Editorial

The first half of this issue is focused on work with children in psychotic and autistic states. We have four papers, each with a different focus, which when read together, really do make a significant, and in some cases, original contribution to our thinking about psychotic and autistic states of mind that might inform our work with non-autistic children too.

Ruth Weinberg explores psychosis in autism through a detailed case study. A review of the literature on autism and psychosis is offered, and useful distinctions are made between psychotic symbiosis and other autistic presentations, including a brief vignette from another case as a point of comparison. The particular presentation under discussion is clearly specified and helpful notes on technique are put forward through the main case study. We join the therapist as she picks a path between the autistic and the psychotic aspects of her patient. Her attempts to engage him interpersonally carry the risk of pushing him into psychotic hallucinatory wish fulfilment. She speaks movingly of having to negate her personhood, at times, in order to get close to him, without pushing him over the edge. This paper demonstrates how arduous and delicate the work is, to make hugely important but very limited gains:

To this day, Matan shows limited willingness for me to do anything that demonstrates I am not part of him and have a mind of my own. Fortunately, there is a slow and gradual development of abilities, and the most frequent feeling is that his slow progression occurs because he can now stay closer to reality and disintegrate less.

Yaakov Roitman offers some thoughts on why the autistic child is so vulnerable to psychotic states and has such difficulties with separating and separateness. Using Bion’s (1965) thoughts around perception and internal representation, he explores how the autistic mind, functioning under the dominance of the pleasure principle, rather than the reality principle, fails to create accurate enough internal representations of her object. This, in turn, compounds her difficulty with recognising her object externally, as distinct from anyone or anything else. Simultaneously, she will not be nourished by her internal objects because they are modelled on hallucinatory phantasmic elements, which vary too wildly from actual experiences of care and being with her mother.

Roitman identifies an important task for the therapist that rests on our capacity for reverie in the room. He tells us: ‘An engram is defined as an unconscious memory trace that holds sensory procedural information’. He assures us that some of these will remain intact or with enough fidelity to reality to help us help the child rediscover her objects. Roitman urges us to seek the ‘invariants’, the glimpses of a good likeness between the signifier and the signified hidden among all the muddling, phantasy-informed, approximations. This is movingly illustrated by a moment when his reverie in the room, while watching her dance and spin, allows him to find the invariant through a series of his own associations, that amble via his own personal experiences with his family and images the patient had given him in earlier sessions. Finally, these drifting images and notions glide into alignment and he suddenly has a startling conviction that he knows what she needs in order to reconnect with her internal object, through an engram represented by a song. He plays it, and she is delighted. It is interesting to note how digital devices are used so helpfully in a number of the sessions described in this issue.

Tami Pollak also presents two patients with autism and a series of visual metaphors. These metaphors render the ineffable confusion of work with some autistic children in a way that I found profoundly helpful. Through exploration of the topology of various kinds of loops, she captures many aspects of this work. I was particularly relieved to be offered, in her use of the twisted loop metaphor, a way of thinking about my experience of excitedly following a child into apparently rich symbolic play, to find myself spat out, landing on my backside in a state of confusion, the moment any attempts to make meaning were detected by the child. I also enjoyed the way Pollak primes us to make full use of our capacity to utilise metaphor, by opening with a beautifully observed description of her response to a piece of art in a gallery. It felt something like having the third eye opened.

Idit Dori shares aspects of nine years of therapy with an adopted girl, whom she describes as having an almost autistic organisation. Dori also uses metaphor, drawing on Bion’s ocular metaphor, to make sense of her patient’s struggles in the work. She explains:

instead of binocular vision, the person develops a split, bi-ocular vision: one eye lives out emotional phantasies concerning object relations through omnipotent sensual gratification, thus replacing dependence with blocked-out object relations in a relatedness-avoiding world. The other eye, the concrete one, lives in reality. Both perspectives are ‘known’, but do not engage in an integrative, binocular encounter (Bion, 1962; De Masi, 2015). One manifestation of this bi-ocular vision was that, while Netta’s ability to reflect on her experience and understand her reality grew as the therapy progressed, her responses to my interpretations or reflections remained on two separate, contradictory tracks: she was better able to take these in, but they evoked an intense need for gratification through sensory means and through withdrawal into grandiose fantastic stories.

Dori elaborates the metaphor as a helpful way of thinking about the dual and sometimes ‘dichotomous experience of the parental gaze: the discrepancy between loving and caring versus abandoning and denying’. Together, patient and therapist arrive at the metaphor of cross-eyes to make sense of both themes in the work. This paper has parallels with Weinberg and Pollak’s papers, in that Dori describes a winding journey with a patient, who uses and misuses, according to fluctuating capacity, various means of communication, in particular a smartphone that she begins to bring to the sessions.

In the epilogue, Dori describes a meeting with the patient some time after the end of treatment. The patient requested this meeting after having been contacted by the therapist to seek informed consent. In particular, mention is made of the significance for both mother and therapist of this reunion after a decade of working together.

I am hearing quite a number of such stories, where the request for consent becomes a form of post-treatment review that, in some cases, can offer both therapist and patient the opportunity to enjoy noting the sleeper effect of the treatment. This will be explored in more detail when we publish the papers coming out of the recent symposium on ethical publishing organised by the Journal of Child Psychotherapy.

In Simon Cregeen’s ‘It’s not my fault, it’s yours: shame, loss, and the ego ideal in work with adoptive couples’ he makes a powerful argument for the importance of parent work, focused specifically on the couple relationship in adoptive families. His, almost forensic, approach to reviewing the literature and building an argument means that he can then render the ‘tangle’ of projective identifications in a family as a complex, but intelligible, phenomenon that can be thought about. First in his mind, and then with the families, the unbearable feelings are returned to their source and then metabolised, to a greater or lesser extent, in his containing presence. Mourning and ordinary narcissism are identified as central to much of the work: ‘If adoptive parents can mourn the ego ideal of themselves as a biologically fertile couple, the development of a shared ego ideal for themselves as a creative adoptive couple may be possible’. He links this with the palpable sense of shame at the loss of the couple’s identification with a shared ego ideal, that throbs through the clinical material, and halts any movement towards mourning. Cregeen describes how the pressure to place children conspires with this resistance to the harrowing work of mourning, as couples are supported to ‘overcome’ rather than mourn their losses.

He turns the same forensic lens to the part of the work that happened in his mind, generously sharing the struggle there too. Refreshingly, no analytic magic is implied:

There was a strong impulse in me to blame them and shame them into behaving better, becoming in my way of thinking a critical and rather contemptuous parental figure, who was sure I’d be doing better in their circumstances. In thinking like this, I felt ashamed of myself, and of my failure to draw upon my own internal parental couple to help me achieve a ‘third position’ way of reviewing the situation. Instead, my parental objects, including internalised clinical supervisors, became judgemental figures who were ashamed of me and would want to disown me.

Cregeen tells us that understanding all of this took a long time – the parents did not benefit from a ‘less persecuted atmosphere’ straight away.

The importance of parent work in the treatment of fostered and adopted children is also the conclusion suggested by the findings of a research study described by Saul Hillman, Carolina Villegas, Katharine Anderson, Asa Kerr-Davis and Richard Cross. Hillman et al. use a narrative approach, the Story Stem Assessment Profile, to gain an impression of children’s expectations of attachment relationships, or their Internal Working Models (IWM) (Bowlby, 1980). The beginning of a story about an interaction between a child and carer is offered, and the child is invited to describe, or act out with dolls, what happens next. The aim in this study was to measure changes in expectations one year into a foster placement. The authors state that findings support other research into this area in that: ‘more positive sets of mental representations develop in competition with existing negative ones, rather than replacing them’. The authors argue that this means foster carers have to work to ‘actively disconfirm’ existing models, whilst ‘building up competing ones’. For this reason, the authors suggest that parent work to support foster carers is crucial. As Cregeen so powerfully describes in his paper, those caring for or offering therapy to children who have experienced relational trauma will feel a powerful pull to meet the child’s negative expectations. Hillman et al. argue that because these IWMs do not get overwritten, but remain more or less active while other models develop alongside, carers will need support to avoid triggering the negative expectations. I found this helpfully brought to mind a minefield that must be traversed. Some mines will be set off and others might be deactivated, but the challenge is to help carers understand that each new mine is not evidence of their failure as carers or the child’s inability to develop new ways of relating, but the legacy of trauma that must be weathered. We need to help carers understand that the task is to limit the damage of each explosion, and become slowly more expert at deactivating rather than reactivating past traumas. However, as Cregeen shows us, perhaps the most challenging part of parent work is to help carers adjust to the actual task of caring for traumatised children, and mourn the fantasies around becoming parents or carers. As a research paper, Hillman et al. use a number of research terms. We have provided a brief glossary, below, of a few of those terms to help readers who might be interested in understanding the design, but might not be very familiar with the terminology.*

Hillel Mirvis describes the significance of offering a second phase of treatment to an adolescent who requested it. He stresses the importance of offering ‘something more’ to a doubly (Henry, 1974) and triply (Emanuel, 2002) deprived girl, who had been left anonymously at an orphanage and adopted at five months of age by a foreign couple. The return to treatment is conceived of as a phantasy of reunion with the biological parents, and so an opportunity to work through the ambivalence surrounding such a phantasy. In this second phase, his patient does seem able to internalise their work, both in terms of a capacity to process thoughts and feelings rather than enacting through overdose, but also a faith in benign figures, internally and externally. Mirvis suggests that all this development seems to coalesce in her wish to begin practising a religion. What I found particularly interesting was Mirvis’ thinking about the significance of himself, the person of the therapist, including his cultural and religious identity, in the work, both at conscious and unconscious levels. He notices the moment that she devises a ‘test of whether I could allow for something authentic and intimate to develop independent of the transference relationship’. He speculates that something like that might indeed have happened in a way that he had not been consciously aware of at the time. They have a shared experience of having an observable difference from those around them, hers being a racial difference from her adoptive parents and his being a small head covering that identifies him as an Orthodox Jewish male in a London clinic. He notes that around the time of the second phase of treatment, he had been exploring the relationship between his religious and professional identities in a way that had afforded a greater sense of integration for him. He wonders whether an unconscious link with him, and this work in his mind, supported her work to integrate disparate aspects of her identity. I like the implicit acknowledgement, here, that our identities are not smudges on the blank slate that might interfere with transferential phenomena, but a rich part of our therapeutic relationships, constantly active and in need of our attention in an ongoing way.

I am very excited to include Judith Edwards’ response to Ricky Emanuel’s article, ‘Changing minds and evolving views: A bio-psycho-social model of the impact of trauma and its implications for clinical work’, published in Issue 47.3 of this Journal. We are keen to foster dialogue and debate in our pages and welcome such response pieces. Edwards draws out what is so important to her about Emanuel’s paper, and helpfully locates it within the historical evolution and occasional revolutions in the thinking of our discipline over the decades.

In Alessandra Marsoni’s book review of Jeanne Magagna’s ‘A psychotherapeutic understanding of eating disorders in children and young people: ways to release the imprisoned self’, we have a heartfelt tribute to the work and the person of her long-time colleague. She, like Mirvis, draws our attention to the significance of the person of the therapist, here focusing on Magagna’s reflections on her personal motivations for specialising in such challenging work, and her ownership of the need it met in her.

Maria Papadima shares the enlivening impact of ‘A practical psychoanalytic guide to reflexive research: The reverie research method’ in her review of this book by Joshua Holmes. Papadima describes immediately being able to envisage specific research projects based on the model Holmes puts forward, giving us confidence in the title’s claim that this is a ‘practical’ as well ‘psychoanalytic’ guide to reflexive research.

Rachel Acheson presents abstracts from research into patient experience and points to the growing sophistication of these studies. Perhaps someone will follow on from Papadima’s curiosity about whether the reverie of the patient can meaningfully be included in research with the evolving complexity of service experience research?

Research terms glossary for Hillman et al.’s paper*

Psychometric tests are used to measure an individual’s mental capabilities and behaviour.

Criterion validity is an estimate of the extent to which a measure agrees with a gold standard (i.e., an external criterion of the phenomenon being measured). The major problem in criterion validity testing, for questionnaire-based measures, is the general lack of gold standards.

Predictive validity refers to the extent that it’s valid to use the score on some scale or test to predict the value of some other variable in the future. For example, do the psychometric test questionnaires actually predict mental capacities and behaviours.

Inter-rater reliability is the extent to which two or more raters (or observers, coders, examiners) agree. It addresses the issue of consistency of the implementation of a rating system. Inter-rater reliability can be evaluated by using a number of different statistics.

Normality refers to a specific statistical distribution called a normal distribution. The normal distribution is a symmetrical continuous distribution defined by the mean and standard deviation of the data. This is usually represented in a histogram, which looks a bit like a bar chart.

Skewness is a measure of symmetry, or more precisely, the lack of symmetry. A distribution, or data set, is symmetric if it looks the same to the left and right of the centre point. Kurtosis is a measure of whether the data are heavy-tailed or light-tailed relative to a normal distribution.

Leptokurtic distributions have a relatively high probability of extreme events, whereas the opposite is true for platykurtic distributions.

Non-parametric tests relate to data that are flexible and do not follow a normal distribution.