Clinical material

Background

Max suffered anoxia during his mother’s labour, which left him with hemiplegic cerebral palsy that affects his right side limbs causing minor but obvious spasticity, some weakness in strength and stamina, and regular pain. Max’s family, which includes his mother, father and older brother Miles (14), understands that the long-term prognosis for Max is uncertain, as ordinary growth across the adolescent years can bring improvement or deterioration. He has access to a wheelchair, which he can use when fatigued, but has never come to his sessions using it.

Max was referred to the local CAMHS clinic when he was almost 10 years old for ‘anger issues’ that included aggressive outbursts in which he physically attacked his mother and destroyed his own valued objects such as the controller for his PlayStation®. Following these explosions he would be very tearful and apologetic, and miserably retreat to his bedroom as though punishing himself with deliberate isolation. He could give no reason for how he felt or behaved. His parents’ attitude to these episodes was telling: they understood his outbursts to communicate that he was in great distress but could genuinely think of nothing that he might be distressed about. In the initial appointment with both parents they were willing and able to acknowledge their son’s disabilities but always in a context of determined positivity, for instance, “He’s been so lucky to get that marvellous customised wheelchair, we’ve been telling him it’s a great piece of kit and all the other kids will be jealous!” They requested individual therapy for Max, hoping someone could “unlock the puzzle” of his unhappiness, and both they and Max reported that he had benefitted from play therapy sessions with a school counsellor but that these had finished unexpectedly when that therapist moved on. On discussing the referral following the meeting with his parents, the CAMHS team agreed to Max being put forward for weekly psychothera