(p. 89) A Case Managed at Home
Not every case in child psychiatry is of direct concern to the social worker. I present the case of Kathleen because in spite of the fact that the case was managed by myself it was not primarily a treatment by psycho-therapy. The burden of the case rested on the mother and indeed on the whole family, and the successful outcome was very largely the result of the work done in the child’s home over a period of a year. Management was required from me, and this meant that I had to see the mother and child for ten to twenty minutes each week for a period of months.
At the first interview I was able to come to a fairly definite conclusion as to the psychopathology of the condition and to form a tentative opinion as to the parents’ ability to see the child through her illness.
The child was referred to me with a view to my arranging for her to go to a hostel, as it had not occurred to those who were initially in touch with the case that under certain conditions a spontaneous cure could take place in the course of time. The important point was that in a careful history-taking in the first interview I was able to make a graph of the symptomatology and from this it was clear that the climax of the illness had been reached and that there was already a tendency towards improvement by the time of the consultation. In the graph there was a peak of acute neurotic anxiety followed by increasing distress and eventually the illness altered in quality and the child became ill in a psychotic way. The neurotic acute phase followed a story told to her by her sister, during a period in which she was already beginning to be upset because she was due to be bridesmaid at the wedding of her favourite aunt. The period of acute psychotic disturbance corresponded roughly with the marriage.
(p. 90) I was interested to find that the child had started to improve, and going into this in great detail I discovered that the family had turned itself into a mental hospital, giving itself a paranoid organization into which this paranoid, withdrawn child fitted admirably. At first the child was able to manage only when in actual contact with her mother, but already at the time of the consultation there was a circle of a few feet around the mother in which the child could be free from acute distress. I found that the mother, who was not an educated woman and not actually very intelligent, but an excellent manager of her home, was interested to know why she and the family had turned themselves into such a curious and abnormal state. She did in fact keep up the mental hospital atmosphere until the child was ready for the home gradually to return to normal. The gradual recovery of the home followed as the child lost her paranoid defence organization. I had the co-operation of the local authority even when I asked that no one should visit the home and for a whole year I took full responsibility, thus simplifying the mother’s task.
It was management therefore rather than direct psychotherapy which brought about a return of the child to normal or near-normal. Some direct work was done with the child in the weekly visits which, however, were of necessity short as I had no vacancy for a treatment case at the time. What was done in these brief contacts was not the main part and not an essential part of the treatment, but was in fact a useful addition.
I will now attempt to describe the case in detail.
Kathleen was referred to me at six years of age, by the psychiatrist of a County Child Guidance Clinic, with a note in which it was stated: ‘She has recently become negativistic, talking to herself and staring into space, and refusing to co-operate with her mother though refusing to be parted from her’.
I was able to draw on a report made locally by a P.S.W.i when compiling the following case-history after I had seen the mother:
Mother: Appears to be stable. Is now desperately anxious and is at a loss how to handle patient.
Father: Alive and well.
Siblings: Pat, aged 11 years. A bright, talkative child. Patient, aged six years. Sylvia, aged 20 months. A very attractive child.
Kathleen had been fed at the breast for three months; she then took the bottle easily and went on to solids and to feeding herself without difficulty. She started using words when about twelve months and talked early. She was walking at sixteen months; clean habits were established normally. The mother was able to compare this child’s infantile development with that of the other two children and there was no question of her being backward.
(p. 91) There had been no important physical illness. She had been through an operation on her thumb in hospital and had not appeared to be frightened by this experience. Recently she had complained of headaches and had looked pale. In infancy she had had screaming attacks which were a little beyond what is normal, and the parents had always had to be rather more careful with this child’s management than with that of the others. They found that she needed more close adaptation. In other words, she was of sensitive type. It was found that she needed to have her questions answered quickly, otherwise she was liable to develop violent temper attacks. She was always highly strung and needed tactful handling. It could be said, however, that she was within normal limits—intelligent, happy, able to play, and able to make good contacts.
When she went to school at the age of five she did not like it very much but was quite reasonable. She was pleasant and friendly and was ‘able to deal with frustration by thinking things out’. She was up to standard in her work until a few weeks before the consultation, when she began to deteriorate.
At home the child liked to help her mother in the house and was quite good at it from the age of about four years. She enjoyed playing with her little sister, she was very keen on keeping her books in good condition and disliked having them messed or torn by the younger child. She was fond of her dolls. She loved going to Sunday School. She seemed fond of her little sister and liked to do things for her.
Kathleen belongs to a family of ordinary working-class people. The father is a collector of old iron and has quite a good business. He started with a plot of land, acquired a caravan for his family’s home, and eventually was able to have a little country cottage and a small car. The mother is a nice woman, not very clever, but able to manage her life sensibly on the basis of not attempting more than she knows she can manage. She comes of a family of limited intelligence and on the father’s side there is an epileptic uncle.
A few weeks before the first consultation Kathleen was due to be bridesmaid at the wedding of a favourite aunt. This wedding was looming up at the time of the onset of her illness. She would say to her aunt: ‘It is my wedding and not yours’. This was not just a playful remark, and indeed it marked the beginning of her distress. She could see herself in her aunt’s place but could not deal with the wedding as an observer. At this time she also began, at first in a mild way, to have delusions of persecution, and she tried to make everyone keep smiling because something nasty about faces was always expected. Soon it was not enough that people smiled. Then, more rapidly, there came a marked change, so that her teacher reported that during the past few weeks she had taken no notice when spoken to, even when her name had been called several times. She would sit staring in front of her, totally preoccupied. Once or twice she had refused to remove her hat and coat at school. Now her crayoning was less careful, sometimes she would scribble instead of writing, and (p. 92) she would make some of her letters wrongly, whereas previously this had not been a feature.
Onset of Acute Illness
At this point her 11-year-old sister, who was in fact affected by the coming wedding in the same way as was Kathleen, did something which just exactly played on the conflict in this child’s mind. She told her a lurid story. Kathleen was fond of the aunt and with the female side of her personality had identified herself with her aunt; but she also had to deal with another side of her personality which was much more difficult to get at, that is to say, her identification with the man in the wedding. She knew him and was also fond of him. On the basis of her own identification with her own mother and her love of her father she would have been able to have dealt with all this if things had gone well. Let us say, she had two potential dreams, one of herself as a bridesmaid, identified with the bride, and another of the male side of her nature in rivalry with the bridegroom. This latter rivalry had death in it, and it was therefore a very serious matter for her when her sister (also caught up in this same conflict) recounted to her a lurid story from a radio programme about a man who was killed, and about blood running all over the floor.
Her defences against the anxiety and the conflicts roused by the wedding had been working well, and her male identification had undergone repression. Now, however, there came a threat of a break-through of the intolerable dreams belonging to rivalry with the man, and she had to organize new and more primitive defences. She became withdrawn and paranoid. This reorganization needed time, and the immediate effect of the sister’s story was very severe manifest anxiety. There was thus a preliminary period of acute neurotic illness; the child developed extreme fear on going to bed; she asked repeatedly whether there was blood on the floor; she repeatedly said: ‘Mum, mum, will he come and murder me? Will I be all right? Are you guarding the door?’ Eventually she was able to be pacified and to sleep.
After this period of acute anxiety she recovered and was fairly normal for a time, but about a week later when she returned home from school she began talking strangely about a man who had wanted to take her in the water. She said that all the children who went into the water with him got new clothes. She had become a psychotic case.
From now on she was never herself, and towards the time of the wedding she began to get very ill indeed in a way that reminds one of mental hospital illness rather than of psychoneurosis. She would sit and stare abstractedly into space and refuse to answer. One morning she looked at her sister and friend and seemed terrified, and she shouted to mother: ‘Take them away’. She said that their faces looked horrible and ugly and that she couldn’t stand (p. 93) the sight of them. She was clearly hallucinated. Once in the street she cried out: ‘Take all these people away. Don’t let them hang around me’. She became totally preoccupied. If asked to do a simple job, she did not seem to comprehend, and she worked herself up into a passion, saying: ‘Where, what do you mean? You’re mucking me about and making me lose my days again’. She would frequently cry and use very bad language and give the appearance of extreme terror. Often she said that she hated her mother and wanted to go right away. Once she doubled herself up as if in extreme pain and said to mother: ‘You’re talking into my tummy, you’re hurting me’. Frequently she talked of a man: ‘Him and me are going it. I’m going to live with him in a bungalow and you’re not coming. He’s going to take me’. Sometimes she would identify a man’s voice on the wireless with this man. She would appear to see him, and would stare fixedly into space as if hallucinated, crying out: ‘He done it’. If given sweets she would hold them in her hand as if uncertain what to do with them.
She was now uninterested in play of any kind and had given her dolls away. She didn’t care if her younger sister scribbled on her books. She didn’t want to go out or play with her scooter. She followed her mother around and would not let her out of her sight. She cried every night when going to bed and wanted one or other parent to stay with her. She could not stand the name of her school being mentioned and would cover her face at the sound of the word. When she was due to go out with her father she had made eight attempts without being able to make up her mind and went to her mother in distress. Following this she would not leave her mother at all. As long as she was very near her mother she was not too bad, but she could not sleep without her mother sitting with her for one or two hours. Even then she would get up at 2 a.m. and go in with her mother, remaining restless and sleepless. There were now no nightmares. (Previous to the illness she had always slept the clock round.)
For a period of time she could not stand the sight of her older sister. She was using the younger sister, however, to represent a normal aspect of herself, somewhere to carry on while she herself was so ill, just as other similar patients use a cat or a dog or a duck. Whereas she had once loved her dolls which she would keep carefully on her bed, now she had left these aside for the baby to use. Her fondness for the baby had some anxiety mixed with it now, as she would keep feeling the baby’s face and saying: ‘Is she all right?’ This made the baby bad-tempered.
She had also given up colour drawing entirely. There was no incontinence although the mother had always had to watch out with this child to help her quickly. Sunday School, which she used to enjoy, had now become impossible as she would not leave her mother. She went once with her mother to church, but got fed up towards the end instead of enjoying it. She could not stand the people.
(p. 94) Course of Acute Illness
A careful examination of details showed that the disturbance started as an exaggeration of the ordinary touchiness associated with the excitement in regard to the wedding arrangements. The sudden peak of manifest anxiety followed the radio story. There was some recovery from this but after another week there developed the psychotic phase in the illness which lasted on over the time of the wedding. Gradually after another week or two the severity of the illness tended to lessen, and this improvement, although slight and gradual, was maintained steadily until the recovery of the child in the course of a full year.
I came into the picture at the time of the slight improvement after the worst phase of the illness, and I had to ask myself what had given rise to this improvement. Was it because the wedding was over or was something else happening to help? Already I had formed an opinion that it was unlikely that I would be taking this child away and putting her into a hostel because it was improbable that I would be able to find a placement able to see her through. I began to go into the question of what the home was like, and I found that the home had converted itself into a mental hospital for the child. The parents had arranged that no one should come to the door, as the child was so frightened of knocks. The milkman was told to leave the milk outside the gate instead of on the doorstep. The postman and the coalman had similar instructions. Not even relations were allowed to visit, and so on. The whole family was involved. What hostel could do all this?
I had to ask myself whether I could provide anything better than was being provided at home, and I decided that I could not. I explained to the mother the significance of what she was doing and I asked her whether she could continue. She said: ‘Now you tell me what I am doing, I can go on. How long will it be?’ To this I had to reply: ‘I don’t know, but certainly for months’.
And so I helped the mother with her task by writing to the local authorities to ask that no one should visit either from the clinic or from the school, and co-operation was complete. As the child began to recover it was the School Welfare Officer who was first persona grata, and it is of incidental interest that his death recently has caused quite a gap in the family, so attached had they all become to this man. Within this artificial paranoid system the child was able gradually to let go her own paranoid withdrawal. Instead of being able to endure life only when catching hold of her mother, she began to be able to be fairly normal if within a few yards of her mother. It was remarkable the way in which the children as well as the grown-ups adapted themselves to the child’s needs. Quite steadily the circle in which the child felt secure enlarged until it was the size of the house, and even larger.
(p. 95) Contact Maintained
All this time, although this cut across the idea of the home as a closed system, the mother brought the child to my consulting-room once a week for a very brief contact. Each week I explained to the mother what was happening, and I gave the child the opportunity to be negativistic. She would refuse to come into my play-room. She looked wild and defiant, and mostly just stood by her mother and stamped and spat and cursed and used filthy language. She was just like a wild animal. Sometimes she would say: ‘Shut up, I’m going to bash you’, or: ‘No. No. No’. It is difficult to describe the violence of her repudiation of me. After several visits the child allowed herself to make a little quick tour of the play-room before going away. In this way she knew that there were toys, and after many weeks she allowed herself even to touch one. Once, although refusing a paper spool from my hand, she looked up from the street to my window as she left, and when I threw one down she picked it up and took it home. These visits to me were accepted by the child as an excursion outside her home, the only one which she could tolerate. Gradually she came around in the course of many of these short interviews to the beginnings of an acceptance of me.
There was a long interval in which I did not see her at all because of holidays. After this I found that the child was so much improved that I did not continue the interviews but advised the parents and the school and the social workers to allow the recovery to go on taking place slowly and naturally.
There was one more episode, which came when she was supposed to stay with the married aunt and uncle. The aunt could not have her, and for a few weeks she went back, in token form, to her illness. The symptoms all became recognizable, but after a few weeks a new spontaneous recovery took place.
Within 15 months from the onset of the illness she was back at school. The teachers said that she had obviously lost some ground but they could accept her and could treat her almost as before.
Two Years Later
Nearly two years later when she was eight she said to her mother: ‘I want to see Dr Winnicott and I want to take my little sister’. The visit was arranged, and when she came into my room she obviously knew what to expect to find there and she showed the toys to her sister. I could not have been certain previously that she had really noticed the toys. The sister played a completely separate game, playing normally with the toys, and I divided my attention between the two children. Kathleen’s play was a construction of a very long road, using the many little toy houses that I had in my room at that time. (p. 96) She was clearly asking for an interpretation, and I was able to explain to her that what she was doing was joining up the past with the present, joining my house with her own, integrating past experience with the present. That was what she had come for, and also to let me know that she had used the little sister for the normal aspect of herself. Gradually during the course of her recovery she had drawn her normal self back from her little sister and had returned to normal relations with her.
I learned that at the time following the setback due to her aunt’s not being able to have her to stay, the mother had felt that she must get the child away from herself because there had developed a relationship between them (the mother and Kathleen) which was based on the management of the illness, rather than on being a mother, and this could not be entirely broken. The mother took the risk, therefore, of sending the child away with other relations. On returning from this holiday Kathleen seemed quite normal, sleeping well, playing and sharing, and with less liability to temper attacks than she had had before the illness.
Recently I asked for a friendly visit. The mother came very willingly, bringing all three children. The elder sister, now nineteen, is clever, well educated, in a good job, and dressed in very good taste.
Sylvia, who is nine now, is developing well.
Kathleen, at 13½ years, gives a fairly normal impression, but she is rather intense, and has not the lively intelligence of her elder sister. She was very pleased to see me, and discussed life in a mature way. At school things have gone well but she is now not good at sums.1 Otherwise she is about average. I learn that she is liked although she has not many friends. Already she has put herself down to be trained as an embroideress and her teachers say that they have every reason to think that she will do that and will do it well.
And so it can be said that she has made a recovery. I helped in my own way. The parents did the main work and to do this they did not have to be clever. They had to feel it was worth while making a temporary special adaptation to the needs of their ill child.
Let me compare the neurotic illness with the psychotic development. Certain conflicts between her identification on the male side (homosexual) were unavailable to her consciousness, so she was unable to work out a satisfactory relationship between her male self and the prospective uncle. Hence the (p. 97) potential trauma of the wedding situation. The lurid story had brought this conflict out into the open so that she had severe anxiety. Personal psychotherapy could have helped at this stage. As the wedding approached the child developed a more serious defence. She developed a psychosis, became withdrawn, and preoccupied with the care of herself within herself. This put her in a vulnerable position, as she had no time left for dealing with the external world. In other words, she became paranoid.
I was called in when this more psychotic defence organization had become established. If I had been in a position to give the child treatment in a deeper way, instead of just letting her come and spit, my room would have gradually developed the same mental hospital atmosphere which in fact developed at home. But I did not need to give this treatment. The parents supplied a setting in which she could be. She could be identified with her own (modified) home because it took on the shape of her own defences.
Here was a case of child psychiatry in which a working-class family were enabled to see a child through a psychotic illness of 15 months’ duration. They were helped by a minimum of personal attention to the child, and by management. The amount of my time actually spent on this case was not more than a few hours, spread over several months.
Perhaps this case may help in the Child Care Worker’s attempt to understand what is going on when children make positive use of foster or adoptive parents, or of a residential school (cf. Clare Britton, 1955).