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This paper describes some of the complexity of providing Child and Adolescent Mental Health Services (CAMHS) input into school settings. Some reference is made to previous writing about psychotherapeutic work with schools, and also to recent government policy changes which are impacting on service delivery. There is discussion of the multiple levels at which interventions need to be conceptualized, and the issues arising when working within systems and organizations that have very different drivers, tasks, aims and cultures. It is argued that, given the complexity of the therapeutic task, clinicians need a high level of experience and robustness, and to be armed with understanding gleaned not just from individual psychoanalytic psychotherapy but also from psychoanalytic thinking about organizations, as well as about therapeutic communities, in order to function effectively. There is discussion of some of the typical institutional defences against anxiety and distress that arise when working with the most complex children and families in schools, and in particular the pressure to locate problems within individuals and to attempt to address such issues on an individual basis while leaving the institutional and systemic issues unaddressed. I suggest that such work demands a complex view of the role of the therapist, which includes taking on a role which has some similarities to working in therapeutic communities. Some vignettes are used to illustrate how one can do effective and useful clinical work with individual children, and with their families when wider systemic issues are taken seriously.