JOURNAL OF CHILD PSYCHOTHERAPY VOL. 31 NO.

3 2005 303 316

Love at rst sight: psychoanalytic psychotherapy with an adolescent boy with severe physical disabilities
MARIA E. POZZI
London

. . . beauty and its linked attributes goodness, hope and truth, form the bedrock for mental health in all of us. (Reid, 1990) Abstract The content of this paper reects the title but it expands upon the technical issues encountered right from the beginning of the assessment. These technical difculties include the management of physical pain during sessions and the request by the patient for physical interventions as well as contact. The problem of discrimination in the setting is discussed: therapist and patient had to make do with a medical room with no windows. The question of how ending can be possible in the context of a patients intense desire for the therapy to continue is also explored. Keywords Secondary Handicap and stupid smile (Sinason); cerebral palsy; manic defenses; physical touch; ending therapy.

Introduction
This paper is an account of psychoanalytic psychotherapy with 12-year-old Harry, who suffered from a severe physical handicap which later led to a learning disability. Harry was wheelchair bound and extremely impaired in his movements, apart from his upper limbs and hands. He suffered from an unknown form of progressive paralysis, similar to, but not called, Cerebral Palsy. His speech, too, was very impaired and just about understandable, with much effort on both his part and the listeners. The once weekly therapy spanned a period of 6 years, during which time he went through many changes in his external life and in his physical and psychological development. He underwent two major operations: one to insert a feeding tube into his abdomen, when eating became too laborious and almost impossible, and the second one to rectify his spinal posture, which had caused him excruciating pain.

Journal of Child Psychotherapy ISSN 0075-417X print/ISSN 1469-9370 online 2005 Association of Child Psychotherapists http://www.tandf.co.uk/journals DOI: 10.1080/00754170500372817

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After the second assessment session Harry was removed from home and after short fostering periods he was eventually placed long-term in a home for children with severe physical disabilities. When I rst started to see Harry my experience with children with physical disabilities and congenital syndromes was limited to short- and long-term work with families with under ves. Harrys treatment was straight-forward as far as his internal world, his phantasies and defences, were concerned in that he was not particularly difcult to reach and I did not have to devise any new technique to make emotional contact with him, as may be necessary with developmentally delayed and borderline patients (Pozzi, 2003). However, it certainly plumbed the depth of my capacity to feel and presented me with a number of dilemmas and technical issues which I would like to share and explore. It was only after I had written this paper to present at the ACP Annual Conference in 2005, that I became familiar with Caroline Owens similar work with a severely physically impaired patient, David. Caroline chaired a very interesting and inspiring discussion at the Conference and I shall link this paper with hers, which also appears in this journal issue. In thinking about my work with Harry, I have drawn on some vital concepts rst introduced by Valerie Sinason, those of secondary handicap and the stupid smile (1988; 1992). The secondary handicap consists of a psychological problem that is superimposed by families and carers on the original, primary handicap. For example, in the attempt not to upset the disabled child further, parents do not set limits and do not maximise the childs chance of becoming more independent. This secondary handicap can cause far greater distress and destruction than the original handicap, but can be treated, unlike the primary handicap, which can only in some cases be ameliorated. The stupid smile is also a form of secondary handicap. It is a defensive, false smile which many handicapped people adopt, for example on meeting a new person, in order to be liked and to deny that they are different and may be a shocking sight. It is a mask that aims to deny differences and feelings of unhappiness, envy and the awareness of being unwanted by society. To be aware that the child with a handicap is still a sentient human being with feelings and reactions, and to begin to understand his or her apparently inexplicable behaviour, can be a rst step towards integration and a happier relationship with that child.

Referral, assessment and the beginning of therapy

Harry, aged 12, was referred by his Social Services Department to the local CAMHS with the specic request for counselling or psychotherapy because of aggressive behaviour at school, particularly when things were difcult at home and especially as a result of having being sexually abused by a family member. Harry had also been physically and emotionally abused in the family context. He showed sexualised behaviour at school and was described as very stubborn. He and a younger brother, also affected by some sort of cerebral paralysis, both lived at home at the time of the referral, but were the object of an interim care order and parental responsibility was shared between the family and the Social Services Department. The evidence Harry had given in court about having been sexually abused by a family member was

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dismissed because of his language difculties, which interfered with him being understood, but the person in question was removed from contact with Harry. His step-dad, newly married to his mother, believed Harrys allegations, and Harry had become very attached to him. However, signs of physical abuse were found on Harrys body, suspicion fell on step-dad and this eventually led to Harrys removal into foster care. Even prior to this, his family had not been interested in getting help for him from the clinic and they did not engage with us. Mother was described as being easily burdened by any request to attend hospital or GP appointments or meetings with the Social Services Department, as she felt threatened by the possibility of Harry being removed from home. The Social Services Department was seen as intrusive and persecutory in their attempts to keep a watchful eye on the children and were unwelcome. Since Harry was spending several nights a week at a special school for children with severe physical disabilities, I liaised mostly with the school and with the Social Services Department in setting up the assessment and therapy. We agreed despite some reluctance on my part that I would assess him at the clinic, not at school, as was rst suggested. My reluctance was based on the fact of having no family contact and facilities for disabled users in the clinic were poor: in the event we changed room three times in the course of 6years of therapy and the one we used for the longest time was a medical room and far from being the right setting. This seemed to me to be a clear form of discrimination towards a patient in need of treatment, who had to manage with a less than ideal solution in order to receive it. However, since that time, a clinic group has been formed to look at antidiscriminatory practice and some useful issues for patients have been taken up. Harrys escort to the clinic at the time had a lot to do with him at school and was skilled in understanding his language, therefore I asked her to be present to act as an interpreter during the three assessment sessions to help Harry and myself communicate a sort of interpreter. It was the rst time I had assessed a child with a third person present, but having done a lot of psychodynamic work with children and parents together, I decided this could be manageable. However, I was aware that I had to adjust my technique to allow for the presence of someone who, unlike when working dynamically with families, was not going to be part of the therapeutic work and who was not familiar with a psychodynamic way of thinking. Owens (Owens, 2005) also had to have Davids carer present during the assessment but had to work in the context of the carers obviously harsh responses to David. Owens had to contain and transform her own strong countertransference feelings in order to mobilise a more ego-supporting stance in the carer and some co-operation in David. When I rst met Harry it was like love at rst sight, as he beamed at me with a radiant smile and I, in turn, was struck and touched by his loving, friendly, attractive and quite angelic facial expression. He had a round face with short-fair hair and looked like a happy, younger child. I believe we took to each other instantly and, as he beamed at me, I felt drawn to him. This was despite my earlier anxieties about his physical appearance and my possible reaction to it. There seemed to have been space in his experience for the establishment of a good internal object, which radiated from the expression on his face. However falling in love also brings pain with it and I was soon to experience this when I became familiar with the many emotions and issues his

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therapy brought up, one of which was his unconscious fear and possibly wish that society/people and myself in the transference wanted him dead because of his disability, and would bring this about by turning off the power of his electric wheelchair. This connects for me with Caroline Owens experience of being drawn into switching off the power on Davids electric wheelchair without being able to think properly nor consider issues of transference (Owens, 2005, ) and how easy it is to be drawn into actions with these severely physically disabled patients. To return to my rst encounter with Harry, I felt rather clumsy when the escort rst introduced Harry to me and I was faced with his wheelchair positioned opposite mine as if ready for an interrogation. I was also struck by Harrys open smile, friendly and beaming facial expression. He was able to let me know that he knew why he had come to see me but had forgotten. His escort like a mother functioning as an auxiliary ego for her incapacitated child reminded him what they had told him, which was that he had gone through so much in his life and that coming to talk about it with me could help him. I was also soon faced with his severe language difculties but he showed me that he was still able to communicate with me. He let me know his age, that he had two brothers and he preferred drawing to talking. After an initial paralysis, I regained some freedom to act, and repositioned his wheelchair next to mine and by the desk, saying it would be easier for him to draw in this position. With great difculty and impaired movements, he managed to get the top off a felt pen and to draw the outline of a cat but then mumbled that the second ear was wrong. I was already wondering how much I should intervene to help him with his physical difculties and how much to let him struggle. In the rst session Harry did not want my help but proudly kept struggling with removing the top of the felt-tip. This would be an easy task for a functioning body but a really complex one for either a disabled person or for a small child who is learning to use his body to perform new skills. I just sat there and watched him, barely containing my pain, as I knew I was not with a young child but with an adolescent boy, who had never achieved ordinary functioning. Was I being cruel in not stepping in sooner or was I right in allowing him to take his time in order to manage this task independently? This was to be a major and enduring concern and the dilemma about when to intervene recurred later when he gave up his brave struggle and became much more regressed and dependent on my help. These difculties also mirror those described as the typical adolescent struggle: the see-saw movement between the wish to stay as a child dependent on his family or the pull to grow into an independent young man. However these struggles are particularly intense and complicated with young people who suffer from physical disabilities. These difculties became heightened at the time of ending Harrys therapy. As he looked up at me with a lost expression in relation to his cats wrong ear, I could not make any meaningful comment with hindsight I wondered whether I had felt stupeed by pain and by the novelty of the situation. Instead I suggested that he joined two lines to put the ear right. He did so and produced an ear shaped like an A. He noticed this and began saying the alphabet until he stopped to search for the next letter. He then drew another cat with only one ear and I put this into words: one ear. He mumbled something which the escort interpreted for me: Year eight, he said. He is in year eight! I said this was a clever pun. At this point Harry began laughing in a

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crescendo of noises, sounding hysterical and manic. I said he was excited, as he was feeling clever. Soon he realised that I could not perform the task he had asked me to which was to count the many dots he had dotted all over the sheet of paper. He looked at me with a teasing expression and began laughing hysterically. I regained my interpretative wit and said I have to be the stupid one, the one who cannot do things. He stopped, calmed down and seriously began telling me about his school, his new electric wheelchair and that he liked staying at school for some nights a week. He said he missed his Mum and Dad and asked me if he could telephone them there and then. He was able to tell me about his ordinary life, once my interpretation had reached him and freed him from his earlier manic spiral. He became manic again after talking about his older brother being in care and no longer at home and I could verbalise that his excitement seemed to cover his worry and painful feelings about the Social Services Department taking children away from their parents. Once again he became serious and anxious and said he did not want to come to see me next week: he wanted to stay at school with his girlfriend and to be able to telephone his Mum and Dad. The escort stepped in with practical suggestions and he agreed to return and began to hit his head shouting Silly me, silly me, when he realised he had done something wrong with the felt pen. I was struck, this time, by his cruel self-attack not proportional to such a small error. Perhaps the tiny imperfection involving the pen reminded him of the bigger ones with which he had to live. Apparently he could not wait to come back for the following session and had been asking all week when he was coming back to see Maria (he was one of the very few patients who always called me by Christian name), thus indicating, from the beginning, that he had incorporated me into his family of friends, helpers and supporters. He looked very anxious as he had been brought early to the session and could not see me instantly. Then he did many things wrongly, such as writing wrong letters and drawing a wobbly teddy bear and he became excited almost in a perverse way and agreed that he was excited when I pointed it out to him. I wondered whether he felt there was something wrong with his head, and this was why he was there to see me. He denied this verbally but proceeded to draw another teddy bear, which was right this time and he then became more relaxed. He had many manic outbursts when I did wrong things mostly when I let a felt-tip drop off the table or was slow in understanding him but he seemed less manic in this session and more, as he put it, worn out. He did not come to the third assessment session as he had been unwell and was off school. However, when he returned to school, it was discovered that he had severe bruising on his back and as a result of this he was eventually removed from home by the Social Services Department. I was condent that he was keen to start therapy and I wondered whether the serious incident of physical abuse, which occurred before the third session, was a communication of his extreme needs. As it turned out, I was to become the spokesperson whose task was to speak on behalf of this disabled and deeply unhappy boy.

Reections
I have given an account of these assessment sessions in some detail as they contain the seeds of many of the issues in Harrys future therapy. In the assessments I felt the

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tremendous impact of both sadness and guilt at being more physically able, as well as my wish to cover up my ability and his disability. At the end of these and many sessions to come, I would feel totally burdened, hopeless and almost in despair, as I walked back to the clinic briskly, guiltily aware of the freedom to move.

Key dilemmas
As the assessments illustrated, I acted out my stupidity by bypassing interpretations and acting out of role, perhaps at moments when the pain and the uncertainty were too much and hit me unexpectedly. Harry turned to the manic defences of splitting, projection, denial and manic laughter, which he used in order to get rid of the psychic pain of his condition, perhaps his only way to deal with it. When I could not understand him despite my efforts, I used to say that Maria was the stupid one, and he would laugh. He would also hit his head painfully, laugh loudly and shout in a selfmocking, stupid voice Silly Billy! Silly Billy! about himself. His internal object appeared to have a rather mocking and denigratory side to it and Harry was either taken over by that aspect or projected it onto me. Harry was, in some ways, also my healthiest patient, especially after some years of treatment, when he had become familiar with working in the transference. He presented neurotic-type defences and in this respect he would have been a fairly straightforward patient to treat, had it not been for some crucial dilemmas which confronted me and which I was not able fully to resolve. Importantly there is the question of how a young person is to enter and then emerge from adolescence properly when burdened with such a high level of physical impairment, which will always require much dependency on others. For Harry the ordinary adolescent struggle between dependence and independence became mixed up with a secondary handicap type of defence, as he soon stopped doing even the simple tasks I had seen him manage (drawing, taking the top off the felt pens, reaching out for things in his box, cutting paper etc.). I had to think and feel my way towards understanding the implications of each request in every single session, and to understand in that moment whether he was being too dependent and if so why at that moment etc., or whether he genuinely needed help. The task of disentangling the real from the secondary handicap (Sinason, 1992) took a long time and became an ongoing theme of these many years of treatment.

Physical pain and physical contact1

While still in the rst year of treatment Harry had started asking me to lift him up in his wheelchair in order to move him to a more comfortable position, or to lift his leg because he was in pain. At rst I complied without thinking, but soon felt uneasy and began to be aware of a dilemma. Having physical contact with him became excruciatingly difcult for me. Firstly I knew that he had been sexually abused by a male family member. The issue of respecting his physical boundaries was therefore especially important. He was also entering adolescence and had, from our rst encounter in the waiting room, shown a keen liking of me. Therefore I had to be especially careful not to

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exacerbate his feelings. It was a process of trial and error for me as I learnt to nd a subtle balance, whenever I could, between encouragement offered through interpretation, such as your left hand and arm are not helping your right hand today and I wonder why? and actual physical help for things he could genuinely not do. A further complication was that I had been told that his condition was progressive; therefore I was aware of the possibility that on any given day he might nd himself unable do what he had been able to do the previous session. I learnt that he would give me a knowing smile and look almost embarrassed as if caught red handed when I reached him on those occasions when I was right in saying that he was tricking me, for indeed he always tested me out and tried to trick me. In the discussion of this paper at the ACP Annual Conference it was pointed out that these disabled children are far too often tricked by people, who try to pretend and act as if they were normal, that is as if these children had no disability or handicap. This is a societal way of not addressing psychic pain. Therefore these severely disabled children reproduce a tricky mode of relating in the therapy relationship and this may become a model of relating for their entire lives. We need to address the reality of their disability in order to help them, as well as the workers around them, to face the truth, despite it being painful. As Bion (1962) afrms, being helped to bear the truth of ones situation will contribute to ones mental health. Once therapy was established, because Harrys escort usually left to go for lunch nearby, I could not rely on her in case of need. I had to be more active with Harry than I usually am with other patients, due to the severe limits to his mobility. For example, I had to open his box, where pens, paper, glue and scissors were kept, when he indicated that he wanted to use them. I had to take the paper out of his folder and arrange it on a suitable surface so that he could proceed to draw and, as I have said, I struggled to differentiate between what he really could not do and what he pretended or believed that he could not do. I was particularly aware of the delicacy of the issue of touching him physically. I was also aware of his physical pain and feared becoming cruel, for example, had I not tried to lift him up to change his position in his wheelchair to alleviate his suffering. I was in a nowin predicament: I was either in danger of being perceived like a sadistic parental gure, who had been discovered to have hit him, or I was seen to be like the seductive family member who had abused Harry sexually. If I agreed to move, and therefore touch, parts of his body, would he have a phantasy that he had seduced me into doing something he liked such as touching him? In the transference situation a reversal would also have then occurred: my professional and personal boundaries would have been interfered with, just as Harrys physical and sexual boundaries had been infringed upon in the past. A seduction situation would have been recreated, but this time with Harry in charge. Meanwhile, I would have been placed in the position of the powerless, abused and confused child. I eventually decided to verbalise this conict in simple terms such as Im not sure you really need me to move your leg or back or whether you just like me to touch you! In response to my verbalisation of the dilemma, he looked straight at me with a knowing smile in his eyes, as if I had caught him red-handed. He then burst out laughing and it became clear to me that he had tested me out. I took his smile and laughter as a conrmation that he just wanted me to touch him. At that point I again recognised his rather tricky side. He had agreed implicitly that he just wanted me to touch him.

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In time I learnt to distinguish between his wish to be touched by me for many different reasons and his genuine need for help with dealing with his pain. The dilemma, a choice between cruelty and seduction, two equally disturbing options, was claried by understanding my countertransference and by interpretation. I felt freer and more certain in deciding whether to hold and lift his leg or whether just to interpret his request according to the specic meaning in each different context. I learned to understand whether Harry was in genuine pain or whether he was having me on through time and through getting to know him better and better. I learnt that whenever he was going through difcult experiences, either in his external life or in his therapy, Harry would especially resort to tricky manoeuvres in therapy, hoping to get sympathy and direct physical comfort from me. This happened when his beloved Foster Mother terminated his placement due to unresolved personal issues with the Social Services Department, when his committed Social Worker moved to a different department and stopped working with him and when long breaks in therapy approached. When the external world was felt to be and actually was fragile and when this threatened the stability of his internal world of relationships, Harry gave up his struggles and tested me, possibly to see if I, too, would abandon him, in this case by giving up my professional stance and would resort to the indulgence of touching/moving his legs or feet to offer him some relief. I often found myself speaking of his body and his heart, too, aching when he was sad, angry or distressed about people leaving. On these occasions he seemed to want not only my understanding presence, but also to experience my physical contact with him, and I would say this to him. Caroline Owens refers to the crying wolf aspect of David, who used to mock his carers and therapist by asking for help such as suction or pressing the emergency button when he did not need physical care. Owens writes: . . . gradually I began to detect the qualities of his cries and was able to discern when he was acting out and when indeed he was in real state of panic and in need of physical care or assistance. (Owens, 2005). I found myself wondering whether when a child has such a severely damaged and aching body words have a more limited effect, and sometimes physical touch can produce the effect of a much-needed painkiller. Indeed Harry had had to manage a lot of pain and discomfort prior to his back operation. The state of his body occupied a paramount focus in his life, as it does in the lives of many disabled patients; it is therefore understandable how much he might have craved physical touch. I have no knowledge about his early relationship with his mother but I imagine that he had had some very good and loving contact with her. When I nally met her, she seemed to be rather caring and like a charming little girl. Although I tried to translate Harrys physical reactions, needs, and movements into the language of emotions, fears, and conicts, this experience led me to believe that the issue of the right balance between body and mind is of vital importance and relevance in our work with patients with physical disabilities and we need much more innovative thinking, in order to be as creative and effective as possible in helping these children and young people. To return to the issue of touching, due to the circumstances I have described, I decided to alter my usual technique at a time when he had to undergo a severe spinal

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operation and was in hospital for several months (Judd, 1989). I decided that I would visit him weekly, after the initial disruption, in order to maintain some link with him. Again I am reminded of Caroline Owens work as she too visited David in hospital when he was bed-bound as his wheelchair was condemned. Harry was very pleased to see me and was desperate to hold my hand, which I decided to let him do for a short while, as I sat by his hospital bed. I said that he was keen to somehow be allowed to break our therapy rules and hold my hand. I said this was indeed a special situation, as we were in a hospital ward with many people coming and going busily, surrounded by many distractions, and other children in need calling the nurses and grabbing my attention away from Harry, which he had certainly noticed. For these reasons I did not reject his request. Harry was very impaired and in this situation especially powerless and had to tolerate huge frustrations. I recognised that to allow him to hold my hand gave him some sense of power and pleasure and I had not the heart to withhold this. At the time I could not know, but now I do not believe that it was a mistake to hold his hand because I could not detect any repercussions after normal therapy was resumed again, once he left hospital and went back to his ordinary life. It is worth reminding ourselves that Child and Adolescent Psychotherapists and Analysts are not only transference gures, especially since we are now treating very disturbed, deprived, delayed and handicapped children, who have missed out on many ordinary phases of their emotional and physical development. We are also new developmental objects as Anne Hurry (1998) puts it so eloquently. She writes Today, with growing recognition of the developmental element in all analyses, such parameters are becoming recognised as mutative elements . . . , and the term developmental therapy is now also applied to work with adults. (Hurry, 1998: 38). She acknowledges her debt to the following: Anna Freud, for having established a developmental help for children with developmental decits or distortions; Loewald, who proposed that the analyst was also a new object and that the analysis implied new ways of being and relating; Takka, who distinguishes three strands in the patients use of the analyst: as Contemporary object, as Past (transference) object, and as New (developmental) object (Hurry, 1998: 44) and this difference provides a corrective emotional experience for the patient. Hurry suggests that the analyst needs to be prepared to move between the developmental/relational stance and the interpretative, as Anna Freud described. (1998: 71). I believe that by carefully drawing the line between what could have been bad, seductive, sexualised touch and caring, friendly, helpful touching, and by describing this in words, I was able to help Harry to apprehend the difference and to have a new and different experience of touching and of myself as a trustworthy adult, when I allowed him to hold my hand in hospital. I was touched by Holders sensitive solution, when he offered his very distressed adult patient the chance to hold his hand, which he had placed at the end of the couch, next to his patients head, in case she needed it. This offer on the analysts part was enough in itself to contain some distress and anxiety in his patient, as she did not need to actually hold his hand (Holder, 2000: 48). Juliet Hopkins, in her paper describing her sensitive work with 3 year old Paddy, whose chronically depressed mother always avoided touching and cuddling him as a baby for fear that his germs would infect her eczema (Hopkins, 1987: 11), explores the issue of making physical contact with children who have been physically rejected as

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babies. Hopkins describes how these children, whose attachments have been severely impaired, become avoidant and feel repellent, contaminated and untouchable. Paddy became gradually able to search for and tolerate some physical contact with Hopkins both when he playfully jumped into her arms to be caught and held and when he climbed into her lap for consolation when he was hurt. It was as if he found in his therapist the physical as well as the psychological lap he had never had from his mother. This left Hopkins anxious about having seduced Paddy away from his parents, who he still ignored and rejected at the time when he became more physical with her. However Paddy was later able to transfer his new-found ability to seek physical comfort to his mother (1987: 13). Although she was aware that this was a controversial technical issue, she doubted whether for Paddy . . .. there could have been a satisfactory alternative to the availability of my lap at a critical time in their therapy (1987: 14).

Ending therapy
An important aspect of this long treatment with Harry was that of ending. I want to question how an ending can be possible when there are such major and enduring needs, which are inherent to the patients physical disability, and when the patients attachment to the therapist is experienced almost physically so that an ending feels nothing other than a wrench and a cruel rejection. For many years I had concluded that since Harry was so keen to see me, beneted from it and was so disadvantaged, I would aim to be available to him for as long as he wished. I had become an important point of reference in his life and had been a reliable gure for him through many changes, rejections and breakdowns in his care. My reliability was much appreciated by Harry and he came to see me almost as a member of his extended family. I took the view that he had been deprived and had had more than enough to contend with in his life, so why not provide him with the comfort of therapy for as long as possible? However, I also gradually began to wonder whether I was colluding with his regressive wish not to grow up by maintaining his dependence on me. Harry loved seeing me. He was also soon to be 18 and together with the excitement of becoming a man, of being able at his age to have a sexual relationship with his girlfriend and of going to pubs and going to college, he also began to feel worried about leaving his beloved weekly boarding school and the weekend home for disabled young people, where he had been living for a number of years. He did indeed have a girlfriend for many years during his treatment and she was a girl attending his school and also wheelchair bound. During the holidays they would visit each other and her family was keen on this relationship. The reality of time passing and the hints, as just described, present in his material eventually gave me a reason to begin to talk and plan an ending to therapy. It was about a year prior to the actual end that I rst introduced the idea of ending when he nished school and moved onto college. He agreed at rst but when the idea became more of a reality as it was spoken about frequently, he began to say that he was only moving locally and he did not want to stop coming to see me. He admitted that he wanted to see me for the rest of his life; he did not want to stop just because he was 18. Being 18 did not mean he had to leave his girlfriend, in fact they were going to marry at some point, he told me. He protested, he was angry, sad and longed to see me

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forever. His phantasies, anxieties and defences about ending were expressed persistently and worked over and over in his sessions, but it somehow never felt enough. We explored his unconscious phantasy that he had been too much for me; that I was like a broken wheelchair/mother, who could not manage his handicap, nor his angry outbursts, just as his mother, stepfather and rst foster carer had not managed him in reality. He feared that he had dried me up like one of his much used felt pens, or that I had lost my memory and was damaged, which he had imagined to be the case when I, once, did not put any new paper in his folder. He showed me that he was feeling dropped, broken into pieces and leaking with urine and saliva: he both wore incontinence pads and dribbled a lot more than usual, as he usually did in the times approaching holidays in therapy; that he felt was inside a container/car with no bottom to hold him safe inside. He expressed all this in his drawings. He identied me as all these ill-functioning objects and also identied with, and internalised them. He took to rejecting me, trying to leave me emotionally before the end of sessions, and to preferring his escort, whose name was similar to mine, and he seemed to intend to tantalise me with this, as when he expressed his love for Mar . . . ta. He put a lot of effort into denying his feelings and putting down his school and home contemptuously, saying they were babyish, but he was also in touch with his loving feelings towards me, his longing for and missing of his beloved school, childrens home and me. He was easily reachable by interpretations about his jealousy, possessiveness and feeling left out, and his tendency to preserve therapy as an important, helpful and good place was maintained all along. Painfully, although also to be expected, his dribbling and leg-shaking became worse during this last phase of therapy, thus conveying to me a sense that both his mind and body were being shaken to their roots by this wrench. I have to admit that in all my years of practice, the ending with him was the most difcult I had ever had to manage because of his strong attachment to me, which I both felt and reciprocated. The profound impact of my attachment to him also confronted me with my own psychological handicap with regard to the issue of ending his therapy. Perhaps sensing this, he kept repeating as an ongoing leitmotif I dont want to stop coming. Why do I have to stop? Reality reasons and interpretations were not enough. I prolonged seeing him for few more months, to help him settle into his new home and college, since he was having difculties in settling in as he kept longing for his previous home and school. Therefore I decided to accompany him a bit longer into his new adult life. It is hard for me to say whether that was necessary or was more based on my need and uncertainty, but since he eventually settled well as I was to nd out in the follow-up session ve months later perhaps, again, it did no harm to him. However these questions remained unanswered on an emotional level and they were similar to his other poignant questions: Why am I in a wheelchair? Why am I disabled? Why cant I play football, drive a motorbike, move freely? His was a painful reality to accept, and I had to face the fact that I could not ultimately alleviate his reality for him, just as, in the end, we both had to bear the experience of the ending of our therapeutic relationship as a heart-breaking wrench. I was left with my own question: Does sharing the suffering and naming it bring some relief to these severely physically disabled patients? Does the physical fact of the disability and its inevitable permanence greatly

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reduce the effect of the psychological work? How can we develop and broaden our ways of working with disabled patients, in order to lessen their suffering?

Conclusions
As I reect on the psychoanalytic treatment of patients and children with severe bodily impairments, I nd myself speculating on the nature of both mental and physical pain and whether the effect of the patients projections of these two different types of suffering onto the therapist is also different. I wonder whether it is easier for the therapist to be pulled into actions in the face of the patients physical discomfort and disability, which can easily be felt by the therapist, too, at a physical level. We are familiar with the physical feeling of hunger which therapists can experience when treating eating-disordered patients. I am also reminded of the Jungian analyst Matthews description of her physical response of discomfort to a new patients projections, which were much later on understood as being linked with the patients own experience of sexual abuse (Matthew, 1998). Owens describes beautifully how Davids projections had the effect of creating movements in others, that is in the able-bodied people around him, who performed the movements that David could no longer make. When David nally recounted, in an e-motion-less manner, the story of the road trafc accident which had led to his paralysis at the age of 5, the therapist was almost moved to tears. Perhaps the actual physical ` response of the therapist vis-a-vis a story of intense physical and mental pain was linked with the nature of the bodily projections and of the physical paralysis. As I believe that mind and body are so much part of each other in all of us to try and separate what belongs to one or to the other in these very complex cases seems articial. As I began therapy with Harry, I often felt moved to tears after his sessions, when I was running back to my clinic, while he was slowly being wheeled away by his escort. The intensity of the therapists guilt and pain at having an able body while her patient is immobile in a wheel chair, feelings which I also felt very deeply, are well expressed by Owens, too, as she struggled to maintain her analytic stance with David. With hindsight, I also wonder whether my excruciating pain during the ending phase of therapy with Harry, which felt at times like a physical wrench, was linked to the nature of his physical problems and bodily projections and was not just a response to the hard process of ending per se, which was particularly difcult for me as an individual. In conclusion, I believe that the therapists body is used more with these patients, not just to perform inevitable, practical acts, but also to stand as a container in which projections are located. I am grateful to those colleagues who took part in the group presentation and discussion at the ACP Annual Conference, where I rst shared this piece of work, my feelings and dilemmas. They shared in turn their personal experience, their creative thoughts and their deep emotions, all of which are inevitably stirred up by working with these children.

Postscript
About 5 months after ending treatment with Harry, and after originally presenting this paper at the ACP Annual Conference, I made contact with Harrys residential home to

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offer him a follow-up session. He was delighted to hear from me and was keen to see me. I was also very happy and relieved: I feared he might respond with anger or retaliation for my having stopped his therapy. However his loving inner object prevailed and he was unambiguously happy to see me. On the one hand, the follow-up session brought back to me all the heaviness and difculties we had always had in communicating; my struggle to understand his language; my sadness when I recognised his frustration but also his trickery when for example he did not use his voice as robustly as I knew he could. On the other hand, I felt greatly relieved to see him having grown more manly and to be told by him, with it being conrmed by his residential workers, that he had settled well both at his home and his present college and was looking forward to the long-planned move to a more specialised college out of the area. I was also relieved as we were able to clarify further why he thought we had stopped therapy. I did tell him that since we had ended I had moved to another clinic and he then thought that was why I had stopped seeing him and not because of his age. However I reiterated that it was because of his age. He was delighted when I gave him my new address, so that he could write to me if he wished to. In that follow-up session he gave me permission to write about him so that, as I put it, I could share the important work you and I have done with my colleagues, who could help other boys like you. He chose the name Harry, Yes, like the Prince, he conrmed smilingly. This moved me deeply as I believe it conrmed that he knew that he had indeed been a special patient to me, my prince and this knowledge has helped him bear the pain of ending and given him the strength to keep on living with his disabilities.
CAMHS, Loxford Hall-Redbridge mariapozzi@tiscali.co.uk

Note
1 Part of this section on touch will be in a chapter (The issue of Physical Contact in Psychoanalytic Work with Children and Adolescents) in the forthcoming book: Dialogues on Touch in the Psychoanalytic Space, edited by G, Galton, Published: Karnac. Kind permission to reproduce has been given by Karnac.

References
BION, W.R. (1962) A Theory of Thinking, International Journal of Psycho-Analysis, 33: 306 10; republished (1967) In Second Thoughts. London: Mareseld Reprints. HOLDER, A. (2000) To touch or not to touch: that is the question. Psychoanalytic Inquiry, 20 (1): 4464. HOPKINS, J. (1987) Failure of the Holding Relationship: Some Effect of Physical. Rejection on the Childs Attachment and on his Inner Experience. Journal of Child Psychotherapy, 13.1.: 517. HURRY, A. (1998) Psychoanalysis and developmental therapy. In Psychoanalysis and Developmental Therapy. London: Karnac Books. JUDD, D. (1989) Give Sorrow Words. London: Free Association Books.

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MATHEW, M.A.F. (1998). The Body as Instrument. Journal of the British Association of Psychotherapists. 35: 1736. OWENS, C. (2005) Moved to tears; technical considerations and dilemmas encountered in working with a 13 year old boy with acquired quadriplegia Journal of Child Psychotherapy, 31.3: 284302. POZZI, M. (2003) The Use of observation in the psychoanalytic treatment of a twelve year old boy with Aspergers Syndrome. International Journal of Psychoanalysis, 84 (5): 13331349. POZZI, M. (in press) The Issue of Physical Contact in Psychoanalytic Work with Children and Adolescents. Dialogues on Touch in the Psychoanalytic Space. GALTON, G. (ed) London: Karnac. REID, S. (1990) The Importance of Beauty in the Psychoanalytic Experience. Journal of Child Psychotherapy., 16.1: 2952. SINASON, V. (1988) Richard III, Hephaestus and Echo: Sexuality and Mental/Multiple Handicap. Journal Of Child Psychotherapy, 14.2.: 93105. SINASON, V. (1992) The Handicapped Smile: Alis Defence Against Trauma. In Mental Handicap And The Human Condition. London: Free Association.