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The session highlights the number of difficulties involved in working with such a damaged and disturbed adolescent in a residential setting. How can hope be maintained in what at times may feel like such a dire situation? Additionally, the therapist must contain and endure the anxiety and uncertainty about the many unanswered questions about the patient's early history and experience. It is commendable that the treatment has continued over three years; it requires a very determined effort by the therapist to keep to his position in the face of Mark's continual demands for management and containment.
The setting poses considerable problems: the therapist comments on the poor institutional communication, and says, “The team's left hand does not know what the right hand is doing.” Seeing a patient in therapy in a residential school produces very particular problems with boundaries, as is noted by the therapist when he arrives and parks his car and sees the patient hanging out his laundry: he fears that Mark will make a demand “out of left field that I will not know how to manage”. It suggests how intimidating such a patient can be, and how necessary it is for both the institution and the setting for the sessions to provide a secure, consistent and containing environment for the therapist and patient to feel that the therapy can take place.
Complex issues arise about technique in the treatment of adolescents who are violent or act out sexually. The rapid shifts that occur in the session reflect the oscillations between infantile, latency and more mature modes of functioning and relating. In addition to this the therapist describes Mark's four ‘personas’, which express very different states of mind in the patient. The manipulative and controlling aspects of Mark's personality inevitably lead to concerns about the development and establishment of perverse and psychopathic features as he grows up.
The therapist wants the sessions to be conducted on a more adult level, pri