find out what my role and my place in it were, what was his role, and how we were going to relate to each other. He does this by posing three different questions or challenges: (a) Can he bring the more delinquent or negative parts of himself into the session, and if so, what will happen? (b) Who is responsible for looking after the boundaries of the treatment (who holds the keys)? (c) Who will be in the driver's seat?

The sequence of the separation of Kiddo and his family can be taken as a symbolic re-enactment of the original separation from his mother. The journey to America with the lion can be considered as an idealized version of our relationship - we would go to America, land of hope, promised land, and the £1,000 can be thought of as the material substitute for the loss of the family (a kind of compensation).

In the sequence of the lion looking for the lioness we can see two things, (a) An explanation of how he tries to deal with the painful things of his life (i.e. separations). When they are out of sight they seem to drop out of his mind and "he never thinks about them again"; (b) It can also be looked at as an expression of his worry about any of my other interests (i.e. my other patients, the school, my family, etc.) and an attempt to separate me from them by splitting so that we can remain together in an ideal and exclusive relation.

When these defences fail his insecurity and jealousy get stirred up. He gets swept away and taken over by a delinquent and cruel part of himself (the money becomes stolen money, the family who was at the vet becomes destitute and finally, all the women get killed in this great war). It can also be seen as a reflection of the fragility of his internal world; everything can easily get smashed up.

Kiddo rescuing the baby and relating to it as part of himself can be seen as (a) an attempt to integrate a part of him and rescue it from all that chaos, mess and destruction, and (b) the expression of an understanding of the process we were about to embark upon, (there was somewhere a baby that needed to be found, rescued from the battlefield and taken in).

First session: He was not in his class when I went to look for him and he came to my room a few minutes later saying that he had been mucking around. (I had arranged with him a change of day.) He tried running into the inner room and locking me out, unsuccessfully. He then wanted to open the locker himself with the key. I did not allow him this and did it myself. He took out the lion and the boy and played with them for a while, not letting me see what he was doing. After some time he asked me which locker was J's (a boy whom he knew I was seeing). When he did not get a reply he said he did not want to stay in the room. He tried to run out and I had to stop him. He tried locking me out of the room by running in and out. Once inside, he tried opening all the lockers and started climbing the pipes. Then he said he did not like coming on this day of the week; he preferred the day he had had previously. Looking out of the window, he started spitting against the windowpane.

Comments: The initial part of the session in which he keeps me waiting, tries to lock me out of the consulting room and finally wants to get hold of the keys of the locker, can be regarded as George's attempt to get into my shoes by reversing the real situation and thus becoming the (daddy) therapist in charge of the (mummy) treatment. He is trying to get rid of feelings that are too painful for him to hold by putting them into me (having to wait for me from one session to the next; feeling that he is being kept locked out when he is not inside the consulting room; depending on me to tell him when he can come, and when he has to go - all these things are unbearable to him).

The appearance of another patient of mine in his mind is experienced as being thrown back into himself and left totally at the mercy of his strong emotions.

His attempts to break into the locker and his difficulties in remaining inside the therapy room can be seen as an expression of what happens to him when he feels shut out. Then rage takes over and as he cannot contain it inside himself, it "spills out".

Another way of putting it is that he feels shut out; in anger he tries to force his way in, and then he is afraid of being trapped inside and has to break his way out.

The anger of this session is related to the change of day of his session, which he felt as his having been spat out of his old time.

He only feels safe bringing his anger into the therapy now that he has secured his place and I have started seeing him regularly.

First session after the first holiday: He was running around the playground with another boy, teasing a teacher who was trying to catch him. After a lot of taunting, he was finally caught and the teacher handed him to me. I held his hand and took him up to the room.

When he got inside he sat on the radiator and asked why he had to come, if this was for him to go back to ordinary school, that we never talked about ordinary school, and that apart from that he did not have any problems. He got down from the radiator and started spitting around the room.

Then he took some black charcoal and started trying to write on the walls. When I stopped him he said indignantly that I had not told him he could not make marks on the walls. He went up to the basin, got little containers, filled them with water and said he was making a bomb that would blow everything up. He said he was going to throw it at me if I got closer, and he threw some water at me. He got frightened, saying it was an accident. (I took the containers away.) He got some crayons out and started writing on the blackboard, and looking at me said, "You think you are tough with those lady boots you have on."

He wrote on the blackboard "I love you" and quickly scribbled over it. Then he said, "You can't understand back-slang" and started scribbling on the blackboard, saying it was back-slang.

I opened a box to look for some chalk for him. He jumped up and tried to look. Although it had nothing inside he thought it was full and said admiringly, "How many toys!" (without having been able to have a proper look). He thought he saw a gun. He said he wanted it, and then he wanted to give me his lorry and wagon and said he wanted to swap them for the gun.

He got a piece of paper and started drawing on it, asking me all the time if I knew what it was (he drew a dog and scribbled). Then he looked at me and said, "I bet you thought it was back-slang".

He told me he was nine now, that he had had a birthday two days before. He drew a pregnant lady pushing a pram, and then started drawing cars and asking me which was faster. When it was time to leave he did not want to, and finally left with great reluctance.

Comments: By playing hard to get at the beginning of the session he is expressing how he experienced me during the holidays. At the same time, he is attacking me by showing everyone how awful it is to have to come to me.

The bomb represents his explosive anger and his difficulties in containing it inside him. Despite the fact that he mentions going back to ordinary school, he is showing by his inappropriate behavior the reasons why he cannot go back.

His challenging and belittling me are attempts to put into me his own feelings of worthlessness, which are too painful for him to carry.

After getting rid of all the anger and mess, he is able to change the quality of what he gives and be more in touch with his feelings.

His worry as to whether I can understand back-slang is a manifestation of a deeper worry; whether I will be able to understand him and his double talk (will I be able to see the loving feelings under the scribble?). This was very important for him because when he got into rages he would lose contact with his soft and vulnerable feeling parts. Therefore, it was crucial for him that I should keep them in my mind by not forgetting. Hoxter touches on this point when she writes that, "for deprived children remembering is very important, because one of the big deprivations of a deprived child is not to be remembered".

In the incident of the box, his feelings of being shut out are again in evidence, although this time he appears more able to contain them inside himself.

The gun seems to stand for the potency and grownupness that I should give him in some magical way, without his having to work for them.

Very soon, it became clear that George's needs were too great to be met with only one session a week. The gap between the sessions was too long for him, making his experience of having to wait an unbearable one. At the same time, my presence around the school on the days I did not see him was experienced as tantalizing and as a provocation.

He was able to transmit these feelings to me in unmistakable ways; by trying to break into the therapy room on days when he had no session, or by looking for me and following me around the school, saying that he was going to come that day despite the fact that it was not the day of his session, or by proposing to swap his session day for another one, etc.

Three months after the start of the therapy, having discussed this situation and his feelings about it at length, we both agreed to increase the number of his sessions to three a week, and this remained a steady arrangement throughout the rest of the treatment.

The Treatment

Looking back on George's treatment, one of the outstanding aspects was the amount of violence and destructiveness that was in evidence throughout. I found it useful to think about them as external manifestations of deep feelings of rage and indignation caused by the terrible experience of being abandoned by his mother at such an early age.

During the course of this therapy, his original tragedy was to be re-enacted time and time again in hundreds of different ways. We would have to travel together through the labyrinths of his mind into dark corners where his nightmares and fears reigned. Apart from being a witness and a travel companion, I would also be allocated different roles in the drama. Sometimes he would experience me as a callous mother who was having a lovely time, not sparing a thought for him, or as a cruel father who enjoyed causing him pain, and in this constellation he would be the unwanted child who was suffering. At other times I would be placed in the position of the poor abandoned child, victim of the circumstances, who would have to be left, attacked and hurt, while he would identify with a sadistic father (who did the attacking and caused the pain) or a disinterested mother (who did the abandoning).

Very often I would be used as a bank in which he would deposit his feelings (especially the painful ones) when they became too intense. A brief example from his material can illustrate this point. He wrote in his notebook, "My mother is a slag". Two minutes later he came up and started punching me furiously while accusing me of having insulted his mother.

His rage could be overwhelming at times and would tend to take over the whole session, leaving very little room for thought. In these moments, George would be lost to the outside world, taken over and at the mercy of his powerful feelings of destruction and devastation. Very often these feelings were directed at me.

They expressed themselves as attacks whose principal aim was to stop me from thinking about what was happening to him, since thoughts would be experienced as very persecuting. He tried to force me to react to what he was doing from a gut level rather than a mental one. Another way of putting it is to say that he would try to drag me down from a thoughtful and mindful space to a visceral one, in which he would feel less separate from me. I would experience these times as having a baby full of rage stuck inside me, who was trying to destroy everything and who did not want to be comforted or taken out of his misery. He just wanted to fill me with all his messes and mess everything up.

This leads me to a very important aspect of the treatment; the function of holding and the different meanings it had for him.

I will deal first with physical holding. Often when he would get into a rage I would have to hold him physically. Holding then was an external limit which helped to protect both of us from the impact of his destructive feelings. It also provided him with firm boundaries which were very important when he was overcome by his dreaded feelings of being blown apart and of disintegrating.

His reactions to this type of holding would vary from coming up to me, giving me his hand, asking me to hold it and then falling asleep (like a contented baby), to feeling totally persecuted and trapped, when I would have to hold him in some of his more violent moods to protect him, myself and the room from his attacks.

But the most important way of holding George was to hold him in my mind, and it was on this score that I would be tested by him time and time again. He attached great importance to my memory and would always be pleasantly surprised when he noticed that I remembered some detail of what he had said or done in a previous session. Boston says that children in institutions often experience changes of personnel as changes of mothers who come in with no memory. For this reason, it was essential that I carry not only his life history and his therapeutic history in my mind, but also the different parts of himself with which he would often lose touch.

The example cited earlier illustrates this point very well. It was crucial that in the middle of his mindless rage I should remain mindful of the part of him that was suffering, and with which he had lost touch, because the pain was too great for him to bear. This reliance on my memory helped him to start developing the rudiments of an inner sense of security. Although he would still get lost there was some trust (sometimes) that somewhere there was a daddy or a mummy therapist who cared enough to go and look for him, find him, clean his mess and bring him back.

The battle for his trust was an ongoing one and we would both have to struggle daily to keep it alive. This constant readiness to lose his trust is related to his early experiences of being abandoned, when he felt dropped and forgotten. These feelings were always present in the sessions and very little was needed to trigger them off, whether it was a momentary lapse in my attention, the gaps between the sessions, the weekend breaks, the holidays, my other patients, etc. He would experience all of these as his being pushed out, forgotten, and dropped out of my mind. I would then be felt to be a cold and distant mother who goes out with different daddies to make new babies, and who will eventually push him out for good (sending him into care).

With his natural versatility, he had many ways of letting me know when he felt dropped. He would do it by trying to hang out of the window and forcing me to stop him, (the consulting room is on the second floor), or by throwing all his toys out of the window, or by climbing on top of the cupboard where the lockers are and diving onto the bed below (he did this so often that he finally broke the bed). The most dramatic way in which he ever expressed these feelings of being dropped was once, a few months before the end of therapy, during playtime, he climbed the outside wall of the school up to the window of the consulting room. With this dangerous act he was denouncing me to the whole world as an uncaring, cold hearted, dropping mother, who did not even care if he lived or got killed. This last act can be seen as part of a broader category of behavior which was always present throughout the treatment; his "accidents" and self-inflicted injuries.

Hoxter says that they are the only self-destructive or suicidal attempts left to a young child. She links them with emotional neglect and says that they can be seen as an expression of the lack of a caring mother who holds the child in her mind and gives her attention and concern to the safety of the child.

We can look at two sessions to see how some of the things mentioned here manifest themselves:-

First session: He came in late and played around in the outer room until he finally came in. Once inside, he started spitting into another boy's locker. I stopped him and he climbed onto the cupboard and started spitting around the room. After some time he came down and tried to have a fight with me. Although he was angry, be was not being very violent so that I was not forced to engage. While he was provoking me, he said in a very threatening way, "I am going to do to you what no other kid has done to you before, and you can't imagine what a kid can do". When I asked him "What?", he shouted, "You wait!" and hurled a string of abuse at me and repeated the same thing again.

He went to the sink, drank some water and then, filling his mouth with water, started spitting it all over the room. He then asked to go to the toilet and came back five minutes later. When he came back he went up to the bed and hid under the blanket. He would pop his head out every few seconds and ask how long to go to the end of the session. After some time, he came out and started pacing up and down the room, asking me what his name was, and as he repeated the question, he would throw pieces of plasticine at me.

Comments: In the beginning we can see his angry feelings getting stirred up and being directed towards the lockers which are a constant reminder to him that he is not the only child I see. This stirs up jealousy and rivalry towards his analytic siblings. His climbing onto the cupboard and his spitting can be thought of as a reflection of how he feels when I am seeing someone else and I am not with him. He seems to experience this as being spat out. He manages to keep some control over these feelings, as they do not carry him away totally. Going to the toilet at that moment can be taken to represent his attempt to get rid of (by evacuation) some of these feelings which threaten to overwhelm him. His change of mood when he comes back can be seen as a confirmation of this point.

By lying under the covers he seems to be using some external container to hold himself together; (this was something he did often throughout the treatment). It also allowed him to feel, for a short time, like 'an inside baby being held by mummy' instead of 'the spat out unwanted baby'. When the idea of time comes into his mind, he also realizes that the session has an ending and so his feelings of being an insider are shattered, bringing his insecurity to the fore.

When he asks about his name, he is expressing his fears of being forgotten and dropped out of my mind when we are not together. By throwing the plasticine at me, he is trying to cause me pain so that I should suffer, and in this way he hopes I will be able to understand his suffering when we are not together. Separations are so difficult for him because with each one the pain of his old unhealed wound (being dropped and abandoned by an unreliable mother) is reawakened.

Second session: George was jumping and kicking by the door. When I brought him in, he struggled, trying to pull away. Once inside, he climbed onto the lockers and started spitting at me and at the room. He climbed onto the heating pipes inside the room, hurling abuse at me and continuing to spit. When he came down, he went to the sink and turned the taps on with great force, trying to splash all the water around the room and spitting at the same time. Eventually he turned the taps off and went to have a look in his locker. Turning to me, he accused me with indignation of 'having ruined everything' (the previous session he had poured water into his locker). He took everything out of it and threw it all over the room. He then went to the window, took his shoe off and started banging against it, while saying in a daring and provocative tone, "If you come any closer I'll break it", increasing the force of his banging. When I got up he tried to break the window, did not succeed, and I took the shoe from him.

He got into an absolute rage, came up to me trying to kick, hit and bite me, forcing me to hold him to prevent him from hurting me. He continued struggling, spitting and insulting me when I was holding him. After a few minutes I let him go. He was still furious, throwing all the furniture around the room and making a great mess.

Then he got his plasticine and started breaking it into little pieces and throwing them at me, admiring the mess he had made. He said in his most provocative way that he was not going to tidy up. Once all the plasticine was broken up, he got up and started stepping on all the little pieces, trying to grind them into the floor and make it impossible to get them off. He refused to stop, saying he was going to destroy the whole room and becoming more and more excited. I got up and held him and again he got absolutely furious. He cried and screamed and kicked, threatened and cursed me.

Nothing of what I said could reach him. He just continued crying and swearing and shouting at me to let him go. When I let him go he kicked me, and then went off and hid behind the locker, saying he was going to pee all over the room. I held him again. After some time I let him go and he got hold of one of the heavy armchairs, hurled it first at the locker and then tried to throw it at me. I held him again and we remained like this until the end of the session. I gave him back his shoes before he left.

When he went out, he remained outside in the corridor, banging against the glass panel of the outside door of the consulting room with his shoes, till he finally managed to break the glass and then he left.

Comments: This session was before a weekend and a bank holiday, which meant he would miss a session. His feelings seem to change from those of an angry baby into those of a raging lion when he is faced with what he experiences as being abandoned. In this session there seems to be very little room left for thought. I am the bad mother who keeps him locked out and makes him suffer. The predominant anxiety is a persecutory one and I am experienced as the persecutor.

His attempts to flood the room, peeing in it and spitting, represent his uncontained feelings which can no longer be kept inside him. They all come pouring out like a flood and sweep him in their wake. The awareness of what is inside and what is outside seems to disappear, and any sense of boundaries becomes blurred and confused.

Another way of looking at this is his need of me as a daddy-policeman protecting the mummy therapy from his mindless attacks.

The breaking of the glass at the end can be seen as an expression of his impotence at not having managed to break into me or my weekend.

In the previous examples we have concentrated mainly on his feelings of being pushed out and dropped, the rage that these would bring up and the function of physical holding as a final container for his inner turmoil, but his real need was of feeling held in my mind.

It was fundamental for him that I should survive his attacks and still be available for him, no matter how awful his behaviour had been (a good mother is one who remains with the child irrespective of what he has done. This would enable him to experience me as a strong, reliable figure, his trust would be re-established and the possibility of thought and growth through understanding would be welcomed. The next two sessions I have chosen as examples will illustrate these points.

First session: He knocked on the door and ran off when I opened the door. He came back fifteen minutes later and tried to hold me by the neck, but he rapidly let go and said, "Let's talk business" as he sat on my desk. "My social worker wants to talk to you because my mother has disappeared again from her hotel. She did not like the flat that the Council was going to give her, and this is why she hasn't come to see the Head with the social worker. She told me that she might leave."

I asked him how he felt and he said, "Bad, I don't want people to think that my mum is a squatter", and he added that he felt badly not knowing where she was, although it was not the first time this had happened. Then he started talking to me about his father, saying that he was very wicked and that his mother had put him into care so that he would not become like him. He continued, saying father was very jealous, he would drink heavily and beat mother up constantly. He would not even let her go out to the shops because he would suspect her of using that as an excuse to go out with other men. While they lived together mother was a prisoner inside the house.

George has never met his father and does not know where he is at the moment, although he suspects that he is either in prison or in hospital.

One day when father was not around, he continued, mother escaped to do some shopping, leaving him and his sister alone in the house. A paraffin heater fell and the house caught fire. When mother came the fire brigade was still there. He did not know how the heater tipped over because he was only a year old at the time, and his sister was one year older. He thought he had done it but he was not sure. After that incident, mother put the two of them into care. About five years later she took his half-sister home but he remained in care.

He then tried explaining to me the composition of his family, in a very confused way. He started by telling me that his step-dad was living with two boys aged ten and that he was a triplet with his sisters. Then he changed this, saying his sisters were living with his mum - two sisters of four and five who had another dad. "So I have two dads", he said. I pointed out that he had three. He looked up at me, puzzled, and then genuinely shocked, he said, "Of course, 1 forgot my own." (He had counted his two step-fathers and he forgot to count his father.)

He was then able to tell me that he was very angry being the only one in the family that remained in care. At this point, he got up from the desk where he had been sitting, went to his locker, took out his pad and a pencil, and started drawing swastikas and National Front signs on it. In the meantime, he mentioned that he had just heard that the superintendent of the home was leaving and he was very sorry because he was close to him. He wrote on the book "My mother is a slag" and asked me to read it aloud. When I reminded him what had happened the last time he had written something like that, he laughed mischievously.

He mentioned the two failed fostering situations, telling me he did not like the people and that they had broken down very quickly. Then he said to me, "You are a psychologist so you are the best person to speak to".

It was the end of the session. Before leaving, he asked me to tell the headmistress about this session. I asked him what part of the session did he want me to tell her about, and he said, "The part of the fire and going into care."

Comments: He is coming to me with yet another situation in which his mother has let him down. In spite of this, there is a part of him that feels loyal to her and wants to protect her. There is another part that is identified with the wicked father and would like to abuse her and beat her up. (He sometimes identifies with the wicked father and at other times feels very persecuted by him.)

The departure of the superintendent who was so close to him is another big blow.

In this session, George is attempting to make some sense of his losses and to clarify his history. He is trying to gather the family together in his mind and allowing himself to think about who is where and with whom.

Within the context of the transference (in the sense that past infantile feelings are brought in to the present relationship) a much greater trust is in evidence throughout this session. George seems less worried about the other children and can use this session more for himself. He seems to value me more and feel held by me; this enables him to contain his painful feelings instead of having to get rid of them.

His asking me to meet his social worker and the headmistress can be thought of as allowing a daddy and a mummy to join in their concern for the child.

Second session: A teacher brought George. He sat on one of the chairs in the outer room, refusing to come in. After a while he looked at me and asked me if I wanted to see his stamp collection. I nodded and he said, "Good, let's go into the other room," explaining that he had not wanted to see me "because I thought you wouldn't want to see them". Once inside, he produced a large envelope full of little stamp books. He started taking them out and showing them to me. As I was looking at them he told me he had not come to the previous session because he had hurt his hand with broken glass in an accident.

He asked me if I had told the headmistress what he had told me, (he is referring to the story of his fostering, and had asked me, and reminded me, about this on several previous occasions). When I said I had, his eyes lit up and he asked me eagerly exactly what had I said, and what had she replied. I told him and he seemed delighted.

He continued showing me the stamps and asking me if I knew where they came from. After a while he put them away and got some glue to stick on the envelope. As he turned the bottle over the top fell off and the glue spilled on the table. He was very worried about the mess. First he wanted to know if it had gone through the envelope and damaged the stamps. Once he was sure they were safe, he wanted to clean the table and started trying to clean it with his sleeve. I gave him a piece of cloth from a drawer and he used it to clean everything up very carefully.

Once he had finished he went to the window and started pulling the ropes of the blind, saying, "My name isn't George, it's Cleo. My sister calls me George, but look in my files, my name is Cleo Rupert". He stopped, reflected a moment and said proudly, "No, my real name is Kunta Kinte".

It was the end of the session. He had to leave five minutes early to go to an inter-school game and said he did not want to miss any of his session. He asked me if I could give him an extra five minutes next time. I agreed and he left.

Comments: In this session, trust does not come easily. He is struggling with his feelings of persecution and the part of him that experiences me as an indifferent parent who is not interested in him or in what he brings.

His persecutory anxieties (linked to the fire - according to him the worst thing he has ever done in his life - and his fears of always being rejected and never being forgiven for it) seemed to be calmed when he had heard that I had spoken to the headmistress, and realized that he was still here. He felt accepted and held by the interest of two concerned parents; this allowed his trust to be re-established. Now he was able to deal better with his own messy feelings and his confusion about his identity (who he really was as opposed to who other people said he was).

When he identifies with Kunta Kinte he gets in touch with a good figure inside him. This enables him to contain his pain and to point to where it hurts. (Kunta Kinte is the story of a boy in Africa who, like George, was kidnapped and taken from his homeland into a land of persecution, and then makes great efforts to rediscover his roots.)

He is able to value and accept this session in the same way as he feels valued and accepted by me.

Preparation and Fostering

After George had been in therapy for about twenty months, the ex-superintendent of his home and his wife offered to foster him. They had left the children's home a year before and remained in contact with him throughout.

When the proposal was put to him he was very pleased and excited. He felt accepted and wanted and was looking forward to living with them as a family. This situation offered him enormous benefits but, at the same time, he was going to have to face many painful losses. The price to pay for being fostered was very high. His prospective foster parents lived in a different and distant area of the city; he would be giving up not only the security of his children's home - where he felt settled after having spent there the last seven years - but also would be seeing even less of his mother because he would be living so far away. Eventually he was going to have to give up his therapy and the school which he shared with most of his friends because it was too far for him to commute.

Initially the fostering situation was set up in two stages, a preparatory period so as to give George and his foster parents time to prepare themselves and explore how they felt about it, and the actual fostering.

For the next six months he was going to spend every weekend and the school holidays with his foster parents, and the rest of the time he was going to continue living in the children's home leading his usual life.

In this period, therapy was crucial. If the fostering was to stand any chance of success he was going to have to come to terms with reality and with his feelings about loss and rejection.

The sessions were very painful at times as he was faced repeatedly with all his losses, which stirred up his persecutory anxieties. Not surprisingly, his violence (which had been more contained in the last year) increased, together with the tendency to evacuate feelings when they became too overwhelming. 

Also in evidence at this time was the part of him which was struggling to contain his feelings and preserve his trust in me (trying to protect it from being swept away by his paranoid anxieties). He was aware that it was essential to attempt to sort out his feelings of chaos and anger to enable the fostering to succeed. The painful work to be done was to effect a shift from unreality towards a more real perception of the different areas of his life.

HIS FEELINGS TOWARDS HIS MOTHER: When he first heard about the possibility of being fostered, he came to the session saying he was going to speak to his mother because he would prefer to go and live with her. After about a week (and having run out of school once to go and see her) he told me that he had been awake all night thinking about the fostering, and that he could not find any reason not to want to be fostered. Then, looking at me, he asked me very seriously, "What has my mother ever done for me?" and he added, "And why is she going to start doing anything for me now?"

HIS FEELINGS TOWARDS ME: The first thing he had to come to terms with in this new situation was that it was someone else and not I who was going to foster him. This obliged him to face his feelings of rejection which expressed themselves in different ways; by his increased violence during the session, by rejecting me (which is what he felt I was doing to him) and refusing to come, or by turning the situation round and saying he would never want to be fostered by me because I am a 'whitey' (his foster parents are also white).

The fostering brought to the fore a second aspect that made him feel unwanted. He had to come to terms with the fact that his therapy would eventually end. His attitude here oscillated between feeling that I was glad to get rid of him (in his more extreme moments he would accuse me, saying that all this was a ploy of mine because I wanted to destroy him) and a feeling of hope and trust in his inner strength.

Two brief examples from his material illustrate these points clearly:-

(a) In one session he asked me, "Aren't you going to be pleased to have all these free hours for yourself when I leave?" (The thought that they might not be free and someone else might use them was particularly painful. In these moments I would be experienced as the indifferent mother who was busy with the sisters and he was the left-out baby.)

(b) His foster parents had asked him to choose what colours he wanted for his new rooms. They had two houses, a country house and a town house. During a session he told me very proudly that he had painted both his rooms with some help from his foster father in the same colours as the consulting room, (exactly the same, he emphasized). Here we see the opposite; he does not feel left out by me because he feels he carries me inside.

His efforts to try to preserve the therapy were also very moving. At times he would insist that there were other schools similar to this one in his area and, if so, why could I not continue seeing him in one of them.

The idea of leaving his school was also very painful. He would have to give up another very important part of his world.

Whether the price was too high was a question he could ask himself sometimes when he was in touch with his feelings of loss. During such times he would be aware of his pain. He also had to face his fear of being rejected by his foster parents, of the fostering possibly breaking down as had the two previous situations. He felt the greatest threat to this new attempt was his violence, which he called his temper.

Often the pain of facing all this was too great and he would deal with it by denying it and refusing to believe he eventually would be leaving therapy or the school. During these periods he would hate me for even bringing up the subject and he would take it as 'the final proof of my intention to get rid of him'. He went as far as going to the headmistress to complain about the awful things I was saying to him, and taking the air out of my car tires to prevent my leaving.

During this time he was able to use the therapy and the school as containers for his pain, his anxieties and his difficulties, thus enabling the trial period to succeed, with both George and his foster parents enjoying each other's company. His existence became much richer and the holidays and weekends were now times to be looked forward to.

After the preparatory stage was over full fostering took place. It was on a trial basis for a period of four months, after which (if it was successful) the fostering would be considered permanent and his name would be taken off the register of his children's home.

He insisted that he wanted to continue coming to the school during this time, although he knew that four months later he would have to leave to attend a school in his new area.

The situation (the premature ending of his therapy and the uncertain outcome of the trial fostering) proved to be too dreadful for him to hold, and he reacted by splitting off his painful feelings. He refused to come to his sessions and he would take every opportunity to vent his anger towards me; he would express it by attempting to split and make trouble between the teaching staff and myself, and by accusing me publicly of being cruel to children and of being hard. He seemed to experience me as an abandoning mother who did not care what happened to him, and as a sadistic father who obtained pleasure from seeing him suffer. This filled him with uncontrollable rage. Needless to say, during this period, he had lost contact with his trusting, caring and loving parts. (These were split off together with his pain.) There was a marked increase in his violent and delinquent behavior around the school.

In spite of the added strains everyone had to endure, both George and the school managed to 'hold on' till the end of the trial period, which was completed successfully.

In an attempt to regain contact with his lost feelings and to re-establish me as a good figure inside him, George came to his last session to say goodbye. He told me he wanted to look into his locker for the last time, then he looked at me, ruffled my hair, and with a big smile said, "We've had good fights together".

At. the end of the session he tried to take a pencil with him. I told him that he was carrying with him all the work we had done together over the years. He smiled, gave the pencil back to me, we shook hands and he left.

The following day he left the school.


George has now been in his foster home for a year and in his new school for eight months. During the preparation of this paper I contacted his class teacher and his social worker.

The teacher reports that George has settled in quite well. He is in a class of eight children, with peer grouping, She says he is a very lively child who can be "a complete and utter pain, but he is controllable and containable". He finds it difficult to settle to work and is behind, but appears to realize that if he tries hard he will improve. He is still "attention seeking and stroppy, but is meeting a united front within the school which seems to be working".

There is good contact between home and school. The social worker reports that the fostering is going well, so that he only visits once every six weeks. He confirmed that George's foster parents are pleased with him and attach great importance to the fact that school and home act in unison; this has resulted in an improvement in his overall behavior. 


BOSTON, MARY Psychoterapy with a Boy from a Children's Home

Interim Notes on a Study of Psychotherapy with Severely Deprived Children

HOXTER, SHIRLEY Private Communications 

Emotional Abuse: How can One Define It?

JACKSON, JUDITH Child Psychoterapy in a Day School for Maladjusted Children