Psychosis or Communication: The Experience of Chaos in a Four-Year-Old Girl

This is an attempt to understand overwhelming psychotic material and mad behaviour in a child seen for therapy at four years of age. Very often I wondered if this child was so disturbed that she needed special placement; was I continuing therapy where I should be suggesting alternative arrangements such as a total therapeutic environment? How could I expect this child to cope in a normal school and to continue living at home? In the beginning I took her into therapy because she said ‘I'm frightened” during my first interview. Despite the psychotic behaviour and the intense psychotic transference, there continued to be moments of contact between us although few and far between. I think this gave me the courage to continue in the belief that beneath the maelstrom there was a person, not a psychotic emptiness. Perhaps a child behaving in this way should sometimes be seen as reacting constructively, not as mounting an assault on functioning but hoping someone can survive the attacks and understand.

During therapy there were three moments when change clearly occurred; these were all prior to breaks in the treatment The breaks can be seen as a relief, confirmation for her that she was not mixed up with the object but separate, we were not muddled together. The therapy allowed the child to internalise the whole therapist good and bad, with strengths and weaknesses she had fully explored. The internalised Dr. Trowell could contain and accept all of herself so that she herself could begin to understand. She did not then need to expend all her energy in maintaining a defensive barrage, in attacking and destroying the me in her memory and mind. Unlike a psychotic child she appeared able to use the internalised me in a positive way, to hold her over the breaks and enable her to continue to work. This then is an account of a very disturbed child who benefited from twice a week therapy.

Anna was presented as a child who ate reluctantly and who had difficulties in making