What Developments can be seen in a Year’s Intensive Psychotherapy with a Ten Year Old Adopted Boy with Mild Learning Difficulties JOANNE NICHOLSON-BINT A thesis submitted in partial fulfilment of the requirements of the University of East London in collaboration with the Tavistock and Portman NHS Foundation Trust Doctorate in Child Psychoanalytic Psychotherapy (M80T) March 2017 Word count: 50,739 i This thesis represents my own research and original work. It cannot be attributed to any other person or persons. ii Abstract The following retrospective single case study aimed at looking at what developments could be seen in a year’s intensive (three times a week) child psychotherapy, within a specialist CAMHS community team, with a ten year old adopted boy with mild learning disabilities who had a history of neglect and trauma until the age of six. It demonstrated that short term intensive child psychotherapy provided a solid foundation for on-going therapy. The referred symptoms included nightmares of being re-claimed by an abusive carer which were eradicated and other behavioural change occurred during treatment the adopted parents thought was not possible. Thematic analysis identified three main themes; ‘multiple families in mind’, ‘things going missing/out of one’s mind’ and ‘problems with sequencing’ which led to concluding ideas that included the central importance of truth and mourning. The themes and concluding ideas relate and expand those described and illustrated within case study material in the existing body of literature on child psychotherapy with looked-after children. The study highlights the value of child psychotherapy for looked-after and adopted children in its ability to facilitate the communication and understanding of the looked-after and adopted child for the child and the family. It demonstrated the value of the single case study. Key words: short term intensive child psychotherapy, looked-after and adopted child, neglect, learning disabilities, single case study, thematic analysis, loss, truth. iii Table of Contents Page Acknowledgements 1 Introduction 1 1.1 Research Question 1 1.2 Rationale 2 1.3 Overview of Thesis 3 2 The clinical case 6 2.1 Introduction 6 2.2 Biographical Introduction 6 2.3 Ben: A Pen Portrait 9 2.4 The referral to CAMHS 11 2.5 Psychological testing 11 2.6 Considerations regarding child psychotherapy as an intervention 12 2.7 Concurrent parent work 14 2.8 Parent Review Meetings 15 2.9 Overview of the sessions 15 2.10 Education 16 2.11 Why Ben was selected for a single case study 16 2.12 What happened next for Ben 19 3 Literature review 22 3.1 Introduction 22 3.2 Treatment modality: 23 3.2.1 Child Psychotherapy 24 Child psychotherapists writing about looked-after children 26 Learning disabilities and looked-after children. 29 ‘Multiple families in mind’ and looked-after children. 32 Kinship care and looked-after children 35 Adoption and looked-after children 36 Oedipal issues and looked-after children 39 The issue of time for looked-after children 41 Adolescence and the looked-after child 43 3.2.2 Intensive Work 44 3.3 Impact of early trauma and disruptive relationships: 47 3.3.1 Psychoanalytic Literature 48 From a Kleinian perspective 48 The development of internal objects and the primary relationship 49 From Bion’s Perspective 51 Alpha-function 51 Container/contained 52 Theory of thinking 52 3.3.2 Perspectives from child development research 55 Impact of early trauma on mental health 57 Impact of early trauma and learning disabilities 57 3.3.3 Neuroscience 60 3.5 Literature Review Conclusions 66 0 4 Research Methodology 67 4.1 Research Methodology Literature Review 67 Single case study 71 Thematic analysis 73 4.2 Rationale and methodology 76 4.2.1 Research Design 77 4.2.2 Single Case study 78 Why single case study as a research method 79 Strengths of this clinical case study 80 Limitations of this clinical case study 80 4.2.3 Thematic Analysis 81 4.2.4 How I decided what to research 82 4.3 Stages in the research 83 4.4 Ethical Considerations 84 4.4.1 The child and the therapeutic intervention in relation to the research 84 4.4.2 Consent 85 4.4.3 Anonymity 85 4.4.4 Data access, security and management 86 4.5 Adaptations of the design 86 4.6 Data Collection 86 4.7 Triangulation 87 Social Services 87 Psychology Reports 88 Supervision 89 Parent Psychotherapy 90 Parent review Meetings 90 Further on-going Psychotherapy 90 Summary 91 4.8 Data Analysis 92 4.8.1 Methods used to analyse data 93 4.8.2 Thematic analysis. Stage 1: Data Familiarisation 93 4.8.3 Thematic analysis. Stage 2: Coding 94 4.8.4 Thematic analysis. Stage 3: Searching for Themes 95 4.8.5 Thematic Analysis. Stage 4: Defining and Naming Themes 95 5 Findings 101 5.1 ‘Multiple families in mind’: ‘He is always calling me’ 101 5.1.1 Family figures: ‘I could balance this for the rest of my life’ 104 5.1.2 Imaginary visitors: ‘You are a kind of burglar, go away and leave us 105 in peace’ 5.1.3 Identity: ‘I am one of them, but I have a parachute’ 108 5.2 ‘Things going missing/out of mind’: ‘Already lost something else’ 109 5.2.1 What went missing: ‘Here I am!’ 109 5.2.2 How things went missing: ‘I will return it to her before she notices’ 112 5.2.3 The impact of things going missing: ‘Powerful and unforgiving’ 117 5.3 ‘Problems with sequencing’ 121 5.3.1 Time: ‘Where is May?’ 121 1 5.3.2 Generations: ‘Granddad Smith wants me to be his son again’ 123 5.3.3 Experience: ‘That is what they did in the one war’ 125 5.4 Excluded Themes 126 5.5 Concluding Ideas 127 6 Discussion 128 6.1 Introduction 128 6.2 ‘Multiple families in mind’ 128 6.3 ‘Things going missing/out of one’s mind’ 130 6.4 ‘Problems with sequencing’ 136 6.5 Links between themes 142 6.6 Time Frame 145 7 Conclusions 148 7.1 Concluding Ideas 148 7.2 What has been learned from this Research? 150 7.3 The Limitations of the Research 152 7.4 Summary of the links between Findings and Literature review 152 7.4.1 The experience of looked-after and adopted children 153 7.4.2 The three themes and links to Literature 154 7.4.3 Impact of early trauma 158 7.5 Contribution of research to the Field 158 7.6 Recommendations for further research 159 Bibliography and References 160 Appendices A Table: Biographical timeline 175 B Table of Themes 177 C Selected Clinical Examples from three Sessions 186 D Consent form used in the research 200 E UREC Approval Letter 201 F Student Declaration Form 203 2 Acknowledgements I would like to thank my patient and his family for consenting to this study and from whom I learned so much. I am extremely grateful to Catrin Bradley and Jenifer Wakelyn for their patient and committed supervision of this research. Thanks to Marija Stojkovic and Arianna Pulsoni for their time and insights. Thank you to Marie Bridge. Thank you to Shiho Main, Davina Brown, Jessie Woods, Lynne Taylor, Helen Erridge, Rachel Smith, Sarah Wilson, Art Patrick and Katherine Nicholson who, in various ways, tolerated and sustained me throughout this project. Thank you, posthumously, to Kathleen Bint and Christine Anglade. 3 0 Introduction 1.1 Research Question This thesis addresses the research question ‘what developments could be seen in a year’s intensive child psychotherapy, within a specialist CAMHS community team, with a ten year old adopted boy with mild learning disabilities who had a history of neglect and trauma?’ Children who have been adopted have already been through possible experiences of trauma, loss and rejection. They may have waited to be adopted having further experiences of loss through multiple foster placements. Children and families may have had experiences of doing life story work, and the parents may have attended parent workshops. They may have been offered support before including Social Services, Education, Voluntary and Charity Organisations and Health Services. The service that I worked in (Specialist CAMHS Community team) offered specialist mental health assessment and treatment for those children and families who were displaying severe symptoms of emotional distress, behavioural difficulties and psychiatric conditions. We received referrals from social workers, schools, voluntary groups, GP’s, paediatricians and accepted self referrals. Many children and families who have been through the fostering and adoption process do not require or want specialist mental health support. However, for some fostered and adopted children and families specialist help is sought. A child’s distress and difficult behaviour may have escalated to a point where it can no longer be contained through the support of Social Services and Education’s input. It might be that the child is putting themselves and others at risk. Their placement with the adopted 1 family may well be in jeopardy despite the very best intentions of everyone involved. Our services were often sought when a crisis occurred. As different disciplines in a specialist team we offered the child and family different ways to understand the child’s distress and behaviour. Thorough assessment and discussion within the team and thinking with the family specific treatment could be offered. The research project took place within this context and what follows is a thesis map (Mewburn, 2008). It contains a thesis rationale including thesis statement, a description of the contribution to knowledge and importance of the work and a list of the main research questions.