Beginning To Sort It Out

INTRODUCTION 

Five years ago, I started working one day a week in an inner London girls’ comprehensive school as a child and adolescent psychotherapist, part of an innovative Child and Adolescent Mental Health Education Service. Ironically, this “pioneering” service was replicating a model from the heady days of the Inner London Education Authority, the intention being to bring mental health services to young people and their families in a setting they already inhabit, in this case, the educational one. In this way, mental health services become more accessible, especially to those young people and families who might never find their way to a clinic-based service. 

ANTICIPATING THE TASK 

While I was wondering how to approach this new task, the service coordinator said she envisaged the role as being ‘a kind of mental health GP’. The idea of a GP as the initial point of contact for all health problems within a community certainly paralleled my position as the initial point of contact for all kinds of mental health difficulties within a large education community of around 1,200 students. The idea of the GP as an initial ‘sorter-out’ of referrals also seemed to fit as, within the wider community, some problems can be addressed and helped by the GP herself and some need referral to a more specialised service. The first question in my mind on seeing a new patient has always been, ‘What’s the matter?’ – just as your GP might ask when you arrive in her surgery. It seems to me this is rather a good question for keeping the mind open to whatever might present itself. It promotes the kind of ‘free-floating attention’ that Freud (1900) advocates for psychoanalytic work, or that Bion (1992) discusses when recommending a freedom from ‘memory and desire’. It is the opposite of the more narrowed focus of a pre-formed theory that can close things down. The observational skills that any good GP brings to a consultation are also essential to my work and are at the heart of the training of any child and adolescent psychotherapist. So here, too, there was a good fit. 

I also realised that I would need to adapt to the educational setting and prove useful to the school and to the particular difficulties of its students. Learning how to do this was part of the challenge. Moreover, what would be my relationship with the teachers? I had previously done some consultation work with staff at two Pupil Referral Units and knew how influential the teacher-pupil relationship is in the course of a young person’s school life and personal development.  

GETTING STARTED 

As I began the work, I sometimes thought, wryly, that the GP analogy might be adapted. I might think of myself rather as a medic in a war zone, seated in a temporary hut, providing a small oasis of quiet while, on some days, an apparently noisy battle raged outside! This might be a music practice, a rehearsal for a school production or a karate class within the hall where my ceiling-less cubicle sat. Once or twice, I would arrive at school to find the hall was being used for exams, so I had no access to my room, despite a series of booked appointments. Nowadays, I have a room within the Special Needs area of the school for ease of liaison with the SENCO, school counsellor and others from the Special Needs Team. Sometimes, here too, a messenger comes, as it were, from the front, with news of an emergency that has to be acted upon right away. And often, again like a GP, I never quite know what sort of case might next walk through my door. 

During my very helpful induction, I began to get a taste of what it might feel like to be a new Year 7 student. Trying to adjust to the huge size, the crowdedness, the noise and bewildering hurly-burly of a secondary school environment, getting lost when trying to find my way, made a striking contrast to the relatively small size and quiet of my CAMHS clinic. During this induction, I had an opportunity to sit at the back of a classroom and discover exactly the sort of thing teachers have to manage nowadays when trying to deliver a lesson. Very different from my own school days! It was heartening to find that the enlightened senior staff attitude to students causing disruption and difficulties within the school was not punitive. They did not think of girls as being ‘naughty’ or badly-behaved but rather, when there were difficulties, asked themselves the question: What is getting in the way of this girl’s learning? This question proved to be the key in orienting myself to my task and set the stage for the nature of the joint work I have since embarked upon. 

THE EVOLVING WORKING PRACTICES 

Referrals are mostly brought to me via the fortnightly pastoral meeting that considers the needs of students who have become worrying to their teachers. I subsequently often meet the particular teacher who knows the referred child best, to get a more detailed picture with this question in mind: which specific difficulties are getting in the way of this student’s learning? This seems to be mutually useful. It provides a reflective space for the teacher and a wider context for them to think about the pupil’s difficulties, whilst also informing me about how the pupil manages in lessons, and in their relationships with school staff and peers. It also sets the stage for the kind  

of applied work that I think is most useful within a school setting. ‘Pure’ psychotherapy would be hard, in my view, to attempt in school. The room is unlikely to be sufficiently private and the child has to return to their lesson straight after their session with me. I find particular attention has to be paid to managing this transition as it can be difficult to settle in class when feeling stirred up by the session. Most importantly, perhaps, I need to be open to a parent, child or teacher asking for the sort of help that might need some adaptation within the school setting – for example, suggesting a child move tutor group if she is being targeted by a gang within her current tutor group; negotiating a lunchtime buddy when a child is finding this unstructured time acutely lonely or asking the SENCO if she can advise other teachers on ways of making things easier in class for an anxious, dyslexic child who does not want to admit she is falling behind. 

PARTNERSHIP WITH TEACHERS 

The teachers and I also dip back into our contact from time to time, reviewing each situation to see if things are improving for particular students. In this way, I operate on the boundary between the child’s external and internal worlds, moving back and forth between the two in a way that might be confusing within the model of child psychotherapy within a clinic setting. 

Sometimes, the role a teacher can play in enabling a child to access help with their mental health is a particularly delicate yet vital one. I am thinking of an unusually vulnerable student; small, blonde, thin and quiet, with a medical condition affecting her bowels of which she was extremely ashamed. I will call her Anna. 

ANNA 

A bright and conscientious student, Anna was persistently bullied. It seemed that certain children knew she had a secret and were determined to worm it out of her. But Anna was a determined child who did not take the bullying lying down. For a while, she would appear not to react but if anyone openly dared to call her names, she would lash out at them in a way quite uncharacteristic of her usual, quiet self. The emotional and physical force of this would take Anna by storm, leaving her weak, pale and trembling for hours afterwards. After these storms subsided, Anna would be brought to me, weeping copiously whilst stammering out how frightened she was by the murderous thoughts that occurred to her when lashing out at her persecutors. But each time I saw her, she would eventually gather herself up, say she was fine now, this would not happen again and she would leave, refusing any idea of seeing me on a more regular basis. I established with Anna’s mother that Anna did not talk to her at home and, although her mother was concerned about her, she felt this was just the way Anna was and had always been. Probably nothing could be done about it. 

One of Anna’s teachers, however, was aware of her torment. She began to make it her business to talk to Anna sometimes after class, especially when Anna wrote essays in which the teacher thought she detected a character who was persecuted and suffered like Anna. Through the medium of these essays, this teacher and Anna built up a dialogue, each of them aware they were talking about Anna’s difficulties via the metaphor of the character in the essay. Over time, the teacher enabled Anna to return to me and accompanied her. I knew Anna needed referral to a specialist service where both her physical and emotional state could be treated. But Anna felt too raw when seeing me in a ‘therapeutic’ situation. She preferred her occasional chats with her teacher. And so the teacher continued to listen to Anna and to talk to her, whilst I remained in the background, offering occasional consultation to the very wise teacher, who was struggling not to step outside the boundaries of her role, additionally supported in this by advice from her line manager. Eventually, Anna agreed to see me once, together with her mother, whom she had imagined would not support her. She was delighted to find, in this session, that, in fact, she had the full support of both her parents. Anna then agreed to be referred to the specialist clinic. Her teacher continues to be an important part of the network supporting Anna as she receives the long-term treatment she so badly needs. I remain in the background, available for the teacher to talk to when she feels the need and appearing at professionals’ meetings to join in the thinking about the case. 

SHAKIRA 

Another teacher accompanied to sessions a child who, previously, had adamantly refused to see me at all. Shakira was excluded in her first year at secondary school for her quite extreme lack of adherence to boundaries which, when it came to science lessons, endangered the lives of other children. Her mother asked for help since, she said, Shakira had changed from being a sweet, biddable girl to being almost out of her control. 

Whilst I began to see mother on a regular basis to try and understand the nature of the difficulty, I heard that Shakira was pouring scorn on these meetings and on mother for coming to see me. I invited mother to bring Shakira with her, thinking that maybe Shakira was feeling left out. But mother felt there was no way she could get her daughter to come with her – or, indeed, to do anything that Shakira did not want to do. I heard that Shakira ate when she felt like eating, went to bed when she felt like sleeping, got up when she felt like it – and was often extremely late for school. I also learned that following a severe post-natal depression, from which I thought mother had not completely recovered all these years later, mother had never imposed any kind of routine or structure on her daughters (there were two) since, she said, she had wanted them to be her friends and expected they would do things by agreement. 

Unsurprisingly, perhaps, there was no father in this household. There was certainly no paternal function. The idea of limit-setting was anathema to mother since it was bound up with an idea of her own violent and authoritarian father and an idealisation of her gentle, suffering mother. Shakira’s mother had chosen as a partner a man whom she had felt to be useless from the word go, telling me, ‘He was absent even when he was present’ – which I thought might be how she had felt to her children when they were small and she had been so depressed. The parents had eventually separated when the children were still quite young. Now, there seemed to be a household of three sisters, in which mother was felt to be the bad one against whom the other two ganged up, since the girls had nothing but contempt for her lack of authority over them. 

Shakira was inhabiting a cynical world where she felt human communication was based almost exclusively on power relationships. Shakira’s teacher, however, with whom I rapidly made contact, had an altogether different relationship with her. The teacher saw that underneath her hard and cynical front, Shakira was a lost little girl, not much liked by her classmates with whom she was always falling out. The teacher’s lively sympathy was the factor that enabled Shakira to agree to see me – on condition her teacher came too. 

In the room with Shakira and myself, the teacher’s attitude helped create an atmosphere where Shakira felt she would be listened to and taken seriously. She was able to list grievances against her teachers, her mother and other children. Even doctors, Shakira thought, were against her and out to hurt her. She let us know of a particularly nasty injection she had had against tetanus. The doctors, she felt, had definitely delighted in hurting her as much as they could. When I commented that Shakira was letting us know she felt no one was on her side, she became very quiet. 

For the next session, she came on her own and, through a conversation we had about her drawings, I began to understand her feeling that no one ever really kept her in mind or saw things through with her. No one, she felt, cared about the things she might be interested in, unlike other children who all got a better deal. She saw her family as poor and had a real chip on her shoulder about this, feeling that other children came from families who were much better off. She took this to mean material goods whilst I felt she was, in fact, talking about children whose parents took an interest in their minds and what potential riches and growth might be inside them. Her own mother, worn down by depression, was felt to be depleted and hence poor. The lack of any father who might have taken an interest in her was also felt to be impoverishing. I began to see why she felt she always had to make such a splash to get herself noticed. Having entrusted me with these painful feelings, Shakira felt unable to come back on her own and we had to wait for a time until her teacher was available in order to have another session. This work is continuing and Shakira seems to be starting to feel there might be a reliable space available where a kind of parental couple, formed by myself and her teacher, might go on thinking together about her. 

JOINT WORK WITH THE SENCO 

Of course, the Special Educational Needs Co-ordinator is invaluable in thinking about and working on cases together. Many of the girls I see fall into her remit through a variety of special needs and, by the time a girl gets to see me, the SENCO is often already involved and likely to know her well. 

This sense of a working partnership means that we can call on each other for help with both greater and lesser issues. For example, one 13-year-old girl I was seeing, who had some OCD difficulties, found returning to her lessons excruciating after a session with me. She became so anxious as the end of a session approached that she was convinced the only way to help would be to call her Mum at work and ask her to take her home. It helped her greatly when I suggested she might sit for a while in the SENCO’s office until she felt ready to rejoin her lessons. This, in fact, helped break a long-standing pattern of over-dependence on Mum and a sense that she had no internal resources to help her manage her own anxiety. 

Another student I saw, Mary, just could not manage in class. Her position at the centre of disagreements between separated parents, between whom she was continually passed, made her feel highly omnipotent yet, at the same time, not the centre of either parent’s life, passed over in favour of each parent’s younger child by another partner. Mary found herself often in trouble with many of her teachers, as well as her classmates, as her high-handed and confrontational attitude was guaranteed to put people’s backs up and repeatedly won her attention of the most negative kind. I asked the SENCO if she could help by giving Mary, who was also struggling to keep up in some of her lessons, a ‘time out’ with her when the going got too tough in class. This worked brilliantly as Mary, instead of feeling excluded from her teacher’s attention and the company of her classmates, now felt she had somewhere special to go to, designed just for her when she was in need of individual attention. The SENCO soon managed to convert this to a regular weekly time – rather than being on demand – to help Mary to catch up with her Maths. 

SORAYA 

With several cases, our joint work has led to the SENCO feeling the time was ripe to begin the statementing process. One particular student , Soraya, had long-standing problems of various kinds. She felt she was a complete failure in almost every area of her life. When she had gone for medical help with her physical problems, there had been no magical cure and so she no longer wanted to attend those appointments. Her way of managing was to avoid all problem areas as much as she could and all encounters with anyone whom she feared would think her ‘stupid’. Of course, these difficulties got acted out in class and she was extremely challenging to contain. For instance, she shouted down the teacher if she felt her own, very poor, results were about to be read out along 

with everyone else’s. Soraya would certainly not agree to see me. ‘What for?’ she said. ‘She’ll just think I’m stupid and, in any case, nothing will change.’ 

However, Soraya had a very different relationship with the SENCO, whom she used to enjoy helping with various tasks around her office, who asked nothing too demanding from her and who never compared her unfavourably with other pupils. In discussions with the SENCO, I commented that I thought a large part of Soraya was operating at a pre-school level. The SENCO then hit upon the idea of providing Soraya with a regular time for toys and play in her office. Soraya enjoyed this hugely and it was a very peaceful time for her, enabling her to feel there was a time in her school day where she was accepted for who she was, rather than struggling and failing to become someone she was not. Soraya would still not agree to my joining her in this setting but the SENCO was able to begin the statementing process, feeling that Soraya would probably be better off in a suitable special school. 

LINKING WI TH OTHER AGENCIES 

Sometimes I can be of help to the SENCO or other members of school staff because of my knowledge of and contact with other Health agencies. 

For example, an ethnic minority community worker phoned, requesting me to see a 15- year old Bengali girl urgently. I was told she was in a terrible state, very distressed, not eating and threatening to self-harm. The girl was saying she wanted to talk to someone and the worker was feeling out of her depth. When I asked the worker whether the girl or her family had ever seen a Mental Health professional previously, the worker obtained the information from the girl that she had been to the Tavistock Clinic with her parents some time ago. She did not know the name of the person they had seen there but, in any case, she would not want to go back because she did not want her parents to know how she was feeling. There was considerable pressure on me from both the girl and the worker to see her that day but I felt it would be counter-productive to see her once if, indeed, the case were open elsewhere. Accordingly, I phoned the Tavistock, discovered that the case was still open, although appointments had lapsed, and was able to secure the offer of an early appointment with the clinician who already knew the family. This clinician promised to phone and speak to the girl herself that day. This seemed a much better outcome than to begin a new clinical episode for the girl with a stranger. 

On other occasions, I have been able to phone the team at my clinic who deal with urgent cases where there is suicidal ideation or emerging psychosis and refer the young person for an early appointment there. Alternatively, I might phone the CAMHS Outreach Team for Adolescents and ask if someone could join me for an appointment in school, or indeed they might phone me to ask if I could help a young person who has had an acute episode of mental illness and may need some mental health support in school to help the return to education. 

When a child is at the point of permanent exclusion, I can liaise with the mental health professionals at the Pupil Referral Unit to alert them to the needs of the child who is about to arrive. A co-ordinated plan, based on current knowledge of her situation and her needs, can then be set up for her. In an extreme case of a child who appeared to be fire-setting, I was able to offer a mental health risk assessment in the school and, since I had some previous knowledge of the girl, and some small sense of a relationship with her, this student and I had a context in which to try to talk about this alarming new piece of behaviour. 

URGENT TROUBLE SHOOTING 

Sometimes, there really is a need for an urgent appointment in school and then I act as a kind of troubleshooter. One day, for instance, a teacher stopped the Deputy Head and myself on our way to a meeting. The teacher handed the Deputy Head a letter written by a pupil in her class. The pupil described her extreme misery, detailing the types of self-harm she had performed and the things that she would still like to do to herself or to other people. The girl had known her teacher would read this piece of paper and it seemed to be a desperate cry for help. 

I offered to see the girl a little later that day and discovered her mum was in hospital for surgery, necessitated by her own long-standing, self-harming behaviour. Her mother had asked a neighbour, the mother of a friend of her daughter’s, to take care of her daughter. The neighbour herself, though well liked by the girl, was preoccupied with her own difficulties and the girl did not want to burden her with her own worries. Chief of these was the idea that her mum was going to die and that it would be the daughter’s fault as, she felt, she had not taken sufficient care of her mum over the years. In this case, I discovered there was a social worker already involved and I rang her whilst the girl was with me. The social worker arranged to see the girl that afternoon and, moreover, offered to take her to see her mother, a task that the girl had been managing, so far, in a lonely way, all on her own. Later, the social worker and I referred the girl to the CAMHS in the borough where she lived. 

MARY 

Sometimes, a student needs referral to our CAMHS clinic team for longer-term work – perhaps for family therapy or for individual child psychotherapy. An example of the latter was Mary, whom I mentioned earlier as being caught between her separated parents. Mary could be tremendously disruptive in class with ‘silly’ behaviour, which could become aggressive when challenged. She also had constantly changing friendships. 

Over the course of a lengthy intervention with her mother, I discovered that twelve-year old Mary’s parents were divorced and had very different parenting styles, with father constantly undermining mother’s efforts to place limits on Mary. The divorced parents did not communicate except through Mary. Both father and mother had another child from subsequent relationships and Mary was left feeling that her needs never came first – there would always be a ‘preferred’ child in her mind. But she also felt in a position of great power where it was she who determined what it was she received from each parent, whether that be in terms of money, time or material goods. Moreover, she was the conduit for all communications from one parent to another and was therefore in control of what each parent was allowed to know about the other. 

Mary was a very overweight girl, whose body looked to me as if she were puffed up with her sense of her own power. On the other hand, when intensely frustrated, she would lie on the floor, face down, for all the world like an overblown, omnipotent toddler having a tantrum. At school, she tried to replicate the dynamic that was for her the norm. Expecting that the other students’ needs would all be prioritised over hers and that she would have to seize some power to effectively ‘wrest’ the teacher’s attention away from them, had led to ‘attention-seeking’ behaviour in class. She set teachers against one another and could not bear them talking to one another about her. In fact, when I first saw her with her mother, she could not bear mother and me talking together about her either. She would hum loudly to prevent us from hearing each other. At home, she would also become violent to her mother when she could not get her own way. When I saw Mary on her own, her vulnerability was revealed as she tore up drawing after drawing – each never perfect enough for her. 

Part of the work I did with this family was to ask father to join me in sessions with mother, to get some agreement between them about joint and consistent limit-setting, predictability and direct communication between them about Mary’s needs. Mary had been implacably and explicitly opposed to my meeting her dad or getting him to talk to her mum, threatening that she would refuse ever to see me again. In fact, when I would not yield to her threats, exerted my adult authority, arranged the meeting and got the parental agreement, Mary was hugely relieved. The agreement has been more or less adhered to for about two years now. I also referred Mary for individual psychotherapy at my clinic, where it has taken her over a year to feel that the space is really hers to use for thinking about some of her difficulties, rather than sleeping and projecting into her therapist her unbearable feelings of being unwanted and superfluous. Mary’s behaviour at school is greatly improved as testified to by her Form Tutor whom I check in with from time to time. Gone is the attention-seeking behaviour and the need to aggravate teachers. She mostly gets on with her work and has made a few friends. 

A VICTIM OF WAR 

Of course, one cannot know how a case might unfold. A 15-year old student who had arrived from Eritrea a year previously was referred to me in school for persistent physical fighting. She was in danger of permanent exclusion and had already had several temporary ones. Each time she returned to school after an exclusion, teachers would meet with her and she would promise to stop the fighting. But she could not. It seemed, when I saw her, that she had the war raging inside her. She had witnessed a pregnant relative being hacked to death and did not know whether her parents were alive or dead. Actual physical fighting, with whomsoever she imagined had slighted her, gave her some relief from the fighting going on inside her. I envisaged a referral to a specialist organisation that work with victims of war but there was no one to take her there and she could not have gone on her own. This girl was traumatised – she could not concentrate and she could not remember. Sometimes she showed me her textbook and we spoke about her studies. She wanted to do well in life and had idealised plans for her future. She often fell asleep in sessions and I let her rest. She then woke, saying she felt refreshed, thanked me, and went on her way. This was a girl about whom I felt very worried and who would, I thought, eventually need much more intensive work. However, to my surprise I must admit, the relief she obtained from the ‘oasis’ of her sessions contributed to the fighting in school gradually abating. 

STACEY 

Often, I do not know what lies behind an initial referral. Will the intervention needed really be in the mental health arena? Or will there be other events in the family or at school that impact upon the mental health of the child? In such cases, the best I can do may be to try and ameliorate the adverse external circumstances so that the impact of these on the child is lessened. 

One such case was Stacey, newly arrived in the school as a Year 7 student. I was told that her learning was at a far lower level than most of her peers, that she seemed not to understand fairly simple learning tasks, had no friends and was often teased by other girls. Her attendance was patchy. The school was surprised that, although these difficulties had been reported by the SENCO from her primary school, she had never been given a statement of special educational needs. 

I thought it important to understand how Stacey functioned at home, how much of her difficulties might be cognitive and how much emotionally determined and, indeed, what Stacey’s parents made of their daughter. Accordingly, I invited both parents and daughter together for the initial assessment appointment. Only mother and daughter turned up as father was at work but I quickly saw that Stacey was operating at a level much earlier than her years. She openly sucked a dummy in the session and told me she always kept it in her pocket. 

When talking to mother about Stacey’s need for constantly available comfort, I learned that Stacey also used a bottle at home and that mother had never managed to toilet- train her, although she had managed this with her two older children. Stacey complained that other children teased her and that she had no friends whilst also making clear her need to be constantly with her mother ‘in case she falls down.’ From this, I began to understand just how worried Stacey was about her mother. Mother then explained to me that she had a potentially serious medical condition that had, for some years now, not been possible to keep under control and that, in fact, she was not supposed to go out of the house on her own. Stacey’s presence at mother’s side appeared to fulfil two functions: she could keep an eye on her mother whilst also retaining the symbiotic bond with her as the baby of the family. 

Indeed, further exploration revealed that Stacey felt school paled into insignificance beside the all-important task of literally keeping Mum alive. There had been one occasion, when mother and daughter were out shopping together, when mother’s blood pressure had dropped alarmingly and she had collapsed. It had been Stacey who had called the emergency services and stayed beside her mother until they arrived and Stacey who had travelled with her mother in the ambulance to hospital. There was a concerned father in this family and two concerned elder siblings but each, whilst still being part of the family group who cared for Mum, also had their own life to live. Moreover, money was tight in this family and father would lose income each day he took off work. Stacey felt she was fulfilling a filial duty by being an important part of the group who looked after Mum. Stacey would not see me without her mother. She had a lot invested in not catching up developmentally and remaining as the baby of the family, which provided comfort to her mother too. I made a home visit and discovered that the whole family system was organised around looking after this vulnerable mother. 

Subsequently, I organised a professionals’ meeting, which included a long-standing and very helpful GP who had also known mother’s mother and could see the inter-generational patterns. I arranged for Stacey to have a cognitive assessment and the results showed she had significant learning difficulties. The SENCO then started the statementing process and we discovered that this had never been attempted in primary school because of Stacey’s prolonged absences. Indeed, the primary school had never learnt of mother’s debilitating illness. I made a referral of mother to Social Services who arranged for her to have an Occupational Therapy assessment. This led to the installation of various helpful aids in the home. Help and care was provided for Mum whilst the school SENCO applied for a statement for Stacey. She was eventually able to go to a special school more suited to her needs and, after a prolonged battle involving myself and the SENCO, to have transport to take her there. 

This kind of sorting out of ‘what is the matter’ is sometimes a feature of my work, although you can see that offering ‘therapy’ was not part of it. A ‘therapeutic consultation’ one might perhaps call it. However, in this case, a more suitable learning environment 

was provided in the end for Stacey, accompanied by some relief that ‘looking after Mum’ was not entirely her responsibility but that there were appropriate adults to help the family do it. 

WORK WITH PARENTS ALONE 

Quite a substantial part of this ‘rag-bag’ of referrals that come my way includes the need for parent work. Again, this would be different from a clinic where, if I were working with the child, the parent work would be undertaken by a different clinician. This is yet another reason why I would not attempt pure psychotherapy in this setting. The parent work I undertake in school is again hugely varied. 

Sometimes I might only see a parent for a few sessions, sometimes for much longer. Sometimes the parent is seen together with their child, sometimes separately but in parallel with their child – or sometimes instead of their child. 

An example of the third kind of case would be the mother of bright, 15-year old Helen, who was referred to me for behaving quite oddly in lessons from time to time, making faces or grimacing whilst writing her personal views about world matters instead of doing the work set. Her teachers were puzzled by this and about how argumentative Helen became when spoken to about this. I met initially with her mother, as I often do, but this particular mother did not want her daughter to know she was coming to see me. She was surprised that her daughter had been referred and felt that Helen would not react well to feeling she was a ‘problem.’ Over a handful of sessions, we explored Helen’s situation. It seemed that she was quite an artistic but isolated girl, not given to sharing much of her emotional life with other members of her close family. It sounded, however, as if she might be quite jealous of her emotionally more articulate brother and of mother’s relationship with her partner, a man whom Helen nevertheless liked. It had never occurred to mother that Helen might be needy in this way as she had always seemed to her to be self-sufficient, even, she recalled, weaning herself at 6 months old. She resolved to spend more time with Helen and, being artistic herself, to take a particular interest in Helen’s art. Within a matter of weeks, Helen was transformed. Her life at school settled down, she began to focus on her work and did well in her GCSEs. 

Another mother came to see me because her daughter was raising teachers’ concerns by her aggressive and quarrelsome behaviour, her extreme rudeness, and her carelessness with her academic work. This mother had, for many years, been the victim of extreme domestic violence from her husband, from whom she was now divorced. The daughter was very protective of her mother, was relieved I was seeing her, but did not want sessions for herself. Almost all my work, therefore, was with the mother, who had never received counselling once the domestic violence had stopped. She wept as she told me about it. 

She was afraid that her younger son was turning out to be like his father and she was afraid to place any limits on him. As she described him, it did sound as if she had recreated, with her son, the sado-masochistic relationship she had previously ended with her husband. I contacted the mental health worker at the boy’s school who acknowledged the worries the school already had about this boy. Some work was undertaken there with the boy and his father. The mother, meanwhile, revealed to me that her own mother’s relationship with her father, in another country, had also been suffused with violence and she had grown up witnessing this. She had come to this country to find a better life for herself, but her marriage had been arranged and she felt she was just repeating history. 

I wanted to refer this mother on for her own therapeutic work, but she was not sure she wanted it as yet. Maternal grandmother came from her own country to stay with her family here for Christmas and the two women had an emotional reunion after many years apart. Something, it seemed, had changed for my mother through the telling of her story. She described the lifting of a burden from her shoulders just as the daughter seemed to have had the emotional weight of feeling responsible for her mother lifted from hers. When checking in with this girl’s form tutor some months after her mother had finished seeing me, I was surprised to find quite such a change in her. I was told that her customary frown had gone. Now in her GCSE year, she was attending to her work, was pleasant to talk to and a responsible member of her class. However, her form tutor intimated she had a boyfriend she was keeping from her mother, since she knew mother, though not intending to arrange a marriage for her, would not permit boyfriends until she was eighteen. I do not know what happened there since my contact with the family ended but I do know that the daughter did well in her exams. 

One mother phoned me recently after a year of no contact. Previously, she had been unable to speak to her husband about their coming to see me together, as I had suggested. Now she said things had got much worse with their daughter and she really felt ready to tackle things; she had spoken to her husband and wanted to know when they could have a first appointment. 

I think it is important to note that many of these cases would never have turned up at a clinic-based service or, if there had been sufficient concern to get them there, few would have managed to ‘stick’, as for instance, in the case of Anna who kept running away in fright. We have to close a case in a clinic after several non-attendances at appointments whereas, in school, I can remain available for the duration of a pupil’s school life: for a Year 7 student that might mean as much as five years. 

CONCLUSION 

I might only have a day a week at school but I have the luxury, unknown to most teachers, of a small case load and a context where I am able to concentrate on one child at a time. 

In this sense, I am time-rich and can give each child or their parent a space to themselves, something that has often been unknown to them previously. Because of this space, I also have the luxury of bringing into sharp focus the detail of each child’s world in school, at home and also internally. I have the opportunity to build up this knowledge over time as I come to know the child better, to meet their parents, to talk to their teachers and to think about the child across several different contexts: in class, with friends in lesson breaks, at home. In this way, I can discover and put together the bigger picture as well as filling in the detail. 

The huge variety in the nature of referrals and the need for flexibility and adaptation in approach are part of the endless fascination of this complex work, despite the inevitable difficulties and frustrations along the way. The crucial importance of the partnership with teachers adds a dimension of privilege and challenge as we work together to support children’s engagement with their mental health issues, to sort out what can be substantial difficulties hindering learning and hence to foster change. 

I would like to extend my thanks to Debra Potel, Co-ordinator of the CAMHS Education Service, who introduced me to this work and has supported me through it. 

REFERENCES 

Bion.W. (1992) Cogitations. 

Bion, F. (ed.) London. Karnac. 

Freud, S. (1900) The Interpretation of Dreams. (1900a).