Clinical Commentary XVIII

[The material was sent ‘blind’ to three clinicians who were asked to comment on the session and on how their way of thinking about the patient would inform their way of working with him. - MB]

The patient, Paul, 16, has been in twice weekly psychotherapy for one year. He does not use the couch. He was referred by a hospital psychiatric department following assessment by a psychiatrist and child psychotherapist. He also underwent a medical investigation for severe headaches and high blood pressure both of which were thought to be linked to his emotional state.

Paul has been having problems since he was 9 years old. He was described as having very little internal control. He was often violent to himself and others, smashing his fist against walls, getting into fights, etc. He also damaged property, for instance, breaking up a class-room when 13, an event which led to his expulsion. He describes this expulsion as precipitating his ‘nervous breakdown’ when he came close to throwing himself from a railway bridge. He has continued to have episodes of depression and suicidal thoughts.

Since a young age Paul has turned to drugs (mainly cannabis) and alcohol in an attempt to obliterate pain. His consumption of both has decreased since therapy began but he still ‘binges’.

Paul is dyslexic and was attending a special school when he began therapy. He was on a very limited contract and hardly attended. He left aged only 15 without any qualifications. He worked full-time in a factory for a few months and was then unemployed. Though the work was exploitative it did provide him with a structure which helped hold him together.

Paul's father moved from Eastern Europe in the 1950s, worked his way through college to become an engineer and married Paul's mother. According to Paul this was their first relationship. She does voluntary work. Paul is the youngest of four children. There is a 10-year gap between him and the next sibling. There is a long history of ps