Bombs in the Consulting Room

Surviving Psychological Shrapnel

Brett Kahr

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9780429798542
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

What does one do when a dangerous paedophile, nearly six feet seven inches in height, threatens to kill you? How does one manage when a brain-damaged, psychotic patient spits on the office floor two hundred times during the first consultation? And what does one say when one member of a warring couple reveals the most horrific acts of sexual cruelty?

In perhaps his most gripping book to date, Professor Brett Kahr offers colleagues a detailed glimpse into the challenge of working with highly distressed and disturbing individuals in long-term psychotherapy. Kahr explains the ways in which such deeply troubled people hurl "bombs" into the consulting room, leaving considerable "psychological shrapnel" in their wake.

The book contains five sensitively and compellingly written clinical chapters, followed by several historical chapters which explore the ways in which Donald Winnicott attempted to manage the bombs in his consulting room, often of his own making. Kahr then examines the pioneering contribution of Enid Eichholz (later Enid Balint) who, during the Second World War, created marital psychoanalysis as a means of dealing with couples ravaged by actual wartime bombs. The book concludes with an historico-clinical chapter on how thoughtful and sophisticated classical interpretation can reduce the impact of clinical bombs. Kahr even provides us with an examination of his favourite "top ten" interpretations in the history of psychoanalysis!

A unique and helpful volume, written by a practitioner steeped equally in psychoanalysis and history, Bombs in the Consulting Room: Surviving Psychological Shrapnel will be essential reading for anyone who has ever felt frightened while treating patients.

PART I

ENGAGING WITH BOMBS

The truth is, we like to talk over our disasters, because they are ours; and others like to listen, because they are not theirs.

“Comtesse de Soissons”, in Anonymous [Letitia Elizabeth Landon],
Francesca Carrara: In Three Volumes. Vol. III, 1834.

CHAPTER ONE


The paedophile who threatened my life

The best chances of recovery in mental disease are obtained when a patient is treated early.

Dr Robert Henry Cole, Mental Diseases: A Text-Book of Psychiatry for Medical Students and Practitioners, 1913 [Cole, 1913, p. 291]

Many years ago, during a fifty-minute session in my consulting room, a teenage sex offender tried to kill me.

Fortunately, I survived.

In the pages that follow, I provide some sense of my experience of working with this violent and troubled juvenile paedophile who threw bombs into the lives of several young people and who, in his psychotherapeutic sessions, also gave me a taste of that experience.

Clinical material

The case of Alfonso

The referral

I began to work with “Alfonso”, a 16-year-old male sexual offender, in the latter months of 1996. Alfonso had committed several acts of sexual abuse, including not only undressing many prepubescent youngsters but also perpetrating full penetrative intercourse on three young girls, all aged 5 years.

Naturally, the local department of social services assigned to care for Alfonso had serious concerns about the aggressive behaviour of this young person. Alfonso had first come to the attention of the social services authority as a small boy: his mother had put him up for adoption during his eighth year, claiming that she could not care for him adequately; indeed, she feared that she might beat Alfonso physically if she had to continue living with him. During the previous year, Alfonso’s father had died from a heart attack, and no doubt the sudden loss of his father proved highly unsettling, not only for Alfonso but also for his mother and his six siblings. Consequently, Alfonso then progressed from one foster care home to another, becoming increasingly violent towards both children and adults, hitting and screaming with great frequency.

At the age of 14, Alfonso attempted to strip a physically and intellectually disabled 10-year-old girl of her dress and brassiere; on another occasion, he had removed his own trousers and underpants in the presence of an 8-year-old girl in a toilet, urging her to take her clothing off as well. Later that year, he progressed to violent vaginal penetration with three different 5-year-old girls, whom he had abducted from a nearby playground. The local authorities became increasingly anxious that this troubled teenager posed a high level of risk to other young children; and a senior social worker referred the case to the Young Abusers Project: a pioneering collaboration among the Tavistock Clinic in London, the Department of Health, the National Society for the Prevention of Cruelty to Children, and the National Children’s Home Action for Children.

The psychiatric assessment

Alfonso first presented to the Young Abusers Project in 1995, for both psychiatric and psychological assessments. His designated social worker requested an expert opinion on three particular issues and concerns:

1. a determination of the risk of significant harm that Alfonso posed to other people in the local community, especially young children, as a result of his physical violence and his sexually abusive behaviour;

2. a recommendation regarding the suitability of Alfonso’s current foster care placement;

3. a recommendation for treatment options, should the Young Abusers Project be able to demonstrate that Alfonso did, indeed, suffer from a potentially treatable psychiatric condition.

In order to undertake a full evaluation of Alfonso’s mental state, my colleagues at the Young Abusers Project drew upon a substantial amount of documentation from social services and the police, as well as reports by previous child psychiatrists and child psychologists who had evaluated this highly troubled person over the years. The Young Abusers Project also arranged for Alfonso to be assessed psychiatrically by a specialist child psychiatrist, and subsequently a clinical psychologist from the Young Abusers Project undertook an even more extensive psychological assessment of Alfonso’s cognitive capacities.

Alfonso arrived at the offices of the Young Abusers Project near Christmas, 1995. The staff who had first evaluated him did not anticipate meeting such a tall, broad-shouldered teenager, of black African origin, standing more than six feet and six inches in height, and weighing roughly 250 pounds. Alfonso proved somewhat paranoid and uncooperative during the two formal psychiatric interviews, and he revealed evidence of his deeply entrenched sadistic tendencies during the very first encounter by throwing a chair across the room. In spite of Alfonso’s violent outburst, the interviewers persevered with the psychiatric assessment, and they managed to ask Alfonso many pertinent questions about his abusive behaviour towards younger children.

Surprisingly, Alfonso spoke rather rapidly and freely about his capacity to become excited by prepubescent girls, and he described how he had inserted his “hard cock” into the “ginas” of the little children, and how this had aroused him. He also confessed for the first time that both he and a male school friend had targeted young girls together, and that on more than one occasion Alfonso and his chum had raped two different girls with great violence and that, in the midst of these sexual and physical assaults, Alfonso and his friend would switch positions, penetrating each youngster in turn. These particular disclosures of sexual abuse by Alfonso emerged for the first time during the course of the psychiatric assessment.

In the midst of undergoing these clinical interviews, Alfonso admitted that he wished to be helped by the Young Abusers Project, and that he spent much of his time worrying about being arrested by the police. Alfonso told my colleagues that he dreaded the prospect of imprisonment.

Shortly after this disclosure, Alfonso became extremely sullen and depressed, and he refused to lift his head. He thus revealed his capacity for feeling shameful affects that might ultimately be mobilised in psychotherapeutic treatment.

Later that month, Alfonso underwent a full battery of psychological testing. During the psychological assessment, Alfonso proved much less willing to engage, and he refused to produce any pictures for the Draw-A-Person Test or for the House–Tree–Person Test, even though the psychologist had asked him to do so. He did, however, respond grudgingly to some of the projective tests, notably the Thematic Apperception Test (TAT) cards, although he complained that he had difficulties concentrating, claiming that he needed to “clear my head”. Towards the end of the testing situation, Alfonso became noticeably tearful. Overall, he performed rather poorly on the Wechsler Intelligence Scale for Children–Revised (WISC–R), receiving a full-scale intelligence quotient (IQ) score of 52, which placed him in the “moderate learning disability” range.

During the administration of the Comprehension Sub-Test of the WISC–R, the psychologist asked Alfonso what he would do if he happened to walk past a stamped envelope. Quite tellingly, Alfonso responded that he would “leave it on the floor, walk past it”. This communication, in particular, seemed highly indicative of both his internal world and of the tremendous neglect and deprivation that Alfonso experienced throughout his childhood. I suspect that he very much identified with the “stamped” envelope lying on the floor, unposted, as this mirrored his earlier experiences of having been abandoned by his mother at a young age and then passed along from one foster home to another in succession, depriving him of any continuity or security during his crucial early developmental years.

After the completion of his assessment, the Consultant Child and Adolescent Psychiatrist at the Young Abusers Project formulated the following conclusions. On the basis of his sexually abusive behaviour, Alfonso displayed all the indications of the DSM–IV diagnosis for “Pedophilia” (302.20), but as he had not yet reached his sixteenth birthday at the time of the report, he could not be ascribed this diagnosis. However, it became quite clear that Alfonso did indeed fulfil the criteria for the DSM–IV category of “Conduct Disorder, Solitary Aggressive Type” (312.00). He also fulfilled the DSM–IV category of “Mental Retardation” (318.00) (American Psychiatric Association, 1994). At the present time, it still remains unclear to what extent Alfonso’s learning disabilities had resulted from a primary organic deficit or had emerged as a consequence of prolonged psychological traumatisation (e.g., Sinason, 1992). The final report summarised Alfonso’s case thus:

“Bringing these diagnostic features together, therefore, Alfonso could be described as a young man with a background of psychosocial deprivation and learning difficulty. His history of generally aggressive behaviour towards peers has now developed into a particular form, that of sexually abusive behaviour towards young females. This pattern is likely to persist and may develop into a permanent personality disorder, particularly if Alfonso’s current and to some extent self-acknowledged difficulties are not addressed appropriately.”

My colleagues concluded that Alfonso posed a serious risk to young children, especially young girls; and they also expressed concern about his capacity for angry or aggressive behaviour or ideation towards older women. My fellow staff members also commented upon Alfonso’s substantial physical size of six feet and six inches, and his muscular capacity to perpetrate actual bodily harm against children as well as against adults.

In view of these serious matters, the Young Abusers Project recommended that Alfonso should never under any circumstances be left alone with children. Colleagues also expressed concern about the viability of Alfonso’s current foster care placement, especially in view of the fact that his foster mother had a 5-year-old son of her own, and that this small boy would certainly be at risk of significant harm from Alfonso, given the patient’s history of arousal in the presence of young children. The Young Abusers Project recommended that a supervised residential care facility would be more appropriate than a private foster care home in the community for such a disturbed and disturbing boy. Finally, the team recommended that psychotherapeutic treatment would be of great value to Alfonso, with the proviso that any such treatment might well cause him to become aware of deeper layers of aggressive affect, and that such a recognition might result in the stimulation of further aggression, which would require careful case management.

Alfonso’s very committed local authority social worker discussed the implications of the psychiatric and psychological reports with senior staff at the social services department; all of them agreed that Alfonso did, indeed, pose a severe risk to children in the community; the local authority therefore agreed that the Young Abusers Project should provide psychotherapeutic treatment for him. The social worker then asked Alfonso for his views on the matter, whereupon he replied that he did wish to talk to somebody, but that he would prefer to speak to a black psychotherapist. At that time, the Young Abusers Project employed only three psychotherapists, including myself, all Caucasian; therefore, the services of a black clinician could not be offered.

The psychotherapy assessment

Alfonso had to wait approximately nine months until I could see him for our preliminary psychotherapy assessment sessions. The Young Abusers Project could not begin treatment until we had received assurances that the local social services department could provide funding for the work on an ongoing basis and, of equal importance, that a professional escort could be engaged to transport Alfonso to and from his psychotherapy sessions. We further insisted that an allocated social worker would continue to manage Alfonso’s case and to support the treatment. It would not be feasible or helpful for Alfonso to travel to my office on his own, as the risk of acting out against children en route would be too great. My colleagues and I assumed that psychotherapeutic treatment would stir up many anxieties for this fragile young person, and that he would need a responsible parental figure to contain some of his fears both before and after sessions.

I had discussed the case at length with my team colleagues, and we all agreed that I would meet with Alfonso for two preliminary psychotherapy assessment sessions in order to determine his suitability for psychoanalytically informed work. In view of the great distance that Alfonso would have to travel, as he lived outside London, it would not be possible to offer more than one fifty-minute session per week.

Alfonso arrived on time for his first psychotherapy assessment session in the autumn of 1996, escorted by his social worker. I opened the door to my office at the appropriate time, and I introduced myself briefly to both Alfonso and to his social worker. I then invited Alfonso to enter the consulting room, and I asked the social worker to remain in the adjacent waiting area. The Young Abusers Project relies on such escorts not only for transportation purposes but also to provide an additional sense of security for both the patient and the psychotherapist. All of our patients know that their escorts will be waiting for them on the other side of the door, and I have come to appreciate the ways in which this knowledge reduces the temptation for patients to become more violent than necessary during treatment sessions.

I then closed the door to the consulting room and I sat in my chair behind the couch. With enthusiasm, Alfonso hopped into a chair on the other side of the room, directly across from my own seat. I now had an opportunity to observe his physical presence. He filled the leather chair fully with his large frame, and he splayed his legs wide open in a truculent and sexualised manner. I realised that I had never before worked with such a physically intimidating patient, and in my mind I became preoccupied with stereotypes of violent young black men. I remained silent, eager to learn how he would respond to this unusual yet long-awaited situation. Alfonso did not speak at all; instead, he began to look around the consulting room, his eyes soaking in every detail, and stared relentlessly at the couch, the bookshelves, the Persian carpet. After he had absorbed the room visually, Alfonso then turned his head towards the ceiling, and he peered first at the upper right-hand corner of the ceiling, and then at the upper left-hand corner. He continued to do so for many minutes, staring anxiously, as though searching for something. It suddenly occurred to me that during Alfonso’s last visit to the Young Abusers Project he would have met with my psychiatric and probation service colleagues in a video suite, where he would have undergone a video-recorded psychiatric assessment as part of the project’s ongoing research work.

Five minutes had elapsed, and neither of us had spoken out loud, but although Alfonso had not verbalised any anxieties at this point, he had certainly communicated extensive fears through his scoptophilic behaviour, thus prompting my first interpretation. I looked at Alfonso and told him that I could see how necessary it seemed for him to scan the room with his eyes, noting that he had never visited my office previously, nor had he ever met me before, and it would therefore be important for him to see what sort of a room he had entered and what sort of a person I might be. I then commented that he seemed particularly concerned with the corners of my ceiling, as though searching for a video camera. I suggested that Alfonso might be pleased that I had no such device in my room, but that he might also be worried, in case the presence of a video camera made him feel safer so that other grown-ups could see what he did at every moment. This intervention seemed to make some sense to Alfonso, and after I had mentioned the missing video camera, he smiled and began to talk to me.

Promptly, he told me that he did not want to speak, because he had very bad memories of my probation service colleague, Mr X, who had co-facilitated the initial psychiatric interview some months previously. Alfonso moaned that “Mr X treated me like some sort of an idiot. He made me show him what I did to those girls by using some dolls. He asked me if I knew the names of private parts, as though I didn’t. He was a real jerk.” I responded to this outburst of denigration by mentioning that I knew that several professional colleagues had diagnosed Alfonso as suffering from mental handicap and learning disabilities at various points during his life, and that perhaps he worried that I, too, would treat him as a stupid person who did not understand what grown-up people had to say. Alfonso smiled once again, as if to indicate that I had succeeded in alleviating at least a very small amount of his anxiety.

Alfonso then began to stare at a delicate nineteenth-century engraving that hung in a frame over my analytic couch. The engraving depicted a group of travellers heading on a journey. Alfonso continued to stare at the picture and then blurted out, “I bet that painting was done in 1980.” I wondered why on earth Alfonso mistook this very old picture for a work of art from 1980. Concretely, I reasoned that even a person with absolutely no training in art history would be able to sense the value and age of this engraving. But I soon realised that 1980 represented, in fact, the very year of Alfonso’s birth. I then shared this insight with him, and I commented, “I wonder whether you chose 1980 as the ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Introduction
• Part I Engaging with Bombs
• Part II Inflaming and Defusing Bombs
• Conclusion
• Acknowledgements
• References
• Index