ABSTRACT

Before introducing what is the subject of this chapter, it may be important to say something about what it is not. It is not about deciding which borderline psychotic, psychopathic, or psychotic children, are able to ‘use’ psychotherapy. This is, first, because it is extremely difficult to predict degree of improvement. A lesser degree of improvement may have as much to do with our own failure, as the patient’s therapist, to understand the nature of his communications, as with his actual original level of pathology. External factors, too, may intervene for good or ill. I think we are constantly being surprised at how well very damaged children or adolescents do do in treatment: the third assessment session, or, for that matter, the thirty-third treatment session, may be vastly different from the first or second, in terms of revealing new sensitivities in an apparently hardened child. Alternatively, it may reveal new horrifying areas of madness in an apparently only neurotic but slightly odd child, so it is dangerous to predict too much. It may, however, be possible to say something, by the end of a few assessment sessions, about the level and type of illness, by attending to three major areas of functioning i.e. the level of ego development, the nature of the sense of self, and the nature of the ‘internal object’ or ‘representational other’. This may cast some light on where the child is on the neurotic-psychotic continuum (already an oversimplification) and possibly on the degree of overwhelming anxiety, persecution, paranoia, despair, the degree of impulsivity, psychopathy, perversion, addiction, the degree of thought disorder, and perhaps, on the chronicity or acuteness of all or any of these. Such assessment may give some indication of how far the child may have to go to reach normal development; unfortunately it may give little idea of how fast he and his therapist may travel, nor how circuitous the road ahead may have to be.