Commentary by a Child Psychotherapist

The therapist's account of her work with Paul, aged 16, includes her synoptic view of the problems and background and detailed notes from three sessions. This gives us privileged access not just to this adolescent boy's way of relating, but to some of the feelings evoked in the therapist, her countertransference. My clinical commentary looks at both these things so that, by viewing the psychoanalytic process in detail, we can learn about Paul's internal world and his very troubled relation to his environment.

As I read the background I found myself asking in places whose account of the history is it? Whose belief is it also that Paul will end up like his sister who has suffered a severe manic depressive illness, his or his parents'? I thought initially that Paul's own fears and phantasies are not easily distinguishable from those of others. This may simply be because this is a brief summary and not that Paul takes on the views of others, or vice versa. I shall return to this issue later. Other questions arose for me too. Paul is the youngest by 10 years, so was he a baby or small child when his sister's illness affected her, and did his sister's illness deeply affect his mother and the family? He now has a breakdown in adolescence and, like her, comes to the same clinic. Does all this affect not just him, but his mother, to whom he is very close, and the whole environment for his adolescent transition? Is a severe state of flux observable between his perceptions of internal and external reality, now in adolescence as in early infancy? Lastly, what of any effective paternal elements? For, from what little we heard, I thought the father whom he treats with contempt as a tyrant may have become a figure in his internal world and in his gang-like tendencies in social relationships. As a preliminary historical hypothesis I was asking, ‘Did he observe his mother's fragile state as a baby and equate destructiveness with his own aggression and expressed neediness?’

In therapy