Clinical commentary

Clinical material

Background

Lewis is a six-year-old boy of mixed ethnicity. He lives with his maternal grandparents and has done so for the past five years. He has a younger brother who also lives with them.

The service where I work is an inner city CAMHS clinic. Lewis was referred to the service because of his unmanageable behaviour at home and at school. He has difficulty making friends and frequently displays aggressive behaviour towards others. He has also displayed sexualised behaviour at home and at school and the threat of exclusion from school is current.

Lewis's mother, Mary, was previously a heroin user. She is now engaged in a rehabilitation programme. At the time of the assessment for psychotherapy Lewis had regular contact, including overnight stays, with his mother and his mother's partner. Lewis has had no contact with his birth father for the past three years. Previous contact was supervised and via a contact centre, however, this ceased abruptly and father's whereabouts are unknown to the family.

The pregnancy with Lewis was unplanned and Mary's drug use worsened significantly during her pregnancy. Birth was by caesarean section and Lewis was born drug-addicted. Lewis and his mother lived together for the first eight months of his life. Mary then returned to using drugs when he was approximately 10 months old and he was placed in to his grandparents care. In the same year, maternal uncle dropped Lewis and he suffered a fracture. He was removed from his grandparents’ care and placed into foster care for five months, before returning to live with them.

The session presented here is the second of three psychotherapy assessment sessions with Lewis. There was considerable uncertainty as to whether psychotherapy should be offered as it did not feel that Lewis's external environment was a safe enough context for him to be able to explore his feelings. I and a colleague (who had been offering monthly appointments to Lewis's grandparents) referred Lewis and his