Transforming Despair to Hope

Reflections on the Psychotherapeutic Process with Severely Neglected and Traumatised Children

Monica Lanyado

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351661973
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Transforming Despair to Hope: Reflections on the Psychotherapeutic Process with Severely Neglected and Traumatised Children offers a thorough overview of the problems and rewards of trying to help severely neglected and traumatised children. Drawing on over 40 cyears of clinical experience, Monica Lanyado provides a historical and social perspective on this challenging population, as well as helpful theoretical frameworks and thoughtful support for all professionals and clinicians working with these children.

This book brings together selected past writings and new chapters from Lanyando. In it she describes the consequences of severe neglect and trauma on a child's emotional development, and then goes on to examine what it is that brings about positive change. By using vivid clinical examples of therapeutic practice with these children, she elucidates the difficulties associated with this population, as well as for those who care for them in families and in residential settings.

Transforming Despair to Hope is a valuable resource for child and adolescent mental health professionals andtrainee clinicians, as well as those in related fields working with children in need.

1 The far-reaching consequences of neglect and trauma in childhood

Some of the greatest literature of the nineteenth century tells vivid stories of children who were orphaned, rejected, abandoned or subjected to cruelty by those who were meant to be protecting them. Charles Dickens’ Oliver Twist opens with powerful descriptions of the misery and deprivation of nine-year-old Oliver who has no parents and is being raised in the Victorian workhouse (Dickens 1837). Having dared to ask for more food he is literally sold into an ‘apprenticeship’ with an undertaker because the misery and unhappiness of his facial expressions make him an ideal person to accompany the hearse in funeral processions.

Oliver runs away from his apprenticeship because of the cruelty and physical abuse he suffers there, and is befriended on the streets by the Artful Dodger, a child thief, who lives with a gang of other child thieves under the protection of Fagin. Oliver has no other choices of how to survive and joins the gang, living under the criminal Fagin’s protection. None of the children in the gang have families; they only have each other and Fagin, who teaches them how to pick pockets and live a life of crime. Fagin exploits the children but provides a bed and food away from the streets on which they would otherwise have to try to survive. He also provides a parody of parenting and the other boys in the gang provide a perverse sense of family. But this is only for as long as they carry on stealing for Fagin. If, like Oliver, they try to escape from the gang, they are ruthlessly pursued and brought back to the gang, because they ‘know too much’ and could tell the police about Fagin and his criminal contacts.

Although the book has a fairy tale-like happy ending for Oliver, Oliver Twist is a powerful description and statement by Dickens about the sordid lives and plight of poor, exploited, neglected and abused children in his time.

Victor Hugo, in his complex and moving book Les Misérables, created the child character Gavroche, who was about the same age as Oliver (Hugo 1862/1994). Unlike Oliver, he was not an orphan but had been thrown out of his rejecting, abusive and criminal home at any early age. He was expected to, and managed to fend for himself on the streets. He is a more resourceful character than Oliver and his name has become somewhat synonymous with the image of a loveable (and sentimentalised) Parisian street urchin. Gavroche managed to make himself useful to other street characters in a less criminal way than the boys in Fagin’s gang, but he mostly lived on his own in odd scavenged nest-like places that he found around Paris. He did not trust any adults and chose self-sufficiency.

Hugo, like Dickens, was concerned with social reform and the vulnerability and desperation of the poor, the ‘Misérables’ of the title. Gavroche’s fate is quite different from Oliver’s. He is shockingly and deliberately killed by soldiers on the Parisian barricades of the short-lived student uprising of 1832, whilst trying to make himself useful to the students.

Great literature enables the reader to identify with characters such as Oliver and Gavroche, and briefly get a sense of what it would be like to live their lives. Great literature also survives the test of time when the issues in which it immerses the reader remain so pertinent and a part of ongoing life. The complex problems of how to help children who are so unprotected from the worst aspects of adult behaviour remain, even though there is much improvement in the attitude of responsible societies towards how this is best achieved. The children that this book is about are the survivors of similar starts in life to Oliver and Gavroche.

Whilst the impact of the reality of childhood trauma, particularly in the form of physical, sexual and emotional abuse, has received a great deal of attention since the 1950s, the subtle and pervasive effects of neglect have been much more difficult to recognise (Music 2011b). However, it is often as a result of parental neglect (however unintentional this may be) that children become vulnerable to being abused. My previous writings have focussed on the impact of trauma, and the psychotherapeutic processes which aid recovery (Lanyado 2004a, 2009). To redress this imbalance of not having paid specific attention to the impact of severe childhood neglect, the first four chapters of this current volume place the emotional significance of neglect in the foreground, setting the scene in which trauma takes place.

This group of children suffer from many serious difficulties which is the reason why it is so hard to care for and help them, particularly when they have had to be removed from their birth parents’ home by the local authorities. In the UK, they are initially likely to be placed in foster homes and in time, if deemed appropriate by the courts, they may be adopted. They are likely to be highly reactive, frightened and frightening, wild, violent, angry, at times withdrawn and depressed, extremely demanding and controlling in all their relationships, full of hatred and neediness, anarchic, encopretic, eneuretic – the list goes on and on. Alongside these problems, they are often diagnosed as being on the autistic spectrum or attention deficit disordered. They are likely to be intellectually impaired or functioning well below their intellectual ability in school. They can become dangerously violent, self-harming and suicidal in adolescence. They can also become sexually promiscuous, delinquent and drug or alcohol dependent, as well as being diagnosed as mentally ill in adult mental health terms – for example, suffering from psychotic states of mind or paranoia.

In addition, the child is likely to have been very frightened, angry, traumatised and distressed by what happened leading up to, and at the time of being taken away from their birth parents. This is true even if there is relief at being removed from violent and neglectful homes. The loss of what is familiar, however awful that may be, is compounded by the unfamiliarity of the foster home despite the kindness and care they try to offer. Many of these children have needed to be removed from their birth parents’ care well before the age of five. They are still very little when all these traumatic events have taken place. Also, the child, because of all the adverse relationships and circumstances of the birth family home, is inevitably deeply troubled, difficult to live with and likely to be resistant to forming a relationship with foster carers. Their basic trust in any adults’ capacity to care for them has been fundamentally compromised by their birth parents’ inability to care for them. This lack of trust is transferred into any potential new relationship including the psychotherapeutic relationship, and results in the child needing to use strong emotional defences to protect him or herself from further distress and trauma. These defences often become self-defeating, leading to further difficulties. The implications for the child of separation from, or loss of, attachment figures for future mental health are well documented and will often be referred to in this book (Bowlby 1979, 1988; Simmonds 2013).

When a child like this comes for psychoanalytic psychotherapy, often some considerable time after these major life events, the remnants of these experiences and relationships inevitably and spontaneously re-emerge within the therapeutic process. They are expressed, sometimes in obvious ways and at other times in extremely subtle ways, within the transference–countertransference relationship, which is the aspect of the therapeutic relationship in which the child’s past is re-experienced in the present. This is a form of unconsciously repeating in the present what cannot be consciously remembered from the past (Freud 1914). This transference of the past into the present can colour the child’s internal world in ways that make the child misunderstand the better external relationships and life experiences that have subsequently become available to him or her. The child cannot help but unconsciously understand the present through the distorting lens of the traumatic past. It is the therapist’s efforts to understand what the child is unconsciously repeating within the transference–countertransference relationship and to disentangle this from the contemporary and new developmental relationship with the therapist, which facilitates the process of developmental change which subsequently emerges (Hopkins 2000; Hurry 1998, Lanyado 2004c, 2017).

Paradoxically, it is from within the present, developmental relationship with the therapist that the impact of neglect can be seen in many small ways. This becomes evident as the therapist gradually realises what has not happened (that is the deficits) in the child’s emotional life. As a supervisor of many therapies of severely neglected and traumatised children, I have been struck by the ways in which, as therapy progresses, the intensity of the therapist’s attention to the details of the child’s emotional life, replicate the ordinary parent’s detailed attention to their child. This detailed knowing of the child, within the therapeutic context, is the result of the therapist’s efforts to listen to and contain the child’s anxieties and preoccupations as discussed in more detail in Chapter 3 (Bion 1962). This intensity of thinking and knowing about the child’s internal life can be utilised to detect very early signs of more ordinary developmental growth, so that they can be noticed and nurtured from their fragile beginnings. It is in this way that the therapist becomes a ‘developmental object’ for the child in the present relationship. This provides some opportunity to compensate for significant aspects of parenting that did not happen whilst the child was being neglected; this is discussed in Chapter 3.

It is much more difficult to capture the emotionality of the transference–countertransference relationship when reporting other clinicians’ work. Whilst these feelings do come alive within the supervisee–supervisor relationship, as dis cussed in Chapter 9, the case illustrations in this chapter, and Chapters 3 and 4 of this volume, need to be read as therapeutic vignettes which capture the overall treatment issues as well as some of the detail of the therapeutic interactions. The following example is interesting because, rather unusually, this child was not neglected for the first twenty months of life and as a result, in comparison with children who were neglected during this same period of time, he is remarkably able to recover from subsequent terrible trauma, neglect and painful separation. I am grateful to the supervisee and her colleagues for permission to use their work as an example.

Eddie was removed from his birth mother’s care at birth because she was unable to care for him properly. This does not happen lightly and careful assessments and legal processes must have been involved in this difficult decision. He was placed with an experienced foster mother and lived with her for twenty months in a loving relationship. She wanted to adopt Eddie but a distant relative of his birth mother came forward in the last stages of the adoption process, and wanted to adopt Eddie. This kinship adoption application was given preference and went ahead and a new adoption process was started. Eddie moved to the relative’s home but after a number of months it became very evident that all was not well in the placement. The social worker noted that Eddie looked neglected and waiflike. Having been a chubby sociable little boy when he left the foster home he seemed frightened and watchful when social workers visited the home. Concerns mounted and resulted in Eddie being removed from the prospective adoptive home, and fortunately going back to his original foster mother. He had not gained weight or height over ten months of living with the prospective adopters. As well as having been severely neglected, there was significant evidence that he had been sexually abused which the social services and police investigated.

Eddie was referred for therapy when he was three and a half years old. He was a bright and expressive little boy who, from early on in the therapy, was able to make good use of the relationship with the therapist whom he clearly trusted, and towards whom he could express a healthy range of emotions: playful, cheeky, loving, angry, aggressive. From the beginning of his therapy, he communicated in various ways to his therapist about the traumatic events, separations and losses he had experienced. For example, there was a strong sense in the transference–countertransference relationship that leaving his foster mother to go with the therapist to the therapy room, and then leaving the therapist to return to the foster mother at the end of the session, repeated at an unconscious level the intense anxiety he had felt when going between the foster and prospective adoptive family, and back again. The level of watchful fearfulness which was projected into the therapist at these times was of a very different nature to the ordinary separation anxiety that many young patients feel when they are getting used to going to the therapy room without their parent, and alerted her to the traumatic roots of this emotional experience.

Early in the therapy Eddie could at times be very rejecting of his foster mother, saying he wanted to go back to his ‘other’ mummy. Fortunately, this mature and understanding foster mother (who was by then again in the process of becoming his adoptive mother) could see the distress, confusion and above all anger, which lay behind these difficult times and could respond lovingly despite the rejecting things that Eddie was saying. It was because Eddie felt secure enough in his relationship with his foster/adoptive mother that he was able to express these feelings at all, and they would then return to their more usual loving and affectionate relationship. In attachment theory terms, the behaviour that Eddie was showing was that of a child re-united with a trusted attachment figure to whom he could express his confusion, anger and love in whatever way these feelings tumbled out of him.

Eddie made very good progress in his therapy and it was evident that he was a bright child and learning well. He made the transition from nursery school to reception class in primary school with delight in all that he was learning, and was clearly able to think and reason. This is in great contrast to many children who have been neglected and traumatised from the start of life and struggle to be able to think and function intellectually at an age-appropriate level. Very significantly, Eddie had had a good start in life with his foster mother and this showed in his curiosity and ability to reflect on his life experiences, to think about them and to ask some very important questions – all before he was five years old.

Eddie’s return to his foster mother after the awful neglect and abuse he had suffered at the hands of his relatives, and his subsequent adoption by his foster mother, was almost like a fairy tale in which one would like to say ‘and they all lived happily ever after’. Whilst they did live happily together, there were many painful emotions and memories which needed to be processed in Eddie’s therapy, as well as his mother’s parent work. Eddie was full of questions and distressing memories. In particular, once he was adopted, he often pleaded with his adoptive mummy never to send him away again to what he called the ‘faraway’ family. When he gradually but still confusingly understood that his foster/adoptive mummy had not been able to do anything about this decision at the time, had also been very upset by the loss, and had missed him a great deal, this raised new questions. Why could social workers take a little boy away from his foster mummy – who of course he had felt then, and felt again now, was his mummy? If they could do that when he was little, he was very worried that they could do it again now. This raised the question for the therapist and adoptive mother, was he also aware that there was yet another mummy that he had been born to?

This was all discussed carefully between the adoptive mother, therapist and parent worker. To what extent could/should the gaps in Eddie’s life history be shared with him more fully, particularly as he was still so young? Would talking to him more about it, help him to recover and to deepen his sense of security in his adoptive home? It was important to enable him to find his own narrative with the help of the grown-ups, but at the same time, he needed some straightforward information to fill in some of the gaps that he couldn’t make any sense of. Whilst these discussions were taking place, Eddie had come to his own conclusions based on what he had talked about with his adoptive mummy. He told his therapist that there was yet another mummy, his birth mummy who as he told his therapist, no doubt based on what his adoptive mummy had told him, ‘cannot come back’. However, there was a theme of being abducted as well as rescued that he expressed through play in his therapy, that took a number of months to be worked through. During this time he had many nightmares, found it difficult to sleep on his own and became very clingy to his adoptive mother. At this point in his therapy these issues were foremost in his mind and needed to be talked about with his adoptive mother and his therapist, so that his memories could gradually become more conscious and bearable rather than repeated in nightmares which he was unable to control (Freud 1914). Any conscious memories that he might have had about the sexual abuse that there was physical evidence that he had experienced, remained inaccessible.

This brief example from a lengthy psychotherapeutic treatment raises just some of the questions that this book addresses about how best to help children like Eddie. Strikingly, whilst the experience of forming a therapeutic relationship with each child is unique and individual, the presenting problems are very similar and are the result of neglectful parenting which has made the child highly vulnerable to traumatic experiences. As already indicated, Eddie was unusual because he received good mothering for the first twenty months of his life and as a result, despite the terrible trauma he subsequently experienced, he had developed the secure emotional foundations on which to build his inner world. However, his life story and this clinical vignette also illustrate the enormous emotional challenges children such as him have to negotiate.

Although it is beyond the scope of this book, it is important to note that an increasing number of unaccompanied young asylum seekers are being accommodated by social care in the UK and are needing psychotherapy for the many terrible traumas that they have experienced – such as witnessing the death of loved ones, being tortured, suffering physical and sexual abuse, and homelessness. From within the therapeutic experience, psychotherapists have good reason to believe that many of these young people come from secure family relationships and had good emotional starts in life before they had to flee for their lives. Whilst different practices in child care and family structure in their countries of origin are likely to play their part in this clinical observation by British psychotherapists, there is nevertheless evidence from within the therapeutic relationship itself that, despite the severe levels of post-traumatic stress disorder that these young people experience, they have a firmer bedrock to their personalities and internal worlds than children who are known to have been neglected from birth (Melzak 2017b, personal communication). In this respect, these children have much in common with Eddie and can eventually, with sufficient therapeutic help, go on to study, make valuable contributions to the new communities that they join and form loving relationships, if they are given a chance to do so. (For detailed accounts of this work see Melzak (1992, 2005, 2017a) and Papadopoulos (2002)).

The broader context: finding a new home for the child

A number of the children may go backwards and forwards between birth and foster homes whilst efforts are made to help the birth family to provide better care for the child. Other children may rapidly lose contact with their birth family, siblings and extended family. Legal processes are involved in attempting to work out what is in the best interests of the child. Some birth parents argue their ca...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Acknowledgements
• Introduction
• 1. The far-reaching consequences of neglect and trauma in childhood
• 2. The historical and social context: influences on the treatment of severely neglected and traumatised children today
• 3. The absence of ‘holding’ and containment, and the absence of parental protection
• 4. Complex traumatic childhood losses: mourning and acceptance, endings and beginnings
• 5. Playing out, not acting out: the development of the capacity to play in the therapy of children who are ‘in transition’ from fostering to adoption (2008)
• 6. The playful presence of the therapist: ‘antidoting’ defences in the therapy of a late-adopted adolescent patient (2006)
• 7. Transition and change: an exploration of the resonances between transitional and meditative states of mind and their role in the therapeutic process (2012)
• 8. The impact of listening on the listener: consultation to the helping professions who work with sexually abused young people (2009)
• 9. Transforming despair to hopein the treatment of extremetrauma: a view from the supervisor’s chair (2016)
• Appendix: Publications
• References
• Index