Clinical commentary

Clinical material

Background

Mohammed was referred to CAMHS by a clinical psychologist who gave a talk on parenting skills at the nursery he attended. Mother talked with her afterwards about her concerns regarding Mohammed, saying he was naughty, easily frustrated, very cheeky and did not listen or do as he was told. Mohammed was isolated at nursery, had no friends, low self-esteem and struggled to start tasks and stay focused. His case was taken on by a clinical psychologist who only worked with his mother, always visiting her at home. Their meetings were infrequent and spanned the course of 1 year. Mohammed was assessed by a child psychiatrist when he was 4½ years old, who gave an ICD-10 diagnosis of ‘excessive masturbation’. During the time that I worked with Mohammed, I saw no symptoms to explain this diagnosis and understood this earlier behaviour as what might have been his way of managing anxiety and holding himself together at a time when he could not have had an internalised containing object.

Mohammed was assessed for psychotherapy at the age of 6½, during which time his mother was pregnant with her second child. The outcome of Mohammed's assessment advised that he be considered for intensive treatment due to his high levels of anxiety, aggression and fear. His play at this time was obsessive and repetitive, and the themes were death and violence. He identified with the aggressors, was unable to empathise with the victims, and was certain that death and destruction were inevitable. There were flickers of hope, but this could not be sustained. Order and meaning were overrun by chaos and catastrophe, as Mohammed threw objects around the room and upturned chairs. However, he showed that he was able to maintain a link between the sessions, and showed an interest in the inside of the cupboard and could think about what was inside. As a way of managing what might have felt like overwhelming feelings, he repetitively licked the backs of his fingers and touched his