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This paper examines the relationship between therapeutic progress and the patient's family or residential situation with reference to the intensive treatment of an adolescent boy who had a severe learning disability and moved placement five times within four years. The idea is explored that the capacity to be thoughtful about emotional distress and to be engaged in learning about one's own mental processes is dependent in part on the human context surrounding the individual. It is illuminated by detailed clinical material using in particular Winnicott's concept of the facilitating environment and Sinason's concept of secondary handicap. The paper also discusses the dilemma for the therapist of whether a thoughtful state of mind and emotional connectedness are always in the interest of the patient's mental health when the external context is so at odds with this and whether retreating into psychic ‘suspended animation’ may sometimes be an adaptive response. Despite this, the author hopes that the paper will contribute to a growing understanding of the potential of psychoanalytic psychotherapy as an intervention for children and young people with severe learning disabilities.