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Psychoanalytic psychotherapy is a new development in the treatment of people with learning disabilities and mental health problems, which traditionally has utilised behavioural management and limited counselling. The papers collected here have evolved from the work of the pioneering Learning Disabilities Service at the Tavistock Clinic, London, which is made up from specialised professionals from the fields of psychology, psychiatry, child and adolescent psychotherapy, adult psychotherapy and social work. The service mainly offers individual psychotherapy but also provides group work, parent work, family therapy and consultative work with professionals where necessary.This volume demonstrates the vast range of work undertaken by members of the service, covering treatment for children, adolescents and adults from the fields detailed above. It also contains an in-depth look at aspects of life in residential settings and at audit and research. Several central concepts reoccur: the theory of early trauma; the theory of "secondary handicap", a term coined by Valerie Sinason to describe the particular use a person makes of their handicap; and the sheer painfulness of having a learning disability to all concerned and the magnitude of defensive manoeuvres used by people to evade this reality.A major and worthwhile aim of the editors is to encourage an interest in training in psychotherapy with this patient group, an overlooked but rewarding field. This book will appeal to many for a variety of reasons. It is pertinent for those from any field who are already engaged in work with people with learning difficulties and will also be of interest not only to general practitioners and students of psychotherapy but also to non-specialists who are connected with the issues raised, such as carers, keyworkers, family members and friends.In this book, psychoanalytic psychotherapy with children, adolescents and adults with learning disabilities is described in detail, with discussion about some of the technical issues which can arise in clinical work with this patient group. The book aims to be accessible to a wide range of readers, and includes chapters on group therapy in an educational setting, on research and on aspects of institutional care. It will be pertinent and useful to all practitioners and trainees in the fields of learning disabilities, child and adolescent mental health, including psychiatrists, psychologists, social workers, and psychotherapists.Contributors:Annie Baikie; Marta Cioeta; Louise Emanuel; Lydia Hartland-Rowe; Sally Hodges; Maria Kakogianni; Pauline Lee; Victoria Mattison; Lynda Miller; Sadegh Nashat; Nancy Pistrang; Elisa Reyes-Simpson; Nancy Sheppard; David Simpson; and Judith Usiskin.

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CHAPTER ONE. The psychotherapy of a little girl with a severe learning disability and a history of deprivation and neglect

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Maria Kakogianni

“Tanet” was a learning-disabled little girl whom I saw in once-I weekly psychotherapy for a little more than a year. She was I referred to the Clinic by social services, who requested an assessment for psychotherapy and help in planning for her future. At that time she was 7 years old and had been in care since the age of 3. The referrer described her as a loveable little girl who displayed ^discriminate affection but could become difficult to control and aggressive when she did not have the full attention of an adult or when she had to cope with minor frustrations. Janet had a severe learning disability and was only able to use a few words. At the time of referral she was placed in a school for children with moderate learning difficulties, but social services were concerned about the suitability of this placement for her needs.

There had been concerns about Janet’s development since the time of her birth. In her early childhood she lived with her parents, who both had mild learning difficulties, and with her two older siblings. According to reports from social services, the children were physically and emotionally neglected, and mother’s contact with them was almost totally absent. It seemed that Janet and her siblings had started life in an extremely deprived environment. By the time they were taken into care, all the children were seriously underweight, and none of them was able to converse. In their report, social services mentioned concerns about possible physical or sexual abuse of the children, which were, however, never substantiated. After having been removed from their family, Janet and her siblings lived in a children’s home for two years. By the time she was referred to the Clinic, Janet had been separated from her brother and sister and placed with short-term foster parents. She had not seen her mother or father in two years and only saw her older brother once a month.

 

CHAPTER TWO. Therapeutic dilemmas when working with a group of children with physical and learning disabilities

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Sally Hodges and Nancy Sheppard

This chapter concerns a group for children with progressive musculo-skeletal wasting disorders that is run at a main stream secondary school. Initially two members of the group had learning disabilities, two did not. The orientation is that of psychodynamic group therapy, and the therapists are grappling with the dilemma of how much to challenge the children’s defences, given the poor prognosis related to their medical conditions. The main issues in running this group are described and explored, specifically the impact of the setting, the use of physical touch, challenging defence mechanisms, and making interpretations. The given task, as requested by the school, was to help the group participants reflect on their mortality—an aim that, it is concluded, is not necessarily achievable or desirable.

The Special Educational Needs Coordinator (SENCO) of a local secondary school made a referral to our Clinic, requesting group therapy. He was worried about four children at the school who all had a terminal condition. He felt that the children would benefit from having some time with a therapist to think about their condition and “the future”. All of the children and their parents had been asked whether they would like to be referred for a group, and all had agreed. We also learnt that the staff at the school were having difficulty in addressing the painful issues of illness and death while continuing to carry out their roles as teachers within the school, and therefore the decision had been made to refer to an outside agency. In our initial consultation with the school, it seemed that they were expecting a psycho-educational group to be set up in order to address issues of loss and bereavement. However, following our assessments with each of the proposed group members, it was clear that the intense nature of the children’s anxiety warranted a less directive therapeutic group. It was felt to be most appropriate to provide a group drawing on ideas from psychody-namic and analytic group therapy.

 

CHAPTER THREE. Some thoughts on psychotherapeutic work with learning-disabled children and their parents from orthodox religious communities

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Judith Usiskin

This chapter describes therapeutic work with patients from orthodox religious communities of several faiths—Muslim, Jewish, and Fundamentalist Christian—that had, as a common factor, that all the children had various degrees of learning disability. The constraints imposed on the therapist in terms of some of the issues that arose in therapy with this client group are explored, as well as the impact of the learning disabilities factor on family dynamics, including cultural attitudes towards handicap.

In order to preserve confidentiality, all personal data have been changed, and, where necessary, the clinical material has been disguised to make the patients unidentifiable. This has not been an easy task, as all the patients described are, of course, very special individuals, with their own particular traits, mores, and family backgrounds; I hope that despite this rather rigorous editing I have been able to capture their individuality and to convey their particular needs.

Organizations like NAFSIYAT (the Inter-cultural Therapy Centre) have been working therapeutically with patients from a variety of ethnic backgrounds for many years. The most recent publications by professionals working in this Clinic—such as Renos Papadopoulos (2001, 2002), Gill Gorell-Barnes (2002), and Inga-Britt Krause (2002), to name but a few—have provided us with further insight and understanding in this area of work. The Tavistock Clinic Bangladeshi Service has been in force since 1996, providing consultation and treatment for members of the Bangladeshi community.

 

CHAPTER FOUR. Facing the damage together: some reflections arising from the treatment in psychotherapy of a severely mentally handicapped child

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Louise Emanuel

In Shakespeare’s play Richard III, the Duchess of York, his mother, complains resentfully:

Thou cam’st on earth to make the earth my hell.
A grievous burden was thy birth to me.
Tetchy and wayward was thy infancy;
Thy school-days frightful, desperate, wild and furious;

[Richard III, IV.iv.167-170]

I am sure we can recognize this as a common description of the early life of patients we see in therapy, where there has been a mismatch or failure of attachment between mother and infant. Parents may feel for a range of reasons that their children are unlovable or incapable of giving pleasure, often projecting these feelings into their infants. Richard’s parents lived in violent, bloody times; his mother must have been more-or-less a single parent while her husband, the Duke of York, fought bitterly to attain the crown. However, I wonder whether Richard’s congenital deformity played a part in her hatred of him. One can imagine her shock, feelings of failure, and outrage on discovering that she had given birth to a deformed child. She almost implies that he was sent to punish her for her sins. The beautiful, loveable baby that may have been there in phantasy for his parents was absent at his birth, had in a sense “died” and was replaced by a damaged baby. The difficult process of mourning the loss of one baby while attempting to welcome another, different baby would need to take place. I think this is a task that is seldom adequately done, and a failure to mourn the loss brings into focus all the attendant difficulties described so clearly by Freud (1917e) and Klein (1940). Richard’s initial handicap, his physical deformity, may have been compounded by secondary emotional damage suffered as a result of his parents’ inadequate mourning.

 

CHAPTER FIVE. Learning disability as a refuge from knowledge

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David Simpson

My work with people who have learning disabilities has led me to the conclusion that a major factor adding to their difficulties and preventing their learning and development is the way in which their disability can act as a refuge from knowledge.

The current use of the term “learning disability” in the United Kingdom, replacing “mental handicap” or “mental retardation” to refer to those people with limited intelligence (IQ score below 70), has added to this problem by increasing confusion. This term obscures the distinction between constitutional low intelligence in which organic disorder and inheritance are significant determinants and difficulties in learning of a psychological origin. This distinction is important because these two entities so frequently overlap, and they can also masquerade as each other. The overlap is seen in mentally retarded people who show psychological difficulties in using the intelligence they have; sometimes this is called “secondary handicap” (Sinason 1992b).

 

CHAPTER SIX. Adolescents with learning disabilities: psychic structures that are not conducive to learning

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Lynda Miller

In this chapter I discuss what I have come to feel is a significant factor in the psychotherapeutic treatment of some young people with learning disabilities. It is a factor that can affect the nature of the transference relationship in a negative way. If it is not understood and interpreted by the therapist, it can impede the patient’s capacity to learn through experience from the process of therapy itself. If the therapist is felt by the patient to have a secretly harsh, critical, or judgemental attitude towards those with learning disabilities, the patient will tend to placate the therapist or conform to what he or she feels is being expected in a self-protective or defensive manner.

I suggest that this kind of relationship, highly detrimental to learning, in which a harsh critical figure is projected into the therapist in the transference relationship, originates in early infancy in the primary pre-oedipal relationship between the baby and the mother.

When parents give birth to a baby with a visible disability such as Down’s syndrome, shock and disappointment may be reflected in their eyes, even if they are attempting to conceal or to overcome these powerful emotions. In a recent paper called “Relating to the Super-Ego”, Edna O’Shaughnessy (1999), a contemporary Kleinian analyst and writer, discusses Bion’s (1967b) concept of the ego-destructive superego. She refers to a psychic condition that can contribute to the formation of an abnormal superego: that of “an abnormal state of mind in the mother condemning the baby for not matching her anticipated ideal”.

 

CHAPTER SEVEN. The creative use of limited language in psychotherapy by an adolescent with a severe learning disability

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Annie Baikie

This chapter is about language and about loss, about thinking and about attacks on thinking, about challenge, and about development.

Individual psychotherapy involves two people—the patient and the psychotherapist—and for the therapy to have a positive impact upon the patient, both parties have to have access to learning. In psychotherapy this learning has to co-exist in a particular way, the psychotherapist getting to know the patient and the patient getting to understand him or herself within the context of that relationship. This is what Bion (1962a) called K, an attempt on the therapist’s part to understand the patient, to get to know the patient, not by an accumulation of theoretical concepts but by an intimate process of knowing, which may or may not be achieved. In therapeutic work with patients with learning disabilities many complex issues become entangled between patient and psychotherapist.

Valerie Sinason (1992b) has written about “secondary handicap”: she writes that in thinking about the nature of attacks on intelligent thinking, we give people with learning disabilities the opportunity not to be stupid, and although people with learning disabilities might never be able to do certain things that we take for granted, they still need the emotional loan of these things.

 

CHAPTER EIGHT. The question of a third space in psychotherapy with adults with learning disabilities

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Pauline Lee and Sadegh Nashat

This chapter is concerned with the concept of dimensions within the therapeutic alliance, and specifically with the problems that arise when the therapeutic relationship is restricted to two dimensions. In psychoanalytic psychotherapy a space needs to exist between the therapist and the patient in order for progress to be made. Within this space, both therapist and patient can reflect on the issues that arise, allowing the therapist to develop insightful interpretations as the therapy progresses. In some situations, however, it becomes difficult or impossible to maintain this necessary distance. As a result, the psychoanalytic encounter may become claustrophobic for both parties, leaving no space for creativity (Symington, 1986). It becomes a situation where there is a lack of symbolic functioning, and primitive psychic mechanisms are brought into play. In theoretical terms, the situation lacks a third dimension, sometimes referred to as the “triangular space” (Britton, 1989)—a dimension within which a variety of desired therapeutic processes could occur. These processes allow for the possibility to make links. This refers to the ability to connect present experiences to past life events and for the patient to realize patterns of repetition, thereby allowing him/her to recover repressed thoughts and feelings. This process involves a transformation of unbearable elements in the patient’s experience into meaningful and tolerable states.

 

CHAPTER NINE. When there is too much to take in: some factors that restrict the capacity to think

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Elisa Reyes-Simpson

In this chapter I consider some of the internal and external factors that inhibit and restrict the development of a thinking mind that is able to apprehend internal and external reality. I focus primarily on intellectual restrictions, which seem to arise not as a direct result of organic damage, but due to emotional deficits. The impetus to explore this area came from the clinically painful experience of the disturbance caused to some learning-disabled patients by the process of individual psychotherapy and the potential of close contact with someone wishing to understand them. What became apparent to me in the clinical setting was that the experience of being understood, and through that gaining some understanding themselves, proved too much for some patients.

I first outline briefly some of the psychoanalytical concepts that have informed my thinking.

From the beginning, the baby develops in the context of another. Melanie Klein (1935) has vividly described the infant’s existence as characterized by the most primitive anxieties: fear of death, fear of its own desires of love and hate, and uncertainty of survival itself. Development is largely shaped by the infant’s experience of these feelings and its ability to process them. This capacity to process feelings is determined by the infant’s experience of being known through the mind of another—usually the mother. W. R. Bion’s concept of container/contained (1962a) is of much value in formulating an understanding of the development of a thinking mind. He argued that early emotional experience is decisive in terms of the development of a capacity to think. Bion believed that the first form of thinking occurs in the process of striving to know the psychic nature of one’s object and oneself. Bion explains that the way in which a mother can allow in and be in contact with her baby’s state of mind and is then able to support and respond to her baby allows the baby to grow psychologically. The baby gains the experience of being known through another and attains a meaningful sense of himself and his experience. Implicit in Bion’s model of containment is the mother’s capacity to be in contact with her own emotional reality. The mother’s mind acts as an active container for her infant. The absence of a mother’s emotional availability can be experienced by the infant as overwhelmingly threatening to survival itself; Bion described this experience as “nameless dread”.

 

CHAPTER TEN. An exploration of severe learning disability in adults and the study of early interaction

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Lydia Hartland-Rowe

This chapter is about difficulties in acquiring and holding on to knowledge and about the role of early interaction in the development of a capacity to learn, examined by drawing on both psychoanalytic and child development sources.

Working with adults with severe learning disabilities prompted my interest in this exploration. The role of early interaction in the development of their profound difficulties in thinking and learning is a matter of distant speculation. The individuals I describe had their own unique experience of learning not to learn, and for each one a significant part of the process had taken place years ago and is now, sadly, unknowable. What I do have available, however, from my work as a music therapist and residential social worker, is clinical and observational material that illustrates the difficulties for my adult clients in thinking and “knowing”. With the use of this material I identify and illustrate certain powerful themes in learning disability that recur and are significant and I speculate about links with early experience.

 

CHAPTER ELEVEN. The endings of relationships between people with learning disabilities and their keyworkers

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Victoria Mattison and Nancy Pistrang

“A keyworker is a friend that you can turn to, and if s a friend who I can talk to when I’ve got problems, like what I’m talking to you about, about what has happened in my life—you know, because a lot of things have happened— They’re helpful, so to that end it makes one feel that they are different to all the others, and it means that I can turn to them when I’ve got that many problems or whatever.”

This was Jim’s account of the role of his previous keyworker, Jean. (All names in this chapter are pseudonyms.) “Jim” was a 41-year-old man with learning disabilities and physical impairment. He grew up in a long-stay “mental handicap” hospital until it closed down when he was in his mid-thirties. He then moved to his home in the community. Jim explained to us that he had had lots of keyworkers throughout his life. He seemed to value the opportunity to talk about his past relationships.

Here’s how Jim talked about how he felt after Jean left:

“I felt lost from hereon… hurtful, very hurtful…It was like saying, ‘I may see you in the future, but I’ve got to go’ sort of thing. ‘I know we’ve been friends, but now it’s time to sever our friendship.’ I felt gutted, you know, I felt really—I mean, heaven only knows where I go from here…It Was hard, because she was one of my special friends, you know. And we got a sort of close relationship going. It was over a course of time that we got to know each other…”

 

CHAPTER TWELVE. Ensuring a high-quality service: clinical audit, quality assurance, and outcome research in the Tavistock Clinic Learning Disabilities Service

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Nancy Sheppard, Sally Hodges, and Marta Cioeta

Recent developments in clinical quality assurance and governance have particularly dictated that an important part of any service provision is the inclusion of means of monitoring and ensuring high-quality, meaningful and effective services. Since the launch of the Tavistock Clinic Learning Disabilities Service in 1995, we have organized methods to monitor various aspects of the service, including the psychotherapeutic treatments we are providing. This chapter aims to explore some of the methods available in assessing or evaluating our work and to give an overview of the projects we have already undertaken. We will discuss some of the issues that have arisen as a result of our evaluation projects and attempt to relate our dilemmas to wider issues in research with people with learning disabilities and services for people with learning disabilities.

Clinical audit and quality assurance

Clinical audit is the approach whereby one measures the effectiveness of clinical activity by comparison with a pre-set standard. This can be achieved by deciding in advance what standards or criteria for local practice should be, then by monitoring how frequently these criteria are met. Audits are helpful in getting an overview of the effectiveness of local services and in considering service development. Firth-Cozens (1995) provides a good introductory text to audit in mental health services, and Davenhill and Patrick’s (1998) book provides examples of more advanced audit techniques.

 

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