Abstract:
The ‘ghosts’ and ‘the angels’ in the hospital
In 1965 Dr. Rene Spitz, psychiatrist and psychoanalyst, observed infants in hospitals and highlighted the importance of emotional care and early relationships in the healthy development of infants. His important work, The First Year of Life (1965) describes how being deprived of ‘responsive maternal care’ might create anaclitic depression in hospitalized infants. In fact, he discovered that hospitalised infants who only received medical attention and not responsive attuned caregiving they died. In the 1940’s to 1960’s parents were often excluded from staying next to their hospitalised infants. Also at that time UK society’s conflicts involving bullying, shouting, racism, misogyny permeated stressed paediatric team relationships. There were inadequately enforced hospital rules against these activities.
We could say these are ‘the ghosts in the hospital’ linking this with Fraiberg’s seminal article ‘Ghosts in the Nursery’ (1980). Lack of respect and care of medical team clinicians can be handed down as ‘ghosts’ from generations of senior medical staff to junior medical staff, from senior sisters to junior nurses, from unavailable parents to their hospitalised children. These ‘ghosts from the past’ involving lack of respect for the psychological needs of both hospitalized infants and the paediatric team created ruptured emotional links which damaged both the infants and the clinicians.
It is now 2024 and the paediatric wards in many places have been significantly transformed so that there exist ‘angels in the hospital’. The paediatric wards have been transformed to such an extent that I have met quite a few young doctors and nurses who describe their choice of career as does Dr. Veronica Bonales (2012: “My childhood paediatrician’s compassion and dedication to his patients inspired me to pursue a career in medicine. I wanted to provide the same level of care and comfort to my patients that he provided to me".? In fact 81% of young doctors attribute their choice of a medical career to a compassionate doctor who became a role model with whom they wished to identify! (Zayapragassarazan: 2018). So we have to ask what has happened to change the experience of a child in hospital from being anaclitically depressed to a child who wants to be a doctor like their childhood paediatrician?
We can utilize the concept of Leiberman et al (2005), "angels in the nursery," to apply to today’s current ideal paediatric ward practice described by Sebastian Kramer (2018). "Angels in the hospital" is a term symbolising benevolent influences including warmth, psychological protection applying knowledge of Bowlby’s) important heories of secure attachments, separation and lossn(1969, 1973 1980), and compassionate understanding of the self, the child, the families and the team dynamics. Multidisciplinary team reflective groups have been incorporated into paediatric-psychiatric liaison work to provide more care of clinicians, children and their parents. Psychologically based medical care involves assessment of parent-child relationships and therapeutic interventions with families to foster loving and secure relationships involving frequent presence of parents with their hospitalised children. Also therapeutic interventions are undertaken to advise on preventative measures to prevent and to ameliorate childhood trauma from hospitalisation. In particular, it is now acknowledged by paediatricians that:
A baby’s consciousness is like adult’s consciousness. A baby has a mind and requires a caregiver to respond to their feelings and cries . Otherwise long-term cognitive, social and physical development occurs.
An infant feels physical pain and it is very important for a parent or familiar caregiver to be holding and talking to the baby when painful medical procedures are being performed.
Shouting at a person deeply disturbs a person’s amygdala, prefrontal cortex and cognitive function. This behaviour is therefore not acceptable in the workplace. (Choi:2016). Also, being shouted at increases clinician’s sick leave and psychosomatic illness (Einarsen et al:2003) and (Hoel et al: 2002).
More detailed assessments of families whose children have frequent hospital admissions are required.
It is important to place increased emphasis on ‘Giving Sorrow Words’ (Judd:1989) thorough addressing and supporting parents as well as staff with a dying child and subsequently after a child has died.
EFFECTIVE LEADERSHIP AND ‘A REFLECTIVE PRACTICE GROUP’
Tim Dartington (2010) suggests that there is a definite need for ‘a leader’ on the paediatric team who provides a space for containment of the staff’s anxieties and uncertainties and therefore their physical and mental health. Containment (Bion:1962) of paediatric staff who are experiencing dependent, vulnerable, suffering children and their parents can be furthered by a ‘reflective practice group’, The reflective practice group allows members to express and process the intense emotions that inevitably arose in their work with critically ill A well-managed reflective practice group creates a sense of safety and stability allowing the paediatric team members to function well with each other, maintain a professional stance andto continue to function effectively, despite external pressures, with colleagues, parents and the child (Dartington:1994).
NECESSITY OF WEEKLY PAEDIATRIC-MENTAL HEALTH TEAM LIAISON
Now, let us take a further look at what very prominent UK child psychiatrist, Dr. Sebastian Kraemer (2010) has to say about an effective paediatricians-child mental health liaison.
Kraemer argues for a UK national policy that mandates the integration of the paediatric and mental health team so that the teams are placed near one another in the hospital. In addition, at Great Ormond Street Hospital, a specific mental health professional is assigned to each particular paediatric ward and meets with the paediatric team regularly. The presence of the mental health team professional improves understanding of important observations of unhelpful as well as very helpful family-child interactions. Noticing the helpful family interaction (the angels in the family’s story which help them to parent) and striving to Improving unhelpful family functioning (the family ‘ghosts’ which interfere with helpfully parenting their child) can significantly improve the child’s recovery process as well as a child’s future physical and emotional well-being. Early interventions which ameliorate pathological family interactions will also be cost-effective for they will prevent long-term psychiatric problems and reduce repeated medical interventions. Kraemer suggests that having the mental health professional as an integral part of the paediatric team , as well as someone who meets with the family in the presence of the paediatrician, makes it much more likely that the family will continue to attend appointments with the mental health team.
When a child has repeated stomach aches, headaches, failure to gain weight it is important for the paediatrician to avoid saying ‘there is nothing the matter’ !!! The child knows there is something the matter! Prof. Bryan Lask (1993) says it is more beneficial to say in the presence of both parents and the mental health professional, for the paediatrician to say, ‘We can try to think about how to understand and relate to this physical symptom with the help of the psychiatric team in order to improve the child’s quality of life’ (Lask:1993).
Dr. Bessel (2014) in The Body Keeps the Score suggests that trauma-informed physical and emotional care is essential for the paediatric-mental health team to discuss in relation toc each child. In particular, paediatricians need to be aware that some illnesses, such as re-occurring pain, may be aspects of a child’s relationship to trauma. Also medical interventions such as repeated injections, chemotherapy and surgery may be re-traumatising to a child who has already been experiencing trauma. In particular, psychological intervention is definitely required for children who appear detached, unresponsive, overly compliant, emotionally numb or ‘pseudo-mature’, intellectualising about their physical-emotional experiences. It is important to empowering children by explaining procedures about to occur, helping them develop coping strategies through play, mentalising (Fonagy: 2004), ego-strenthening and physically relaxing activities. Considering ‘What can we do to help you ‘get through this time in hospital?’ is an essential aspect ofs collaborative discussions between clinicians, each child, and the parents.
PROVIDING A CORE TEAM COORDINATOR FOR EACH CHILD
When a child remains in hospital for a few days or more, with investigations by several different paediatricians , the U.K. Bristol Report (Kennedy:2001) strongly recommends having a core team coordinator when different paediatricians and professionals are involved with the child. The core team coordinator was to coordinate the medical investigations and ensure treatment recommendations were followed. There is also a need for this core team coordinator to arrange more active parental participation in the child’s care and to write down, and to see being effected, a care plan for the child’s daily routine and care. As much as possible this care plan should provide what the child would have if the child were well and at home.
This means that there should be regular provision for the child’s educational needs and, if well enough, the child should spend some time in the hospital school and also have a regular time for leisure activities with other children on the ward which the play specialist can organise. Otherwise a teacher and play specialist will need to visit the child. When family members have difficulty visiting for variety of reasons other adults should be provided to spend time with the child. When this has occurred Great Ormond Street Hospital utilised play specialists, psychology and psychotherapy trainees as well as trained volunteers to engage in meaningful activities and discussions with the child depending on the severity of the child’s illness. Communication between long-stay children has also been facilitated with mobile phones in the cancer ward of University College Hospital and a hospital radio programme in Great Ormond Street Hospital. In a Rome hospital I have witnessed Friday night movies and musical events to which families and their long-stay inpatient children looked forward.
DEVELOPING ‘THE TRIPLE NARRATIVE’ (Magagna: 2024)
As I mentioned before, both Dr. Sebastian Kraemer (Tavistock Clinic) and Dr. Arnon Bentovim (Great Ormond Street Hospital) are advocating that a mental health professional be assigned to work collaboratively with a specific paediatric ward multidisciplinary team consisting of paediatricians, nurses, physiotherapists, students in training, teachers, play specialists and occupational therapists. The paediatric-psychiatric liaison has the task of creating A Triple Narrative for each child. The Triple Narrative includes:
The coordinated medical narrative regarding the child’s medical investigations and treatment.
Understanding the verbal narrative of reciprocal family-child interaction from conception onwards.
Observation of the non-verbal narrative which involves having one clinician assigned to use one’s emotional responses and intuitions while making careful observations of the child’s reciprocal relationships with clinicians and family members.
The important function of the paediatric-mental health team multidisciplinary meetings and reflective practice meetings is that all staff pursue ongoing development of their sophisticated psychological skills in observing patterns of reciprocal relationships between the child-parents-clinicians. Staff should be cognisant of behaviour associated with fabricated illness, ensuring they can detect and appropriately respond to such cases. Dr. Bentovim suggests a clinician should be assigned to each child to gain a detailed picture of both useful and pathological relationships between the child and significant others. Staff need to learn to use both their observations and their emotional responses as they observe reciprocal relationships between the child and significant others.
Much of what I could say in this talk are omitted for they are incorporated in the other talk I shall give today entitled ‘Enhancing Trust in the NICU’. For this reason I shall now only focus on four important paediatric issues:
Fictitious illness
2. Emotional neglect
2. Attacks on life
3. Giving up life
FABRICATED ILLNESS AND RELATED ISSUES
In the Italian Hospital in Buenos Aires child psychoanalyst and psychiatrist Dr. Monica Cardenal helps the entire paediatric team study the Bick Method of Infant Observation (Cardenal: 1998). This involves the paediatric team members all learning to observe minute details of reciprocal parent-child-clinician interaction before making a medical diagnosis. This is done in order to assess what is promoting the child’s development and what aspects of parent-infant-clinician interaction need to be modified to provide good containment of participants’ feelings. Only through learning to observe the essential minute aspects of clinician-parent-infant reciprocal interactions can the clinician foster both the clinician’s and the parent’s capacity to attune to a less responsive, less healthy, less physically integrated infant.
Fabricated illness (Bentovim: 2018) in Great Ormond Street Hospital sometimes required video cameras to notice the mother’s poisoning of her child. When such a mother was engaged therapeutically it was clear that the mother had her own history of trauma, unresolved psychological issues such as depression. Inducing illness in her child also meant that her ill child could make the mother feel needed and allow her to maintain contact with the medical team. She was often seeking compassionate understanding, sympathy and support from medical professionals. In these situations It is clear that if there is a husband, the medical team needs to work therapeutically to ‘create ‘a couple’s cradle’ for the emotional development of the child ( Magagna:2021). This is done by strengthening the husband’s capacity to respond empathically to his wife and her fostering his relationship with the child rather than being ‘a gate-keeper mother’ (Allen et al. 1999) . Most importantly, in the case of a fabricated illness the child may need to be in the care of relatives or others until , if and when, the mother is psychologically capable of properly caring for her child with the support of her husband or significant others.
2.EMOTIONAL NEGLECT
When a child in hospital is failing to get better in situations where the doctor’s expectation is that the child should be improving and developing physically, or when the child is very frequently brought with a medical concern to the hospital or to an outpatient paediatrician, it is important to carefully observer the nature of the couple’s collaboration with one another and the way in which each partner or a single parent is relating to their child. Here is an example:
A 26 year old mother, was raised as one of 9 children on a farm, lost her mother when she was 18. The mother’s husband was unavailable to her because of his long working hours. Her brother, Andrew was killed in a war just before the birth of her 18 month old baby, Andrew, died of croup. Mother’s penumbra baby, Andrea, was born five weeks after baby, Andrew died. From infancy onwards Andrea was brought to the paediatrician almost weekly with physical complaints. (The penumbra baby is a term given to a baby replacing a dead baby whose loss has not been adequately mourned (Reid: 1995). Mother’s medical complaints about Andrea included failure to thrive, not sleeping, croup, tonsilitis, anaemia, excessive fears. When the mother-child relationship was observed it was clear that the severely depressed mother alternatively controlled and neglected her daughter. Baby Andrea avoided eye contact with her mother’s flat, sullen eyes, often refused mother’s food, didn’t like to be cuddled, and had an avoidant attachment to her mother.
It is clear that mother’s repeated visits to the paediatrician were linked with an problematic reciprocal relationship between mother and daughter: mother was alternatively too intrusively close or emotionally distant and neglectful. Mother’s traumatic loss of her dead youngest brother, Andrew, and her 18 month old son, Andrew, seemed to prevent mother from achieving appropriate separateness from her daughter, Andrea for she was terrified that Andrea too would die. Unconsciously Andrea was being related to as a replacement for mother’s beloved lost brother, lost son and absent husband. Mother gave her baby Andrea inappropriate medicines to make her sleep and daily intrusive anemas. Although this isn’t exactly a ‘fabricated illness’, this mother similar in many ways to those mothers in hospital who secretly poison their child to keep them in hospital. The child unconsciously was fulfilling the role of protector of her mother’s sanity by holding mother’s projected neediness, pain and fear. A mental health team was necessary to transform the mother—child-pathological relationship into one in which mother was therapeutically supported WITH HER HUSBAND in order that her daughter could develop her own separate identity. It is important for the clinicians not to supplant the role of the husband, but rather to transform the parents’ collaborative cradle of concern for their child, Angie.
Dr. Danya Glaser, ( 2002) , a prominent Great Ormond Street Hospital child psychiatrist, describes emotional neglect as the parents’ failure to meet a child’s emotional needs which are essential for the child’s psychological and social development. This form of neglect is often more subtle and less visible than physical abuse, but it can have profound and lasting effects on a child’s emotional and physical well-being.
Glaser identifies several key elements that constitute emotional neglect. These include:
Emotional Unavailability, Unresponsiveness, and Neglect: This occurs when parents or caregivers are emotionally distant or unresponsive to a child’s needs, ignoring the child's need for affection, not providing comfort when the child is distressed, and failing to engage in meaningful interactions with the child. Such neglect can lead to feelings of worthlessness and insecurity in the child.
For example, Andrea’s mother in the previous example was too depressed and detached emotionally to respond appropriately to Andrea’s emotional needs, but instead she very frequently brought Andrea to the paediatrician for medical problems.
Negative Attributions and Mis-attributions to the Child: This involves parents or caregivers consistently negatively attributing a child's sadness, fear or temper tantrums to laziness or manipulation of the adults. This of course leaves their child to feel misunderstood.
Developmentally Inappropriate or Inconsistent Interactions: This includes interactions that are not suited to the child's developmental stage, such as expecting a young child to take on adult responsibilities, leaving them home unsupervised, making them ‘a parentified child’ or treating a teenager as if they were a young child.
Failure to Acknowledge the Child's Individuality and Psychological Boundaries: This occurs when parents do not respect the child's need for autonomy and individuality by intruding on the child’s privacy, sleeping with them when they are a teenager or when the partner is absent, dismissing their opinions and feelings, and not allowing them to develop a sense of self.
Failure to Promote the Child’s Social Adaptation: This involves not supporting the child's ability to form healthy relationships and function in social settings by avoiding providing opportunities for social interaction with others.
Concrete examples of emotional neglect might include a parent who is frequently preoccupied with their own issues and thus emotionally unavailable to their child, a caregiver who dismisses or mocks a child's attempts to express feelings. The impacts of emotional neglect, such as consistently leaving child alone for long periods in hospital without emotional support or engagement are far-reaching and can include difficulties in forming healthy relationships, low self-esteem, anxiety, depression, and a host of other psychological issues.
It is crucial to construct ‘The Triple Narrative’ for each child for toxic stress from adverse childhood experiences (ACEs) can lead to changes in brain development and gene expression which in turn affect physical health outcomes. Chronic stress impacts the hypothalamic-pituatry-adrenal axis and immune system function (McEwen et al: 2017). This is an excellent reason to put forward to obtain funding to enable increased liaison between the paediatricians and mental health team!
2. ATTACKS ON LIFE
Arriving in the accident and emergency department, are children and adolescent who have frequently fallen from heights including stairs, trees, playground equipment, bicycles, starved themselves, cut themselves, drugged themselves or attempted to kill themselves. As difficult as this may be for clinicians, a care coordinator needs to ensure that The Triple Narrative is completed.
A. Of course, the child’s medical condition will first be investigated and treated.
B. Cutting, attempted suicide, starving, drug overdoes all require a mental health team professionals to observe the verbal and non-verbal aspects of the reciprocal relationship between the adolescent and significant others. In particular, if the parents are too critical, angry and persecuted by the event and cannot be assisted to move to a position of concern for their child it is unwise and actually dangerous to send the adolescent back to the family. The risk of repetition of the self-harm is high in those situations where family members or foster carers remain critical and angry rather than compassionately trying tunderstand what the matter is.
Dr. Ougrin et. al. (2010) from the Maudsley Hospital in London suggests that coming back to see a mental health professional for further appointments is much more likely if a more elaborated assessment of issues regarding the self harm occur before the young person leaves hospital.
The essence of the Ougrin Narrative Assessment Technique involves the following:
Creating a therapeutic alliance with the young person by being non-judgmental and empathic as well as showing one is trying to be curious about the conflict with which the self-harm is trying to deal. The therapist wonders with the patient if self-harm is an attempt to communicate distress to others, a way of regulating emotions and also a way of expressing underlying psychological conflicts with others that are difficult to understand and articulate verbally. There will be an exploration to understand the patterns resulting in the self-harm as a solution.
The triggers for the self-harm are identified.
The understanding of self harm as a coping mechanism and thoughts about what other coping strategies in lieu of further self-harm can be developed to relate to the present conflicts.
iv. The assessment involves a systematic approach that considers multiple factors contributing to self harm. A collaborative approach with the patient and his network explores the young person’s psychosocial history, current family dynamics, social support network, academic experiences, current circumstances and any traumatic events they may have encountered.
v. There is also a mental health assessment and this could be one using Dr. Nancy
McWilliams Psychoanalytic Diagnosis (1994).
Once again the assessment method involves the whole system around the young person. It is important to think about the patterns of relationships which exist between the patient and the others external to him as well as looking at the young person’s internal world of relationships. Internalized relationships can also be examined using Rustin and Quagliata’s book: A Psychotherapeutic Assessment of Children (2000).
vii. Ougrin also suggests trying to work out with the young person what they consider to be a core pain. For example, I asked Hanna, an anorectic 14 year old, ‘What was going on through your mind when you felt most distressed? ‘ Hanna , at times when she cut , said, ‘No one cared about how I felt. I felt rejected.’ This might explain the starving of herself as an acting out of her feeling of being felt emotionally starved. On the other hand, until being compassionately interviewed, because she trusted no one, Hanna had not been able to tell people about being raped. The rape seemed to carry a sense of being intruded upon in a disgusting way and she felt controlled and disgusted about herself. The starving was a way of trying to rid herself of ‘overwhelming disgusting feelings’ which left her feeling physically fat.
And LESS OBVIOUS ATTACKS ON LIFE
Frequent Falling
Psychotherapists are very aware that children experiencing a painful separation or a sense of ‘no one caring’ can be insecurely attached (Bowlby: 1969, 1973, 1980) to a ‘good parent internally’. Lacking a sense of an internalized trustworthy caring figure can lead one to become accident prone. For example, anorectic Hanna had a severely depressed mother. Before Hannah started self-harming she had a history of frequently falling from trees, garden walls, and building frames in the garden. She also fell down the stairs losing some teeth.
Frequent Epileptic and Asthma Attacks
In our book, The Silent Child: Communicating without Words (Magagna:2012) I describe Nina, a four year old girl, who had twenty hospitalisations for epilepsy and asthma before she was three! Unfortunately, the concept of formulating The Triple Narrative regarding child-family reciprocal relations (Magagna:2024) was not utilized. The asthma and epilepsy were treated numerous times with none of the paediatric team discovering that young Nina, under three, was left at home ALONE with the dog and a canary from 8am to 5pm everyday. Nina’s story was only known when her 18 year old mother abandoned her, age two, at social services saying she could no longer cope with Nina’s illnesses. In the care of adoptive parents and a psychotherapist, both Nina’s asthma and epilepsy significantly decreased. In psychotherapy with Nina I understood that her hurt and hatred regarding being a neglected child could conceivably have been directed to an internalised neglecting mother and be potentially contributing to both Nina’s asthma and epilepsy.
3.Giving Up Life
I have become increasingly concerned about the number of children and adolescents internationally who have given up walking, talking and eating. Paediatric teams get worried not being able to imagine that, although someone is verbally mute, they can still form a meaningful relationship and staff can speak to them about their emotional state just as a parents speak with their baby. I shall share some thoughts about the nineteen children I saw who suffered from PAWS (Pervasive Avoidant Withdrawal Syndrome (Nunn et. al: 2014 ) previously given diagnosis of Pervasively Refusal Syndrome (Lask:1991. I have coordinated and/or provided treatment for nineteen of these children living on the paediatric ward and described my therapeutic work ‘Compelled to Die’ in A Psychotherapeutic Understanding of Children and Young People with Eating Disorders (Magagna:2023). I shall now explain more about issues linked with a child ‘giving up life’.
On June 2023 I heard about a ‘Poor-will’, a bird in the American desert in the state of Arizona. Poor-will is used to the very hot desert weather; however, when it is an unexpectedly very cold winter period, instead of migrating, the Poorwill hibernates in order to survive the freezing cold. This means that a Poorwill enters a torpid state, with lowered body temperature, heartbeat, and lowered rate of breathing, for days or even weeks at a time. The Hopi Indian name Poor-will means ‘the sleeping one’.
Hearing about Poor-will reminded me of the 70 asylum seeking children who were pulled into a ‘sleeping state’ when faced with the Swedish authorities saying they must return to the ‘cold’, the cold of hate, the cold of war, the cold of torture and persecution which they and their families had faced in their countries of origin. The children retreated into ‘their sleeping state’ of appearing unconscious, not moving, talking or eating when their parents could not protect them from Swedish government notice that they would be forced to go back to their violent, traumatising circumstances.
When he recovered, one of the 70 children, Georgi, described this mental state saying:
‘I felt as if I were in a glass box with fragile wall, deep in the ocean. If I spoke or moved, I thought it would cause the glass to shatter. Then the water would pour in and kill me’ (Aviv; 2017).
This mental state, seeming to cause Georgi to reside inside the object, as described in Donald Meltzer’s concept of ‘the claustrum’ (Meltzer:1992). These 70 children had staff nursing them with food and physiotherapy to see that they didn’t die. These 70 children represent the extreme state of dissociating and absenting themselves from the re-occurrence of an terrorizing external trauma.
I am deeply disturbed when people say a child not speaking, not playing, not drawing, not responding to interpretations is unsuitable for psychotherapy. What is needed is a suitably supported psychotherapist to work with such a child in a setting in which the child has an understanding and protective family or a trustworthy psychiatric core team in an paediatric or psychiatric inpatient setting who will ensure that the child can access reliable, consistent, trustworthy psychotherapy. Home based team approach is also helpful if family has enough funded physical and therapeutic assistance at home.
Many of the children of traumatised families from war-torn countries will be experiencing less extreme versions of Georgi’s post-traumatic stress, dissociation, blanking out, panic attacks, depression, disorganised attachments and be preoccupied with internal and external hostile figures.
In their comatose state these children require the presence of others to experience their need to retreat from life and with immense patience the use of the bodily and emotional countertransference to lend meaning to the silently screaming child’s communication without words. This is the title of our 2012 book, The Silent Child:Communicating without Words (also in Spanish, French and Italian) in which I describe our work with 19 not moving, talking or eating children most of whom were removed from the paediatric wards to reside in our psychiatric inpatient unit.
Although many of the young people you may see may not be as extremely ill as these children, I am giving this presentation to share ways of working with traumatised non speaking children, and listless children who have no will to live, whom many psychotherapists would reject as ‘unsuitable for psychotherapy’. I have consulted with professionals all over the world who can not imagine how important it is for these children for the professionals to revise their usual techniques of working using CBT. Pressure and praise foster the children’s regression!
I shall show a variety of approaches and techniques in understanding these children which heavily rely on core team, family and peer relationships. The approaches are structured in such a way that the non-speaking, retreating traumatised child feels safe and not required to speak until ready to do so. Family therapy, reflective group sessions with the nurses are provided to enable parents, peers and clinicians to be patient and bear the rejection and withdrawal of the non-speaking child, communicating their feelings without words. Group therapy, creative and school groups, parents’ group and physiotherapy were all essential part of the treatment. We consider relationships within the parents’ network and the children’s peer group essential in facilitating recovery from traumatic events. All the psychiatric team, the family members and peer group learned to rely heavily on Mrs. Esther Bick’s infant observation method of looking a sequence of events and using the countertransference experiences to lend meaning to their interactions with the pervasively retreating child.
I shall now describe some of the clinical work with these traumatised children , some of whom recovered with a therapeutic team working with the child and family in their home.
Why a silent scream?
This clinical material from a recovered pervasively retreating child from long ago is heavily disguised.
One child, Gulsan, aged 9, was lying in the paediatric ward looking as if she were in a coma. Because Great Ormond Street Hospital Consultant Psychiatrist, Bryan Lask, decided that she would receive better care in the psychiatric unit she was removed there.
I was engaged in psychotherapy with Gulsan’s Pakistani family who had fled from terrorism and violence in Pakistan. Her Islam mother was dressed in a full Niqab which covers the face and head entirely with a place cut out for the eyes. An older sister, aged 13, brother aged 11, and younger brother, aged 8 were also present in the family sessions. The Pakistani father was head of the house. He was the one who spoke to the outside world . That was his role, but also his wife spoke no English. The family had lost their home, all their possessions, their native language and their supportive extended family. Before fleeing to England Gulsan’s father was severely beaten over a period of three days and his life was threatened in an uprising in their village. The father was depressed, had lost his job as an accountant and he was now working as an unskilled factory worker. He hated everything about his life in England.
Through the therapeutic milieu Gulsan recovered; however, each time we were getting ready to send Gulsan back home she stopped walking and eating. Finally, without knowing what the problem was at home, we decided that she could not bear to be with her family and she was sent to boarding school. Eight years later, aged 17, Gulsan came back to the hospital to see me.
Gulsan’s return visit eight years later
Gulsan arriving wanting to see her hospital notes. She had brought me a teddy bear puppet saying, she knew in her individual psychotherapy I used to talk to puppets sharing my thoughts about her and she felt I could use this new puppet with other children like her. Gulsan and I looked at her notes, about which she could remember little , but said she was grateful to me and the hospital team for not sending her home. Tentatively she offered that would like me to understand something that would help me in my work with other children similar to her.
Slowly a new story emerged in which Gulsan told me her father beat her mother and children like a cruel military prison guard, the moment they stepped out of line. Gulsan wanted me to know that while at the hospital the children and her mother were terrified to speak about father’s violence. They would be too terrified to put their experiences into words for fear they will be thrashed or killed at home for destroying the father who financially supported them and was the only adult who could speak English to deal with government authorities. For this reason they were silent about the home situation. The children were also afraid to talk about the mother’s lack of protection of them for fear they be sent to a children’s home. Gulsan , a now well but somewhat obsessional 17 years old, wanted me to understand this inability to speak out. Gulsan was so very helpful in making me fully aware of the impact of trauma on fathers and families like her own.
Post-Traumatic Stress Disorder and Identification with the Aggressor
I knew very vulnerable Gulsan got pulled into a fully dissociated state, into what Donald Meltzer describes as the claustrum ; however, I also understand that fathers who have been terrorized, beaten, have lost their income, all their possessions, their family network and their native country can also be rendered hopeless, helpless and often suffer a different version of Post Traumatic Stress Disorder (Lanyado:2004) and (Nooner: 2017). Gulsan’s father and other fathers , and sometimes mothers, who feel helpless in supporting all the trauma the family is experiencing may also be pulled into what Sandor Ferenczi (1924) and Anna Freud (1936 ) describe as Identification with the Aggressor .
A portion of the fathers whose children had pervasively retreated had experienced torture and had been chronically mistreated by life threatening oppressive dictatorships. Identification with the aggressor occurred when the fathers internalised the characteristics, attitudes, and behaviours of the tyrannical powerful governments and integrated them into their own self-concept. This omnipotent psychological defence of identifying with the aggressor enabled the fathers to believe that they could gain a sense of control, security, or even protection in relation to their feelings of fear, helplessness and vulnerability.
Likewise the damage to their physical brains and their psyche meant they were easily provoked by any irritating family situation. Having internalized their country’s harsh behaviour, some of the fathers became physically and verbally aggressive towards the family. Some families were gradually able to describe the fathers harsh, rigid and authoritarian personality structure. Other fathers of the pervasively withdrawing child felt it was their duty to financially and emotionally take care of and protect their families, but got extremely depressed, helpless and vulnerable when they could not do this. Some mothers potentially could also identify with the aggressor and treat their child in a physically or emotionally abusive or neglectful manner, but often the mothers of these children were passive recipients of the father’s violence, thus offering their children no protection.
Psychotherapeutic Intervention Involving the Core Team
Family Therapy and Projective identification
A sense of numbness, forgetting and denial seemed the families’ only ways of coping initially. The symptomatic pervasively regressing child held the ‘family wounds’ which required repair due either to such hardship both within their cruel societies, past and present, and/or due to the presence of such cumulative trauma within the family itself. Maud Mannoni (1973) , French psychoanalyst, in The Child, His Illness and Others suggests that the pervasively retreating child may be unconsciously utilized by the family to unconsciously project vulnerable feelings into them as a way for the family to maintain existing dynamics or conceal underlying conflicts. The child’s illness may serve as a focal point around which the family's emotions, conflicts, and relationships revolve. There is a complex interplay between the child, their illness, the family system, the school and the social environment. Mannoni argues that the family can unwittingly contribute to the perpetuation or exacerbation of the child's symptoms. Her thoughts were further elaborated upon by Zinner and Shapiro (1972) in their article on projective identification in families.
Initially there was a tendency not to require the busy for those to come to the family sessions where they were working or looking for a job . Later we wrote letters to the employers saying was absolutely essential to have the fathers present. We made it crucial for fathers to attend for part of the family’s personality got split off and projected into various family members. In particular some family members massively used projection or projective identification of their own aggression onto the father and split off their own needs, their sadness, their hurt, their vulnerable feelings into the pervasively retreating child.
Here is a vignette from a family therapy session:
The Pakistani pervasively retreating daughter, Gulsan is hunched over with her long, curly black hair draping over her face. She has not spoken to anyone for months and she was still not eating, but naso-gastrically fed. She is in a wheelchair for although she is now sitting up she doesn’t walk. The father, older sister, two brothers and mother covered in her hiquab are present. I put a small chair next to Gulsan and I ask her older sister to sit in it. I later ask other family members to take turns sitting in the little chair near Gulsan and imagine her experiences. The older sister says, as Gulsan, ‘I don’t want to be in hospital away from my family.’ When I ask mother, then sitting in the little chair, she speaks with her older daughter translating, “My brothers are rough. They hit me sometimes when they are cross with me. It hurts.’ I ask mother, who is still speaking in the role of Gulsan, ‘Does your mother know any other reasons for your hiding away?’ Mother, in identification with Gulsan, says, ‘I am frightened.’ Mother now starts crying and wiping away her tears. I gently say, ‘Your tears are saying something to me.’ Mother replies in translated words, now in her own identity as mother, ‘I cannot cope any longer.‘
,In fact, each family member was encouraged to speak for themselves and speak about what they imagined the nonspeaking child to be feeling. Names and narratives were given to fear ,sadness, hurt, neediness, vulnerability and anger. A stronger more competent mother allowed the father to diminish some of his assertive, authoritarian control and some of his own sad and vulnerable feelings. Family therapy enabled a couple to fast to the development of the mothers capacities, including finding her voice, learning English, owning her own aggression and developing self-confidence in identification with the therapist. The mother also found ways to structure family life better with the children.
The goal was to enable both parents to negotiate with each other and support one another rather than father feeling overly responsible for everything in the family, particularly disciplining the children, which mother had delegated to him. When more compassionate understanding and nurturing of the parents’ capacities occurred, parents were able to develop a firm, but for more kind discipline. Simultaneously they were enabled to create many enjoyable, nurturing and understanding experiences with each child . At least those were the goals which we felt were being fulfilled. Clearly, with Golson’s mother always needing an interpreter because she was still learning English and because her eyes being all that was visible, other aspects of the family functioning were never fully apparent to us.
A parents’ group
There was a weekly parents’ group and later under the influence of Hennie Symington, one of the parents, an international online PAWS support group now exists for about 56 families internationally. Parents say that this group gves them information, reassurance and vitality. It also enables the families to talk to each other, feel understood and thus to feel they are not alone in coping with their rejecting children pervasively retreating from life. The hospital parents’ group which I led with a colleague supported parents to bear the anxiety that their child was so unwell that the child might die. The parents were supported to bear their pervasively retreating child’s intense terror of life which led the child to ‘break-down’ in the form of an escape from the pressure of everything in every day life. The parents’ group also enabled the parents to bear the severe disappointment that , as their child came out of their cocoon. The child was still severely regressed, talking and playing like a much younger child. Very importantly the parents learned that praise implied that the parents wanted the child to make progress and therefore praise pressured the child to regress. They also learned in the company of each other to observe their interactions with the child and to reflect upon their countertransference experiences. In this way the parents no longer felt not helpless victims of an illness little understood, but rather active participants in understanding their child’s non-verbal communication with others including themselves.
Nursing Team
Gulsan lay in her bed, with her mother frequently visiting her. She was assigned a key nurse and an auxiliary therapeutic care worker. One of these two would be responsible for her physical feeding and regular nursing care as well as for building an emotional relationship with her. Here is a description of some of the care worker’s experience:
The particular treatment approach involved an acceptance of the child’s current state of withdrawal from a terrifying world and the minimising of expectations placed on her over and above non-negotiables which are clearly delineated, predictable and consistent’ but changing at different stages of the child’s development.
As the child recovers her capabilities her hands, instruments for self-survival from infancy onwards, became active only in order to fend of anything that might help her reconnect with the world. This is baffling, disorientating and deeply challenging to the usual nursing assumption that a hospitalised child wants to be helped. For example, some months after her hospitalisation, Gulsan jolted violently when being placed in a chair for the first time. Tears ran down her face as she shook her head from side to side, silently signalling: “No! No! No! NO!” Thus we understood that change of bodily position by the nurses was terrifying! In fact, each change in routine was intensely anxiety provoking until Gulsan developed trust in the nurses and introjected them as caring, dependable, trustworthy caregivers.
Nurses’ Reflective Practice Group
For months the child’s retreat from life can frustrate the staff and parents, eat away at empathy, stir up wishes to retaliate with neglect or anger as one is continually rejected by the pervasively retreating child. A weekly nurses’ reflective practice support group was facilitated by me and a colleague. Only because of this weekly group were we able to enable nurses for many months to continue to work with a n unresponsive, then frightened and fighting out child and then a child out of fear resisting to make changes in routine. For months the nurses complained of feeling so rejected and helpless in the face of such a non-receptive child. Gradually they learned from utilising Bick’s Baby Observation Method that something was happening all the time! They just needed to notice more carefully what the child’s presence suggested and speak as a parent does to a non-speaking baby. Gradually the nurses eagerly brought their experiences with Gulsan to the reflective practice nurses’ group. The work with Gulsan and others like her made such a deep impression on them that later some of the nurses actually became psychotherapists!
Peer Group and Group Therapy
We learned in working with these retreating children that the peer group is a very important therapeutic agent. Much significant progress occurred in sheltered spaces when nursing staff were on the periphery. As time progressed the other young people on the unit read stories, played music and formed little groups who learned to talk with the retreating child without asking questions about things which they thought could be interesting. A daily morning meeting was held for all children in which each inpatient child took turns saying something about the person next to them . That included talking about what they felt was the nature of the pervasively retreating child’s experience the previous day. Similar work was done to enable young people in group therapy to try to understand the pervasively retreating child. Subsequently they were assisted in owning at their own feelings that they had projected into the retreating child. I believe it was partially because several of these children became so engaged in the therapeutic process of trying to sensitively perceive and compassionately identify with the non-speaking child that they later also became psychotherapists and doctors!!
School is also a therapeutic place as well as a weekly creative group
When the severely ill child came, with eyes shut, not moving , she was still able to be in the classroom and weekly creative group with one of the adults sitting beside her. Thinking was verbalised by the children and adults, but also art materials were there for non-verbal expressions of feeling. Gulsan, for example, made her first move in the group when she took some orange and green tissue paper and began to tear it, more and more until all had all been shredded. Tearing the paper was a way of expressing her aggressive feelings. It also offered the possibility of containment and nourishment as the other children created something rather beautiful out of her torn tissue paper. Her first drawing was a shark , a very persecutory monster, but she did not speak about its meaning; however, other children in the group mentioned how much danger one could feel swimming in the sea near that frightening shark.
Individual psychotherapy
Bruce Perry, in The Boy Who Was Raised as a Dog (2017) warns us that traumatised children’s rights should be respected. He urges therapists not to expect children to talk about their conflicts until they feel their relationship with the therapist is trustworthy enough for them to spontaneously do so.
If we understand and feel the ‘musicality’ of interaction as Dr. Bjorn Salomonsson suggests in Psychoanalytic Therapy with Infants and Parents (2014), we realize there are many ways of understanding a child. Also in every communication there are serious limitations to what can be comprehended by relying solely on ordinary verbal communication. In our book, The Silent Child (Magagna: 2012) the first therapeutic work with the dissociated, pervasively retreating child is to receive physical and emotional projections emanating from being present in the room with the child.
Being with the non-moving, not speaking child, reminds me of Edward Tick’s description in his book War and the Soul (2005). He says:
Firstly one feels terrified to death. Then one feels helpless. As this sense of helplessness and terror continues one can feel when the connection between the soul and the body breaks. The cord snaps. The soul which is the centre of consciousness, the essence of being alive, Is out of the body. Without a soul one cannot contemplate wo one is and what gives meaning to one’s life. There is just a body, without the soul, without life.
The psychotherapist and the nurses need to be present with the child to give meaning to the child’s experience. The first sign of consciousness is when the child flinches with panic. Gradually the child opens his/her eyes, at first quickly averting them if one looks directly at the child. These bodily experiences can be felt and sometimes described. Often though I initially avoid creating narratives directly to the child, for that directness is too intrusive.
The book, The Silent Child (Magagna: 2012), shows how I used toy animals, dolls, metaphors, stories, drawing, poetry and singing to the side of the traumatised, pervasively retreating child. This way of allowing myself to be observed thinking, initially not directly to the child, created the possibility of a non-intrusive encounter with the child afraid to come out of her protective cocoon.
For example, I held the toy turtle and talked about the need of the turtle, when seeing me, to go back into its shell. I said, ‘It is not at all sure who I am, what I will do. At the moment It needs the shell to feel safe. I took some of my lessons from Monty Roberts’(1997) in The Man Who Listens to Horses where he talks about letting the traumatised horse watch him, get to know him, and subsequently notice the traumatised horse’s relaxed muscles and growing interest in him.
One pervasively retreating child, Helena, 14, now leaving hospital but continuing psychotherapy, brought this dream which she said was one of her ‘non-terrible dreams which is as follows:
There is a father who has three children. He cuts out the brain of the mother and puts it into a vase. The brain can’t move. It seems to be like a human being. Later the brain talks like a person. It gradually grows. It becomes a person. It has arms, shoulders, but it doesn’t have any legs.
I talked with Helena about how she was trying to work through the trauma of residing psychologically inside this internal mother. I said there seemed to be a frightening experience from which she needed to hide. The aggressive father had to let go of his ‘identification with the aggressor’ with which he protected himself. The mother and the child were paralyzed until father could take care of his vulnerable feelings differently and relate to his family in a more benevolent manner. When there is a sense of safety a human being can emerge. I thought Helena was describing what happened to her. I said, ‘ You had lost almost all your thinking capacity. You lost memory, the capacity to read, write or do things. Now your trust us to protect you and take care of you. Now your are recovering your will to live, recovering your capacities to think and dream. You are working with me to understand yourself.’
Alan Schore (2002) suggests that the therapist’s own bodily sensations in the therapeutic encounter are needed to provide a deepening of empathic connection with the child. More than the clinician’s verbalisations it is his/her non-verbal activity the bodily and emotional containment by the therapist of the child’s projected and disavowed experience that needs to precede verbal processing. It could be argued that these spontaneous, emotional pre-attunements constitute a conversation between the limbic systems of child and therapist. The pre-attunement experiences create a safe holding environment promoting transformations of the personality. I used my bodily and psychological resonance and my sensitive use of sequence of bodily interaction developed through infant observation to understand Gulsan’s communication without words. Most importantly, I did not try to get any of the 19th pervasively retreating children to speak in weekly or bi-weekly session. I let them speak with words when they felt ready to do so.
In the words of T.S. Eliot in Four Quartets: I said to my soul to be still … and Wait without thought … Until I was ready for thought. So the darkness could become the light. And T.S. Eliot went on to say: ‘We must be still, and still moving Into another intensity For a further union, a deeper communion.’
T.S. Eliot (1940), p125-129
REFERENCES
Allen, S. M., & Hawkins, A. J. (1999). Maternal Gatekeeping: Mothers' Beliefs
and Behaviors That Inhibit Greater Father Involvement in Family Work. Journal of
Marriage and Family, 61(1), 199-212.
Aviv, Rachel (2017) The Trauma of Facing Deportation. New Yorker April 3, 2017?
Bentovim, A., Vizard, E., & Gray, J. (2018). Therapeutic interventions to reduce the harmful
effects of adverse childhood experiences. In A. Bentovim, P. Bingley Miller, & J. Gray (Eds.), Safeguarding children living with trauma and family violence: Evidence-based assessment, analysis and planning interventions (pp. 199-218). London: Jessica Kingsley.
Bick, E. (1968) The Experience of the Skin in Early Object Relations. In: A. Briggs (Ed.).
(2002). Surviving space: Papers on infant observation. London: Karnac.
Bonales, V. (2012) My paediatrician inspired me to become a physician. Reflect Hammer
Education. June 12, 2012)
Bowlby, J. (1969) Attachment and Loss Vol 1. Attachment. London Hogarth Press.
Bowlby, J. (1973) Attachment and Loss, Vol. 2: Separation Anxiety and Anger. London
Hogarth Press.
Bowlby, J. (1980) Attachment and Loss: Vol. 3: Loss: Sadness and Depression. London:
Hogarth Press.
Cardenal, M. ( 1998) A psychoanalytically iinformed approach to clinically ill babies.
International Journal of Infant Observation and its Applications. 2 (1) June 1998.
Choi, Jung-Min; Kim, Hye-Sook; and Cho, Soo-Ryun (2016) Effects of Verbal Aggression
on Emotional and Cognitive Processing: Insights from Neuroimaging Studies" by,
Social Cognitive and Affective Neuroscience in 2016:
Dartington, T. and Menzies-Lyth, I., Henry, G.(1971-1975) The Psychological Welfare of
Young Children Making Long Stays in Hospital: Final Report. An Action Research
Study, April 1971-June 1975. Tavistock Clinic Institute of Human Relations CASR
Document.
Dartington, T. (1994). Where Angels Fear to Tread: Idealism, Despondency and Inhibition
of Thought in Hospital Nursing. In A. Obholzer & V. Roberts (Eds.), The Unconscious at Work: Individual and Organizational Stress in the Human Services (pp. 111-120). Routledge.
Dartington, T. (2010) The Art of the Possible: Leadership in an Age of Uncertainty. London:
Karnac.
Eliot, T. S. (1940) East Coker. Four Quartets. In:T.S. Eliot, The Complete Poems and
Plays. (pp. 123-129) Boston: Houghton Mifflin Harcourt, 1971.
Einarsen (2003) The nature and causes of bullying at work. International Journal of
Manpower, 20(1/2), 16-27.
Ferenczi,S. (1924) Thalassia: A Theory of Genitality. London: Karnac (1989).
Fonagy, P., Gergely, G., Jurist, E. L. and Target, M. (2004) Affect Regulation, Mentalization
And the Development of the Self. London: Karnac.
Fraiberg, S., Adelson, E. & Shapiro, V. (1980) Ghosts in the nursery. In: S. Fraiberg (Ed.)
Clinical Studies in Infant Mental Health.(p. 164-193). London: Tavistock.
Freud. A. (1936) Ego and the Mechanisms of Defence. London: Hogarth Press.
Glaser, D. (2002). Emotional Abuse and Neglect (Psychological Maltreatment. Child Abuse
and Neglect (26) 697-714.
Hoel, H., Zapf, D., & Cooper, C. L. (2002). Workplace bullying and stress. In P. L.
Perrewé & D. C. Ganster (Eds.), Historical and Current Perspectives on Stress and
Health (Vol. 2, pp. 293-333). Emerald Group Publishing Limited.
Judd, D. (1999). Give sorrow words: Working with a dying child. London: Routledge.
Kennedy, I. (Chairman). (2001). (Bristol Report) The Report of the Public Inquiry into
children's heart surgery at the Bristol Royal Infirmary 1984-1995: Learning from
Bristol. London: The Stationery Office.
Kraemer, S. (Various years). Liaison Between Paediatrics and Mental Health.
Kraemer, S. (2010). Paediatric Liaison in "Child and Adolescent Mental Health Services:
An Operational Handbook".Cambridge: .Cambridge University Press.
Lanyado, M. (2004) Trauma and Recovery in the Child Psychoanalytic Process: A Guide
for Professionals. London: Routledge.
Lask, B. (1993) Personal communication as he was the inpatient consultant at Great
Ormond Street Hospital.
Lask, B. et. al. (1991) Children with pervasive refusal. Archives of Disease in childhood,
66:866-869.
Lieberman, A., Padron, E., Van Horn, P. Harris, W. intergenerational transmission of
benevolent parental influences. Infant Mental Health Journal. 26 (6) 504-520.
Magagna, J. and Pasquini, P. (2021) YOU TUBE Spanish audio of book:Observar,
entender y ayudar a los ninos y a sus padres en la guarderia. Book by same name:
London: Karnac.
Magagna, J. (Ed) (2012) The Silent Child: Communicating without Words. London: Karnac.
(El Nino en Silencio La Comunicacion mas alla de las palabras. London: Ediciones Karnac.)
Magagna, J. (2023) A Psychotherapeutic Understanding of Eating Disorders in Children
And Young People. London: Routledge.
Magagna, J. (2024) The Triple Narrative. In: The Silent Scream presentation 2024. Madrid.
Mannoni, M. (1973) The Child, ‘The Illness’ and Others. Harmondsworth: Penguin.
McEwen, B. S., & McEwen, C. A. (2017). Social Structure, Adversity, Toxic Stress, and
Intergenerational Poverty: An Early Childhood Model. Annual Review of Sociology,
43(1), 445-472.
McWilliam, N. McWilliams, N. (1994). Psychoanalytic Diagnosis: Understanding
Personality Structure in the Clinical Process. New York: The Guilford Press.
Meltzer, D. ((1992) The Claustrum: An Investigation of Claustrophobic Phenomena.
Strathtay: Clunie.
Nooner, K. B., Litrownik, A. J., Thompson, R., Margolis, B., Leve, L. D., & English, D. J.
(2012). Factors related to post-traumatic stress disorder in adolescents.
Traumatology, 18(3),
20-32.
Nunn, K.P., Lask, B., Owen, I. (2014). "Pervasive refusal syndrome (PRS) 21 years on: a
re-conceptualisation and a renaming." European Child & Adolescent Psychiatry,
23(3): 163-172.
Ougrin, D. (2010). Self-Harm in Children and Young People: A Therapeutic Assessment
Manual. Hodder Arnold.
Perry, B. (2017) The Boy Raised as a Dog. New York: Little and Brown.
Reid, M. (1995). The Penumbra Baby: A Replacement for a Dead Baby. Journal of Child
Psychotherapy, 21(2), 179-197.
Roberts, M. (1997) The Man Who Listens to Horses. London: Arrow Books.
Roitman, Y. (2023.) Psychosis as a sacrifice of sovereignity: Journal of Child
Psychotherapy, 49 (3) 360-373
Rustin, M. and Quagliata, E. ( (2000). Assessment in Child Psychotherapy. London:
Karnac.
Salomonsson, B. (2014) Psychoanalytic Therapy with Infants and Parents. Hove, East
Sussex: Routledge.
Schore, A. N. (2002) Clinical implications of a ``psycho- neurobiological model of projective
identification. In ( S. ALHANATI, Ed.), Primitive Mental States, Volume II: Psychobiological and psychoanalytic perspective, and Early Trauma and Personality Development,. ( PP.1 -65). London: Karnac.
Spitz, R. (1965) The First Year of Life. New York: International University.
Tick, E. (2005) War and the Soul. Wheaton, Illinois: Quest.
(Zayapragassarazan: 2018). About 81% of doctors
Van der Kolk, B. A. (2014). The Body Keeps the Score: Brain, Mind, and Body in the
Healing of Trauma. Viking.
Zayapragassarazan, Z. (2018). Role models in medicine. Journal of Educational
Evaluation for Health Professions, 15, 22.
Zinner, J. and Shapiro, R. (1972) Projective identification as a mode ofperception and
behaviour in families of adolescents. International Journal of Psycho Analylsis,
53:523-530.
