Psychotherapy with Young People in Care

Lost and Found

Margaret Hunter

• Publisher: Routledge
• Year: 2002
• Print ISBN:
  9780415191913
• eBook ISBN:
  9781134652921
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Whilst there is a wealth of literature on working with children and adolescents, very little focuses on those who are in residential or foster care. Psychotherapy with Young People in Care is a practical guide to working with this group from a psychoanalytic therapeutic perspective.
Drawing on the author's years of experience and illustrated with a wealth of clinical examples, as well as a comprehensive glossary, the book tackles those issues most relevant to those working with children and adolescents:
* the place of psychotherapy in residential/foster care
* ethical considerations: confidentiality and sexual abuse
* particular problems faced by young people: ADHD; trauma; PTSD.
This refreshing and valuable book is an essential teaching text for all those who work with young people in the care system, including child and adolescent psychotherapists, psychiatrists, clinical psychologists and social workers.

Chapter 1

Beginnings

First impressions

– what gets communicated

– the psychotherapeutic task

– debates about interpretation and the ego

– the use of psychotherapy as an assessment

– the importance of preventive work

Jenny, 9 years

‘What’s out there? Can we play outside? Why not? Whose is this? Does Mark O’Reilly come here? How does this work?’

She moved rapidly through my room, touching one toy after another, stopping at none of them, asking questions but giving little attention to my answers, bombarding me with dilemmas. When she came near me she rarely made eye contact and, as if on elastic, swiftly recoiled to the far walls, to the windows, to the door. At 9 years of age she was small and wiry, with an engaging but fleeting smile and boyish wavy fair hair. She smiled often and placatingly: it was a struggle to pause and resist her direct ‘Can I? Why not?’ Within minutes I felt unbalanced, slow, guilty at saying ‘no’ so often and with unclear reasons. With an effort I pointed out to her the cardboard storage box I had placed for her on the table. It was my standard issue for children in therapy: plain, larger than shoe-box size with a good lid and able to hold an array of stationery and art materials, Plasticine, some family dolls of a size that would fit the doll’s house, some small toy farm and zoo animals with fences, a folder to keep any paintings and drawings in, a plastic container useful for finished Plasticine models and lots of paper. She looked at the box but did not approach it.

‘What’s in it?’

‘You can look. It’s for you to use.’

She turned back to an open box of Lego and began to rummage through it.

‘Do you know how to make this?’ she asked, pointing to an illustration on the box.

For a few moments we looked for pieces together and she tried to command me to make the construction for her. As suddenly as she’d come near to me she sprang away and, notwithstanding her dress, began to do handstands in the corner of the room, her legs perilously close to the windows. Her dress fell over her head, her knickers on view, her bare legs in the air.

‘No, you make it, you do it,’ she complained as I stopped the Lego building to watch her. I pointed out a better, safer section of wall for her to use, keeping a little distance from her, yet still, without warning, I found her legs catapulting into my arms. She wrenched herself free and, breathless and laughing, climbed up to the window and tried the catch which was fortunately securely locked …

In the fifty minutes we spent together on this first meeting alone (we had met days earlier with her social worker) she went several times up to the box that I had specified was ‘for her’. Each time she seemed distracted by another idea, or played with something else; she never touched it or opened it. At our second meeting she seemed to ignore her box altogether and I again pointed it out to her. At our third meeting I noticed how she ricocheted from the box into swift breathless excitement. Or was I imagining it? Perhaps because the box had strong significance for me I was assuming, projecting onto her a reaction that was noteworthy. Perhaps lidded cardboard boxes are not particularly interesting. A stray wish for prettier plastic boxes that might be more attractive went through my mind. As she filled up the sink with water to see if a Lego construction would float I found a few unusual minutes of quiet to gather my thoughts. As she dashed away from the sink with a wet construction that she deposited back in the Lego box, I resisted the invitation to reprimand her and asked, ‘Jenny, why do you never look in that box I’ve given you?’ She went up to it then and touched the lid with both hands.

‘What’s in it?’ she asked.

‘Why don’t you look and see? I replied.

‘Has it got sweets in it? Chocolates?’ she asked.

‘What makes you think that?’ I wondered aloud.

She moved away and to the window saying, ‘If we had a skipping rope I can do a trick.’ I didn’t reply, allowing myself to continue being puzzled about the box. She looked directly at me then, from the safe vantage of several feet away.

‘I bet you used to have chocolates in that box but probably they’ve gone now.’

‘How would that be?’

‘Probably the others have eaten them all by now.’

As the reader can see, there were many things going on in my encounter with Jenny: her wariness, her wish to control me, to keep me busy and at a safe distance, her wish to escape. I felt as if I were with a caged animal who was wary and predatory. But there was longing for contact here too: the sudden physical contact, the exposure of legs and knickers in excited energetic play, the bombardment of me into compliance, all added to my growing suspicion that she had been sexually abused. An aspect that I only noticed after the second and third sessions was that somehow pieces of Lego went missing from the room following her visits. So there was an undercurrent of trickery and distraction of me whilst she secretly took something from me. Did she think herself a thief, secretly enjoying the credulousness and carelessness of those with possessions? Or was she certain that she would never be given and would have to take, surviving on her wits as a scavenger, treasuring the detritus of adults the way street children pick up and appropriate effects in third world countries? The experience of being with her was one of struggle, unease, alarm. I felt her rapid changes of direction disconcerting. I was crowded by her rapid-fire questions and challenges. I seemed to have little room for thought, for feeling, for wondering, when I was with her. I was very puzzled and nonplussed by her. We met but we made little contact. We might have been sword-fighting or sparring. That was the emotional tenor of what was occurring.

But what comes back to me most clearly, is that sudden look, that moment of real contact when she said to me, ‘I bet you used to have chocolates in that box but probably they’ve gone now.’ She said this with an urgency and despair which were oddly at variance with the alluring idea of chocolates. At that moment what was conveyed to me was longing and sadness for what might have been, for what had been but had got lost. This communication was the crucial one in our encounter. Jenny, in three fifty-minute meetings, showed me what it is like to be anxious, mistrustful, ready to flee or fight, to be ever wary and ever on guard. But in a few seconds of real human contact she threw into me a kernel of sadness, of loss, of her attempt as a little girl to cover over her experience of an empty, depleted ‘other’, her experience of a gift that holds only disappointment.

Jenny caused me to wonder whether she was really impervious to the box I gave her or whether it was my own sensitivity to rejection that made me notice her lack of interest in the box. I had found myself wishing my gift was nicer, more attractive. Her later remarks showed me that I was not wrong to attribute this rejection to her, a transference of her own feelings from past disappointments to me and my gift. It was a counter-transference feeling that was aroused in me when I wished to improve my offering to a prettier plastic box. That is, it was a feeling aroused in my unconscious as a response to her unconscious communication.

If one imagines being Jenny’s new foster mum, with subtlety and then more openly Jenny will give the message, ‘You don’t have what I need. I will not consider what you have on offer because I know it will disappoint and fail me.’ The foster mother may have an equivalent thought to my wish for bright plastic: ‘I don’t have what this child needs: I wish I did. I’m not very good for her.’ When these feelings are caught, traced back to their origins and considered consciously quite a different situation is the true one. This is a sad, disappointed and self-destructive child. She is robbing the potential mother. She is rejecting what is on offer without knowledge of what that is. A child who stays in this state is going to prevent good-enough mothering from reaching her. The beginning of therapy with Jenny then is to understand the communication of pain and disappointment with which she approached me. I need to feel it, to share it and to reach beyond my own vulnerable responses to it. I have gradually to absorb this knowledge into my perception of her and gently to disentangle it from the present on her behalf. So I will begin to draw these feelings to her attention, to notice them and name them. But more importantly, I will hold onto these feelings and not push them away, nor respond ‘in the counter-transference’ with either guilty placatory gifts or with retaliatory rejection. In the quiet of a therapy room, with time after and before each meeting, time in which to think and disentangle my responses, I can hope properly to understand our exchanges. This is the essence of psychotherapy. In effect I will, by example, feel and face the despair before we together relegate the pain to where it belongs – in the past.

In Kleinian theory (Klein 1975) one thinks of the unconscious encounter in therapy as one between child and mother. Or rather between the child and the child’s idea of a mother – what is confusingly called ‘the maternal object’. Object here refers to the ‘object’ of desire, meaning the target of the person’s affections. Not every aspect of the meeting between child and therapist falls into this category, of course, but the therapist by her receptivity, by her restraint at performing other roles (not a teacher, not a friend, not a substitute real parent) hopes to filter and gather in those aspects of the child which are related to early assumptions about the mother. The situation of seclusion, of meeting one-to-one with a person whose task is to help with personal pain will automatically evoke some of these ‘transferences’. Feelings experienced in bringing the earliest needs to another are bound to be awoken. The therapist scans through the mass of incident accumulating in the room and asks: ‘What assumptions is this person making about me? What sort of “maternal object” am I for her?’ It is therefore extremely important that the therapist keeps an open-minded stance toward the client and questions her own assumptions and projections. The therapist also tries to exclude her own actual and personal details from the sessions. Of course, the therapist is a particular human being with very many observable qualities that the client will correctly apprehend. But the more children are allowed to bring in preoccupations of their own, rather than those of the therapist, the more can be learnt. The more receptive the therapist, the more children will use assumptions and perceptions arising from their own personality and experiences. Accurate perceptions of the therapist show the child’s intact receptivity. Inaccurate perceptions reveal unconscious aspects of the child and will become the material to be worked on. Children learn from their projections which are caught by the therapist and gradually reflected back to them. The child learns that unconscious ideas and past memories frame their own current experiences. Jenny, excited to be with me and to use me, cannot help but reveal her assumption that I must be tricked into providing for her. She is not simply open to what I can offer: she is in fact certain that I will disappoint her.

The first task of a therapist is to apprehend the children in all their communications, conscious and unconscious. So a therapist has to be aware of her own projections and distortions. We all see the world ‘through a glass darkly’ to some degree and indeed we have to have a personal framework on which to hang our experiences. But a therapist must strive for clarity between the emotional baggage that she herself brings into the room and that which belongs to the client. It is for this reason that psychoanalytic therapists have to have their own analysis as part of their training. We need to know what we project, where our common areas of confusion and distortion lie, where are our vulnerabilities and our strengths. We need to have scrutinised our own baggage so that we are more or less sure that the despair or anger or joy flooding the consulting room belongs to the client and not to ourselves.

Eloise, 16 years

A very angry, very powerful 16-year-old came to see me one day. She had been cajoled by her residential social worker to ‘give me a try’. Her social worker thought I might help her through the maze of drinking bouts, drug overdoses, self-cutting, shoplifting and running-away episodes that had become her life. She was a tall, imposing girl with a pallor to her skin that made her look ill. Her hair was dyed black and cropped short and jagged. She looked hard, aggressive, fierce. Perhaps a warrior about to engage in battle might adopt this look: it said ‘don’t mess with me’. I felt intimidated by the way she swept into the room and sank into a chair, looking furious. The conversation we managed to have was fitful and awkward. She responded to my attempts to engage her with monosyllables and challenges. Eventually I had little choice but to say what seemed obvious: that she didn’t want to be here and was annoyed that she had to talk to me. Instead of the angry response that I expected – in fact I was almost expecting a slap – she looked panic-stricken, fearful. I then realised how thin was her veneer of protective hostility and how much she feared this meeting. So I did my best to be non-threatening and matter-of-fact. I talked about therapy as a possible relationship where you can talk things over privately without repercussions. I said that I wouldn’t be in the middle of her life participating in the plans about her placement (which she told me she hated), her education (she also hated that), her access to her boyfriend (a 30-year-old man), or her curfew (she was in a secure unit). I tried to explain that therapy is ‘off to one side’ as a place to talk and think. Of course, it depended on whether we two could get on together and, since we did not know one another, that was hard to predict. All I could do was offer to see her a few times and then she could tell me whether she thought it useful to continue or not.

In this way I tried to give Eloise control over the decision about therapy. I tried also to ‘set out my stall’ in a clear way: this is what is on offer. Perhaps, Eloise, you will, or perhaps you won’t, find it useful.

By doing a lot of the talking at this first meeting I was, of course, missing what I could have been gathering in from Eloise. In an easier encounter I could let the young person set the agenda, I could sit back and let her preoccupations, her phrases, her expressions and emotions wash over me and filter away like a receding tide. I could be relatively passive, receptive and keep to the analytic stance, asking myself: ‘What is this that I am being given? What sort of quality does it have? What is its meaning? How does she perceive me?’ This is the process called ‘gathering up the transference’. This was not possible with Eloise, however. She was scared of me and feared my perceptions: I guessed she wanted to give me nothing I could use to hurt her. In a younger child who is afraid it may be useful to offer back this insight in a gentle way: ‘I think you might be afraid I’m like that monster in your game …’, but sometimes this can be overwhelming if the fear is too acute. With a young woman of 16 years, there is the added difficulty of a loss of face, when to admit to fear or timidity cuts across the need to look poised and adult. So at the beginning it may be wiser for the therapist to act on the basis of her perceptions rather than interpret them in a classical analytic way.

Eloise was hostile and fearful. I tried to help her master these feelings, initially by demonstrating she had little to fear from me, later by reflecting back to her that I was unknown and she would have to experience our relating before she could judge whether it was like her fantasy of me or not.

In this way Eloise half-heartedly agreed to see me again. At our second meeting she was more poised and less afraid. After some brief pleasantries she launched into an account of sharing a room with a new resident at the secure unit. Eloise liked the idea of sharing because she did not much like sleeping alone. But this other girl wanted the light on and Eloise was not able to sleep with it on. It transpired that the light was a small night light and the other girl had agreed to have it as far away from Eloise as possible. But it was useless. For Eloise, just the knowledge that there was a light on in the room bothered her. On a rising note of indignation Eloise put to me this other girl’s irritating habits and described the argument they had. She confronted me angrily: ‘So who’s right then, me or her?’

I re-described the situation she was putting before me as a dilemma that might apply to myself and herself. We were ‘being told’, or so it may seem to her, to share a therapy room. But she feared we were incompatible. I may want different things from her: she may find my wishing to throw light on things upsetting and irritating. But she wanted companionship, she didn’t like being alone. The dilemma was so upsetting that she wanted an immediate end to it, a yes-or-no final solution. Yet, we could hear at the beginning of her account, a wish to share, a hope that she might not be alone in the dark.

Eloise regarded my interpretation with incredulity and then contempt. That’s what she had heard about people like me, she replied. People like me twisted what was said and just went off onto something else. I did my best to assure her that I was not meaning to do this but that I did have a different way of thinking about these things.

However, this seemed all that was needed to intensify Eloise’s anger. Her resentment at being made to come and her perception of the care staff and myself as self-seeking bullies and hypocrites came pouring out. There was a despair laced into her angry rejection of me which I could feel but could not address. An angry tidal wave seemed intent on buoying her up to the point where she was going to sweep out of the room. As she reached a sort of crescendo of anger and hostility about all adults, she gave me a sudden moment of sympathy and said, ‘It’s nothing personal. I never wanted to come.’ I replied that she seemed to think this meant that we had to end, but it may be a good, honest place to begin. I saw the momentary hesitation as the idea reached her, but it was swiftly crushed. She was on her feet and out of the room, shouting for her escort to take her back in an angry and public display of her rejection of me.

The uncomfortable aftermath of this sort of encounter for the therapist is the question of whether my interpretation was precipitous and caused her rejection of me. The alternative, however, may be that one is bullied into compliance and collusion. In addition, holding back on honest exchanges can quickly make a therapy session feel boring to an ambivalent adolescent. Eloise found ambivalence an intolerable state. There was therefore little room for looking at opposing feelings or contradictory thoughts. She insisted on myself or the staff adjudicating between rights and wrongs, between herself and her roommate, between the part of herself that wanted to share and the part that was utterly intolerant of difference. Eloise sought to answer her dilemmas by powerful, final, precipitous action. This is anathema to therapy. Whether the small, overlooked wish to share and to not be alone in the dark was ever to be heard by her remained to be seen.

This illustrates one of the points on which theoretically Melanie Klein and Anna Freud diverged (Segal 1979: 42). Klein argued that unconscious fears are better brought out into the light where they will dwindle into more realistic proportions. Anna Freud was afraid of overwhelming the ego – the reality sense – by too great an acknowledgement of unconscious fantasy. Theoretically the two approaches are quite different and seem incompatible. Is the therapist to use her intervention to support and shore up a weak ego? S...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Foreword
• Acknowledgements
• Introduction
• 1. Beginnings
• 2. A view from the bridge
• 3. Confidentiality
• 4. Joseph – a therapy in pictures
• 5. Charlotte
• 6. Child sexual abuse
• 7. The longing in belonging
• 8. Identity in crisis
• 9. Restless children
• 10. Trauma and its treatment
• Epilogue
• Glossary
• Training schools of child psychotherapy
• References
• Index