Wednesday, 18 April 2012

Stories for Posterity 3: Child Psychotherapy at the Royal Free Hospital in the 1970s

This is the third of my stories about events I have witnessed that I believe should be ‘preserved for posterity’.  Once again it concerns children.

In the 1970s, I worked for over four years in the Department of Psychiatry at the Royal Free Hospital, Hampstead, London.  For the first three years I was undergoing training in clinical psychology.  I worked mainly with adult patients but I also did some sessions with children.  There were two clinical teams there that took referrals for children, adolescents and families; one was headed by Dr Joan Cornwell and the other by Dr Alick Elithorn.  Dr Cornwell’s was the larger team and included a number of psychotherapists who were training at the nearby Tavistock Institute, as well as qualified staff.  Every week there would be a case presentation by a therapist, often attended by a woman called Isca Wittenberg who came up from the Tavistock in a supervisory capacity. 

The dominant school of therapy in which most therapists had been trained or were training was the psychoanalytic approach of Melanie Klein.  The therapists were taught to interpret, often directly to the child, much of what the child did or said in therapy by reference to certain bodily parts, how big these parts were, what the child wanted to do with them, what he or she unconsciously thought about the therapist and wanted to do with her, and so on.  (I did not formally train in child psychotherapy and was, accordingly, limited to using more mundane methods in my efforts to help children who were referred to me).  

As an example, I recall a case presentation in which the therapist described how in one session a child she was seeing, a boy I shall call ‘John’ who had either encopresis or enuresis (I am not sure now), was playing with some toy soldiers.  While he was doing this, the therapist gave an elaborate explanation to him of how the soldiers represented penises of different size and what his playing with them revealed about his fantasies.  It was either in this or a similar presentation that the therapist described how the boy would put his hands over his ears while she was offering these interpretations. 

When, nearly 35 years later, I recall these and other similar events, I think about how people in any other context might land themselves in trouble by this kind of activity with a child and how the law would distinguish the licit and illicit circumstances in which such activity takes place.  I do recall reading a letter that the mother of one child had written to his therapist, describing how her son had arrived home confused and upset from his last session in which the therapist had referred to penises.  The mother, while expressing gratitude to the therapist for the help she was giving her son, expressed the view that she really oughtn’t to be talking about penises with him.  It was evident that the mother was unable to relate this to her son’s problems.

There appeared to me to be no lack of restraint, such as the requirement for good evidence, on the notions that the staff were willing to entertain and express.  For example, I remember at a case discussion the presenter referring to a little boy she had seen who was born with a medical problem that impaired his hearing.  One member of staff immediately interjected, ‘I wonder what he didn’t want to hear!’  It seemed that those present at least did not share the view that I imagine most people would have of this comment. 

Indeed in many important aspects, the ideas about child development and childcare that informed the work of most of the staff would be alien to those held by the majority of the public, including parents and others professionally involved with children.  It was also clear that amongst those most hostile were the psychiatrists on the adult wing.  I recall an invited case presentation to the whole psychiatric department given by two of the psychotherapists from the unit, who chose to discuss several session of family therapy they had undertaken in the case of boy with incontinence.  The rationale of their opting for family therapy was that they considered the boy’s wetting to be a manifestation of unacknowledged or unresolved emotional conflicts in the family as a whole.  When, at the meeting, the time came time for questions and discussion, the psychiatrists from the adult department expressed with some vigour their disdain for the therapists’ theory and outrage that the entire family had to be subjected to this kind of treatment on account of the boy’s having a not uncommon problem.  As it happened, the therapists reported that the family stopped attending after about five sessions, the boy still being incontinent.  I was surprised that the therapists had chosen to present one of their failures, but what I have to say later may go some way to explaining this.

What has now brought these memories to my mind is the current publicity surrounding a film entitled Le Mur or The Wall in France concerning psychoanalytic theories of autism and the psychoanalytic treatment of autistic children.  The underlying message of the film is that psychoanalysis provides a misleading and potentially damaging account of autism; that it does not offer an effective treatment modality; and that there are now behavioural and educative programmes that can have profoundly beneficial effects for autistic children.  The film also reveals the powerful influence that psychoanalysis exerts on French psychiatry.  Three of the psychoanalysts who were interviewed in the film have successfully sued the film’s producers, who have been fined and charged legal costs and have been forced to remove the film from the internet.  .

It is clear from the accounts of those interviewed in the film that, in France at least, psychoanalysts continue to adhere to an early, and now little-held theory of autism, namely that the source of the autistic child’s problems is a failure of the parents, particularly the mother, to bond emotionally with the child - hence the expression ‘refrigerator mother’.  Nowadays, mainstream psychiatrists and psychologists consider the condition to be a developmental brain disorder with a genetic basis.

Viewing the film (before it was censored), rekindled many of the memories of my time at the child psychiatry unit and these include the level of criticism and belittlement that staff expressed about the mothers of the children referred to the unit – not directly, but in case discussions, conversations, and clinical notes and records.  In other words, because of her own emotional weaknesses, Mother was usually to blame.  I have a particular memory that encapsulates this attitude.  One of the therapists had interviewed the family of a child with emotional problems, the mother of whom had a physical disability of some severity which affected her gross body movements and articulation (though her intellect was spared).  The therapist illustrated this poor woman’s difficulties by vividly re-enacting her responses to some of the questions raised in the interview, the purpose clearly being to convey to us what she believed to be the damaging impact on the child of having a mother who was incapacitated in this way.  The outcome of the assessment of the family was that it was proposed to have the child sent to a residential school away from the mother.  I do not believe this happened and I recall reading a most aggrieved letter that the mother wrote to the therapist in question, informing her that there was no way that she would allow her to break up her family.     

If, to me and others, the ideas and practices of the staff at the unit seem, as I noted earlier, ‘alien’, is it not fair to ask, ‘Who are we to judge these “experts”?’ and should it not be insisted that what matters most is how successful they were in helping the children overcome their problems?  This is exactly what I would say to myself at the time, being mindful that I was only a neophyte psychologist myself.  However, I have to say that as time went by I could see very little evidence that the children, young people, and families who attended the unit derived much benefit; in fact, the majority defaulted on their attendance after a few appointments, usually one or two.  In other words, ‘The punters voted with their feet’. (I confirmed this by periodically studying random samples of patients’ files as a way to learn more about child and family therapy; for the reason given it proved a disappointing exercise.)  

It seemed to me that the people working in the unit should have been aware of all this and been questioning the validity and utility of the theory and practices in which they had trained or were training.  Yet everyone seemed curiously indifferent to outcome; the main source of interest – indeed fascination – seemed to be what the children did in their therapy sessions and how it was to be interpreted.  For example, at the case presentation of John and the game of soldiers, the therapist revealed that he had been in therapy for quite some time (at least a year - my memory is unclear on this point).  Someone asked in passing what was the current status of his presenting problem, incontinence.  The therapist stated, as though this were a minor detail, that his problem was unchanged.  Yet at the end of the meeting she was highly praised by those attending for her skill, insight and ingenuity.  It was also agreed that it was time to draw the boy’s therapy to a close; this process would require another six months of therapy to deal with ‘separation issues’. 

If there was any criticism or questioning at all about ideas and practices, the response was usually to interpret this in terms of the dogma espoused at the unit, ‘negative counter-transference’ being a favourite expression at such times.  

I was reminded of this indifference as to outcome when viewing Le Mur. Towards the end of the film, the therapists were asked what an autistic child can gain from psychoanalysis.  Their reactions suggest that they considered the question to be completely absurd.  The response of one of them was to put his head down for an inordinate length of time, look back up, grin, and announce, ‘the pleasure of taking interest in a soap bubble’.

Looking back, I believe that my time on the unit taught me more about child psychotherapists than children themselves.  The experiences at the unit that I have described are ones that colleagues have also informed me they themselves have had at similar departments.  I need to say that I have since had experience of other child and adolescent services which I would highly commend for offering a range of psychological interventions and which encourage a more critical approach to the work undertaken.  Also, nowadays there is greater emphasis by NHS managers on continual audit, cost-effectiveness, and performance and outcome measures. 

Incidentally, one of the adult psychiatrists at the Royal Free Hospital (Dr Sylvio Benaim) informed me that he once had dinner with Melanie Klein (she died in 1960); he mentioned behaviour therapy (then up-and-coming) and she told him that she thought there was ‘something in it’.