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A child psychotherapist in a nurse-patient groupKerry Kelly NovickPublished online: 24 Sep 2007.

To cite this article: Kerry Kelly Novick (1976) A child psychotherapist in a nurse-patient group,Journal of Child Psychotherapy, 4:2, 107-119, DOI: 10.1080/00754177608254966

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Journal of Child Psychotherapy 1976

A CHILD PSYCHOTHERAPIST IN A NURSE-PATIENT GROUP by K E R R Y KELLY NOVICK

This report is an attempt to describe a year’s work in a weekly group for adolescent inpatients and their outpatient parents. The group, originally staffed by the two or three nurses on the adolescent unit, was part of the treatment offered in the small adolescent unit, which is part of the Cassel Hospital. The unit consists of about twelve adolescent inpatients, aged approximately 14-19, two to three psychiatric staff, two to three nurses, child psychotherapist, psychiatric social worker, educational psychologist, with the backup of other medical and psychotherapy staff in the hospital. The adolescent patients’ treatment included twiccweekly individual psychotherapy, twiccweekly clinical groups with their own nurse, daily area meetings of the adolescent group with its own staff and the single adult patients and staff, thrice-weekly community meetings, involving the whole hospital population, and the parents’ group. In addition to this, all patients were expected to contribute to the domestic and administrative work of the hospital, and most either studied or worked as soon

Parents, on the other hand, had originally little formal involvement with their children’s treatment programme, beyond the stage of initial consultation before admission, and the nurse’s home visit. After admission of the adolescent patient, contact with the family was maintained by nurses, on the basis of mutual demand, and thus varied greatly from one family to another. A similar pattern of occasional consultation by parents with the consultant in charge of the unit prevailed. The weekly parent-adolescent group, held in the evening by the nursing staff, was at first the only formal help offered to parents, and, at the time I joined the adolescent unit, the “parents’ group” appeared to be suffering the effects of mixed feelings both in the staff and in the parents. From the side of the hospital, it seemed that we were unsure of what we wanted the group to accomplish, and, perhaps as a result of this, parents’ attendance at the group was not presented to the family as an integral and required part of the adolescents’ treatment.

From the parents’ side, resistance to attending and/or using the group appeared to have more complicated roots. The wish to abdicate from responsi- bility for their disturbed children was often strong, especially at the moment of admission; part of this may have been simply relief of enormous stress - most of it seemed related to feelings of guilt and failure which were extremely difficult to acknowledge. A further problem related to their wish to be given a clearcut role to play, often their wish to be patients themselves. Pressure from the parents who did attend to have an explicitly therapeutic group, run by one of

as they were able.

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the doctors, was intense. This was resisted by the nurses in the group and by the unit supporting them, but, as parental problems and parental pathology were brought into the group willy-nilly, it was difficult to use them constructively without tending towards “treating” the parents themselves.

The adolescent patients presented a fairly wide range of severe neurotic disturbances. During the year of my work in the parents’ group th is included school phobia, agoraphobia, self-injurious behaviour, suicide attempts, severe depression, paranoid symptomatology, anorexia, and one or two cases of behaviour disturbances, with delinquent activities and some drug-taking. The parents of these adolescents also could be seen as suffering from a variety of problems; although we did not undertake any specific psychiatric diagnosis of the parents, manifest disturbances included depression, obsessional neurosis, paranoid disorders, sexual perversions acted out (transvestism, incestuous be- haviour), and schizoid personalities and/or symptoms. In general, there was a picture of disturbed families, but the children all had, by the time we saw them, well-intemalised disturbances in their own right, which required individual treatment. Thus I did not see the group as a setting for “family therapy” as such, but rather as an adjunct of the treatment the adolescents wen receiving. Another observation, which I will refer to again in discussing the role of marital difficulties in the functioning of the group, was that not one of the approxi- mately forty parents who attended the group over the year could be described as without problems in the marriage.

For the first six months of the year, there was no provision for contact with individual families outside the group, apart from the nurse’s own attempts, which were ad hoc. Thus m often experienced considerable frustration at not being able to contain, much less try to influence, some of the more pathological patterns which appeared in parents and affected their relations with their children and with the rest of the parents’ group, both staff and patients. Two types of parental disturbance were particularly difficult to deal with in the group: severe, withdrawn depression in a group member seemed to paralyse the group, and, at the other extreme, bossy aggressive obsusionality expressed in attempts to “organise” everybody provoked bickering and despair in everyone. I will discuss these problems more fully later, in dealing with my experience within the group, but I mention them now to stress how crucial it was to the effectiveness of the group to obtain the services of an excellent psychiatric social worker ‘for the second half of the year. She undertook casework with those families who were disrupting the group extremely, and the combination of individual and group attention proved effective There were clearly problems which were impossible or inappropriate to deal with in a group with parents and their drildren together, and yet it was precisely those problems which impeded our progress in any dimension within the group. Once these thiigs could be dealt with outside the group, these families became useful members within the group.

In reporting on the functioning of the parents’ group, there are two ways of

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looking at what happened during the year. The f i t concerns the role of the parents’ group in the overall treatment of our adolescent inpatients, and its place in the work of the adolescent unit. This I hope to discuss in another paper, in conjunction with the other staff involved, who were better placed to understand and assess the effects of the group on our work as a whole. The second concerns my specific experience of working with other professional staff, nakely these nursing sisters attached to the adolescent unit, in what was, in many ways, an experimental setting. Putting a child psychotherapist into a “nursing group” w a s experimental for the hospital, in that, while a lot of time was spent in staff consultation and discassion, very little clinical work was actually undertaken jointly. So the nurses and I had a twofold task: we had to learn how to work together, while maintaining our separate professional skills and roles, and we wanted to evolve and then, hopefully, to understand techniques of working in a large group of parents and adolescents. What follows is an accohnt of my experience of working with the nurses, and of the techniques I evolved, on a trial-and-error basis, for working with our patients and their parents in the group

My fixst contact with the parents’ group was vicarious: for eight weeks I met with the two sisters holding the group, on the following morning. We Wac trying to explore what was happening in the group, to understand the resistances being encountered, and to discover what useful role I could play. Several things emerged from these meetings: we began to get an idea of the type of material which was surfacing in the group and to realise that there was no way to disregard or to set aside unconscious wishes and feeling - some way had to be found to deal with this level of material or nothing on a more conscious level would be accomplished. The problem of falling attendance at the group was directly related to this. Another area of difficulty we were able to describe together was the question of whom the group was supposed to be helping - was it primarily for the parents, or for the patients, or for the staff? We could not answer this, but it became explicit. More important than either of the above was the chance these meetings gave us to confront our mutual fantasies and fears about working together, and these were considerable If we had not had the chance-to deal with these, or at least to recognise that we had work to do together in this area, anxieties about ownership of the group, threats to professional status, and confusion about the value of our respective skills would have seriously interfered with our work in the group. The practical plans we made stemmed directly from these discussions.

We decided to meet briefly before each group (5-10 minutes) and to meet directly after each group for a short discussion of what had gone on, and I then entered the group. Our explicit aim for ourselves was to deal with the feelings surfacing in the group,. consequent on our recognition of thar impact on and their impedance of the practical a i m s of the group. Within the group itself, there were perhaps three inter-related aims which had been made specific:

setting.

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1. the group existed to explore the situation of having a child in hospital, with the emphasis on practical d i f f id ties; 2. the group was to provide an opportunity for information and news to be shared among parents, adolescents and the hospital; 3. it was hoped by all that the group could assist parents and their children in communicating about major decisions that had to be made at various points in treatment, e.g. schooling, work, family changes, length of the adolescent's stay in hospital, plans after leaving, etc. The inter-relation and correlation of our staff aims with these conscious group aims was the technical problem we were trying to solve. We had an idea of the tasks, but we had no idea of the technique needed.

When I entered the group my only preconception about the appropriate technique was that, as it was explicitly not a therapeutic group for parents and, as it was potentially a rather large group (20-30 people), interpretation was not the technique of choice. Initially, I followed the nurses' lead and was probably indistinguishable from them by the patients and their parents - indeed the group took more than a month to remember my title. Within 8-10 weeks, we realised, in our post-group discussion, that a dear distinction of function had emerged. While the nurses brought the culture of the hospital to the group, relating what came up to that week's events in the community and/or any one patient, 1 seemed to be carrying the cultwe of the group, linking each week with the past meetings and defining the group as having a history of its own. Two factors seemed to be contributing to this: the Fist was that I was actually spending almost no time in the community - I really was an outsider to the hospital life, just as the parents were - and thmfore the group constituted the single clinical setting that was important for me; the other factor was that I was doing a different kind of listening from the nurses. My training and experience predisposed me to have the aim simply of understanding, without having necessarily to act on the understanding; I was interested in the motives behind what was expressed, more than in the effects of any given behaviour at a particular moment. The combination of the experimental tinge to the whole endeavour and of my lack of real responsibility for the conduct of any one case freed me from the pressure of feeling that a particular clinical goal had to be reached or a particular practical problem had to be solved in any one meeting. On the basis of this division of function we began to evolve conscious ideas of technique.

We used our short meeting before the group to tell each other what we hoped to bring up in the group. This was a reflection during the initial months of the passivity of the parents and patients, who looked to staff to set the tone of the group or introduce topics for discussion. At fist we responded to this by feeling that we had to oblige, and groups often began with one of the nurses making an announcement, for instance of a forthcoming jumble sale or of someone having started work. Gradually we realised that the initial expectations of the parents of

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us as authority figures were distorting the flow of material and that we were colluding. We made two shifts in technique accordingly, at the same time as we recognised that there was an important theme to be dealt with in the area of parents’ idealisations and disappointment in us. The first change was that we deferred any announcement until at least the middle of the group, and tolerated periods of silence at the beginnings of groups. Sometimes the silence was broken by a parent, to ask a question, raise a problem, or complain of the lack of leadership. Sometimes I broke the silence to link the difficulty in beginning with difficulties the previous week, or simply to ask for further information about something discussed earlier. Here my role as an outsider to the community was important, because I could ask for information without the adolescents’ feeling that my ignorance was contrived and calculated to embarrass them. In fact my ignorance often was contrived: for example, one week we spent almost the whole time discussing one boy’s difficulties in finding work. The parents united with the patients in stressing the practical and reality factors - scarcity of part-time jobs, lack of qualifications, working from the hospital, etc. - and- shied away from the issue of their own feelings about mental illness, with externa- lisations about employers’ attitudes to hospital patients. Before the next group, that boy’s nurse told us about the work she had done with him in the interim on the internal factors interfering with his looking for work, and her wish that we could bring this into the group. It was not possible for her to bring this up, without the patient feeling attacked, but it was appropriate for me to ask for news of his work situation as a follow-up to the previous group. He was then able to talk about what he had understoood of his own role in the delay in finding work; the parents accepted this and then turned to supporting the boy’s mother in her increasing anxiety over his independence.

The second change was that we began to try not to answer questions. This was tricky: when a parent asked what one of us thought about, e.g. a girl of 17 spending her weekends with a boy friend instead of at home with her family, we began to return the question, asking what the father himself thought, or if any of the other parents could help with this. One problem was our own, that of either not knowing what we thought, or of feeling provoked by the question and therefore actually being aggressive in our response. But when we turned the questions back in a spirit of genuine enquiry, the response was constructive. At f i s t the parents were made very anxious and this related to the whole issue of how they wanted to view us. One father, after a few weeks of this, had a violent outburst of fury and despair at one of the nurses, “You only answer with a question! What use are you!” Then I could usefully interpret his feeling of helplessness as one shared by all of us at times when faced with the problems of the adolescents, and begin to redefine the purpose of the group as one of us working together to understand what was happening, rather than for the staff to tell the parkts how to feel and behave towards their changing children.

After two or three months, attendance at the group had improved, and

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support from the adolescent unit had increased, in that two or three new families whose children were admitted around this time had been told that attendance at the group was required as part of the treatment. We had also insisted that all the adolescents attend, whether or not their parents were comirg; this created another useful pressure on parents to attend, and we also observed that those patients who happened to be in the group without thar parents found their voices in talking to other patients’ parents and behaved very differently the next time their own families attended.

I would like now to describe a sequence of three group meetings from this period, both to give the flavour of the proceedings and to illustrate what emerged as the central theme in the material of the whole year and thus became the major unspoken task of the group to work through. The first meeting was difficult and bitty, with everyone changing the subject frequently, and two of the fathers trying to take over, with suggestions for changing the structure of the group, making agendas, etc. These two fathers were important figures through- out the year; they and their wives were the oldest members of the group in time and their daughters became friends. Mr. S used his considerable intellect and business acumen in the service of trying to be therapeutic towards others. He was often very helpful, both in the group and practically, by arranging job interviews for patients etc. He was also a thorn in the side of any attempts to talk about feelings. Mr. L. was a very disturbed man, paranoid with extreme obsessional traits, and obviously very upset about his daughter’s growing up. Mr. L. disrupted the groups with his harangues about his daughter’s sex life and his suggestions that the only way to deal with such things was to %eat it out of them”, he abused the nurses particularly, in his attacks on the usefulness of the group and our competence in general, but he also often expressed the desperate formulations of many of the other parents in their attempts to deal with their present situation. In this f i t meeting, the two men most clearly exemplified the undercurrent of anxiety about loss of control within the adolescents themselves and the hospital’s inability to regulate sex, aggression, drugtaking, etc. The parents and their children continued the meting after the staff left.

The following week the group was giggly, superficial and strange. I remarked that I was at a complete loss - I felt that there was some mystery going on, some secret that I was being left out of. It soon emerged that the group, m its continued meeting the previous week, had agreed that the men were not to talk for the fist half-hour, in other words, that the women were to be in charge. This was clearly directed against Mr. S and Mr. L. The whole atmosphere was highly sexualised, and the parents vent the rest of the meeting attacking the staff and the hospital in general as hostile authoritkans who were of no use. I took this up obliquely by turning the group’s attention to the feelings of the new patients and their parents, their wish and/or expectation that we were the experts who would quickly sort everything out; when they discovered we could not do thin, they felt disappointed, and I suggested that one of the outcomes of disappomt-

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ment was anger. I did not go any further explicitly and for the rest of the meeting confined myself to variations of this verbalisation of feelings being experienced by members of the group. My comments were based on under- standing the sequence of the material as follows: the initial reproach in the f i s t meeting was that the hospital could not contain the adolescents’ anger and I felt that the parents were similarly afraid of loss of control of their own anger and had thereby identified with their children in the second meeting. All the parents disagreed with everything I said in the second meeting, but by the following week the tone had changed radically. The third meeting in this sequence was quiet and sad - it had almost the flavour of mourning. Nobody spoke at the beginning of the meeting, until Mrs. L. broke the silence to remark on how painful she was fiiding the groups, but how she no longer felt reluctant to come. I askcd her if she could share with us and particularly with the new members of the group some of the feelings she had experienced on first joining the group, and the word “failure” was mentioned for the f i s t time. From that point on, we felt like a group, rather than an assembly, and the issue of answering questions with more questions became a running joke, rather than a source of anxiety and anger.

Through these fiist few months, the parents’ group met in a shabby, all-purpose room at the top of the hospital; the room was dimly and harshly lit by a single bulb in the centre of the ceiling. The week after the sad group described above, the nurses and I arrived to find one of the fathers standing on a chair changing the light bulb. This seemed to be another sign that the ownership of the group had shifted from the staff to all of us. As attendance had improved, we had begun to feel crowded in the room, but the staff was reluctant to suggest a change of venue. As we had hoped, within another week, the group demanded a more comfortable home and delegated the nurses to ask the Matron for permission to use the “community room”, a spacious, carpeted, well-lit room, furnished with armchairs. We moved into our new home and, for the next few months, with a fairly stable population of staff and patients, got on with the work of the group.

Parallel with these shifts within the parents’ group came changes in our small staff group. We had been aware throughout of the importance of our post-group discussions in understanding what went on in the meetings and we had gained confidence in the value of what we were doing by seeing changes in the patients and their parents. But while the group identity had remained tenuous, I felt we had directed our own discussions more towards the group and kept in abeyance our professional anxieties about each other. From my point of view, I had discovered during the first few months that it was possible to overlap functions with the nurses and not feel threatened if they talked about feelings, nor to feel that I was intruding if 1 suggested something practical; 1 felt that this experience had been mutual and that we had learned to rely on each other for support and even rescue m the group by a degree of interchange in our skills. We also simply

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taught each other about ourselves and our strengths and weaknesses in relation to particular adolescent problems and particular personality types in parents. The issue of who owned the group remained unresolved until one evening when we admitted to each other that the parents’ group was no longer a “nursing group”, nor had it become a therapeutic group, but it was our group - we had made something new and we were proud of i t This coincided with the move to a new room and we noticed that, from then on, rather than dreading Wednesday evenings, as we had done before, we looked forward to them. Our pre-group meetings came to be used more and more to trade news about ourselves and we stopped worrying about what would or should come up in the meeting.

During the middle months of the year, we faced’two sorts of problems in the group. The staff‘s problems revolved around defining what could and couldn’t be dealt with in the setting, and here the question of how and when to use the psychiatric social worker came in. Here too belong questions about the structure of the group, which were raised by parents and patients and by ourselves. Exampla of these problems came up in relation to the L family. As I have mentioned earlier, Mr. L was a v a y disturbed man; Mrs. L had her difficulties too, although these took longer to emerge. What was dear when they entered the group was that their marriage was a 20-year battleground. Periodically, fights erupted between them in the group. When the fights were about child-rearing methods and their conflicts over handling their daughter, who was a patient, or their other children, the group tried to use the material and help them to come to some compromise, if not agreement. But it soon became clear that their sexual difficulties were at the root of the fights, and the group retreated into pained silence in the face of the bitterness expressed by this couple. We did not feel that we could help in that context, nor did any of us, s t a f f or group members, feel comfortable about airing Mr. and Mrs. L’s sexual problems in front of their own daughter or the other patients. Matters reached a crisis, where every meeting was monopoliised by this couple’s trouble and we could neither help them, nor move to anything else. So we arranged for the psychiatric social worker to work with them. Mr. and Mrs. L had consulted various professionals ova the years in relation to their children’s problems, but they had never talked about themselves. Within a few weeks, it seemed that the pressure had been eased and, although both parents appeared at the group exhausted from their intexviews with the social worker, they became able to contriiute to the parents’ group as parents, and could hear what the other parents and the staff had to offer them in relation to their daughter. They also became stalwart helpers of others and were invaluable in introducing new members to the gioup.

This family made us thiik again about whether it was appropriate or most useful to have both adolescents and their parents in the same group. Initially I had often felt that the parents needed something for themselves and both parents and patients had often said that they were afraid to speak freely in front

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of the other generation, for fear of wounding or provoking angcr. We felt that this was an important function the group could perform - the group should be a safe place, neutral ground, in which parents and patients could discover that nothing so terrible would come of talking to each other. That w2u a reason for keeping everyone in one group. ARethcr reason emerged as time passed: we had underestimated the work the adolescent patients could do in helping each other, each other’s parents and the staff. It was the patients who kept the group from polarising into a hospital faction with the staff representing an unsatisfactory management while the parents played the role of irate customers. The adoles- cents’ ability to shift their own identifications, change role and ask questions seemed related at times to the processes which were going on in the nurses and me; we were learning to take care of each other, visibly, to examine what was happening slowly and the adolescents began to do this too. For example, Miss S. and Miss L. had become good friends and each defended the other when either was attacked by parents. One evening, Mrs. S. began the group by complaining interminably about her daughter’s behaviour, Criticising her carelessness and lack of consideration. Instead of leaping to the defence of her friend, Miss L listened with amazement and then, in the rather baffled silence which greeted Mrs. S’s speech, began to ten Mrs. S. directly of her own experience the previous weekend. Miss L. had cooked meals for her boyfriend and a visitor of his and had then been left to clean up while they talked and she had been hurt and angered by feeling that she was just a ‘‘useful piece of furniture.” This sharing across the generations seemed to dissipate the anger and the group moved to examining why Miss S. and Miss L’s boyfriend needed to use others in a need-satisfying way. None of this would have happened if one of the staff had ventured to suggest to Mrs. S. that internal factors m her relationship with her daughter were at work. On another occasion, the group helped Mrs. and Miss S. to see that many of their conflicts were based on the problems which arose with Mrs. S’s mother, who seemed to cliig to Mrs. S. in much the same way MIS. S. clung to her daughter. We could not go any further, however, as the grand- mother did not attend the group, but it was the other group members who recognised that Mrs. S. and her mother needed help for themselves and suggested that the social worker be asked to intervene. Thus there had been a shift from the staff protecting the group, as we had done with the L. parents’diffidties, to the group protecting itself and its work.

At the time of the summer holidays there were several changes. Some patients left the hospital and all the adolescents were expected to spend a few weeks at home, during the peak period of staff holidaya One nurse and I remained available and we deaded to hold the group as usual once a week, for those families who were not going away on holiday, but were spending the time at home. Despite our reduced numbers, there seemed little change in the feel of the group, and parents wcrc able to bring some of their anxieties about having their children at home during the holiday period. The size of the group had always

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been a question, with staff and members, and the issue was raised again in the autumn, when there was an influx of new families, who, for the f i t time, outnumbered the older members. I had observed that each new family who entered the group through the year had complained initially of embarrassment and inhibition at the idea of talking about themselves and their difficulties in such a large group of strangers. It was impossiblc not to sympathise on one level, and yet a shift always seemed to occur within about three weeks. From a rather paranoid position of anxiety about the large anonymous group, most parents and adolescents seemed to relax into a feeling of safety, almost as if they had realised that the group was too large to gang up togefher on any one person - someone always came forward to present another point of view or defend the pason feeling attacked. Also three weeks seemed about enough time to discover that no dire consequences came from talking about feelings. My feeling eventually was that the size of the group was irrelevant, but parents were unable to hear me say that, as it was experienced by them as a rejection of what they were feeling. Mr. L. had usually been the one to raise the problem of numbers whenever the group faced a difficult meeting and, one evening, when he was absent and a new parent suggested that the group ought to be split in two, it was one of the adolescents, a hitherto passive boy, agoraphobic and severely inhibited, who burst out laughing and remarked ‘‘It’s a good thing Mr. L. isn’t here, or we’d spend the whole evening on that.” Some of the older group members then took it up and explained to the new families that they had experienced similar feelings, but these had passed.

Despite these signs of continuing group identity, i.e. a sense that we had a history, the nurses and I felt that the older members were carrying the poup, that the new families had somehow not coalesced into the structure. We did not understand why, as we could discern little change in the actual content of the group discussions. We were still dealing, as we had been all year, with the questions of how does one deal with depression in oneself and others? How can one continue to love and yet allow for separate development? How are these adolescents different from ordinary kids? Who is to blame and what will their futures be? And all the practical expressions of these problems - moods, violent behaviour, problems over weekend comings and goings, pocket money, holidays, illness and health, differences between parental expectations and their children’s own aspirations, etc. Then one evening discharge dates for two patients were communicated to the group. That meeting was not spent discussing those patients or even the subject of leaving in general, but the whole tone of the group shifted. In our post-group discussion we realised that, just as wc had to mourn the loss of a fantasy ideal of omniscience in the staff in order to become a real group several months earlier, again we had to accept the possibility of change and loss before the new members could feel part of the organic l i e of the group. We could speculate on the parallels that appear between this process and the effect of loss of a parent in the continuing maturing of adults. The lesson we

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learned about the design of the group seemed important; I had womed about the impact of a changing population on the group’s effectiveness, but it appeared that, rather than interfering with the work of the group, a degree of change was a necessary ingredient, particularly in the setting of work with adolescents, where it is precisely the changes in relationship, the conflicts over leaving each other, which have proved so difficult for thcse families.

The work of the latter months of the year was similar to what had gone before, with the group sometimes spending a whole meeting on one family’s present difficulties, sometimes attending to each family in turn and drawing parallels or observing differences among patients with similar problems. Thus the difficulties of two molhers whose sons both had travel phobias were examined and we discovered that Mrs. B. was terrified of the possibility of violence between h a husband and son, while divorced Mrs. K. gradually realised that her son’s threeyear inability to leave the house had become the focus of her life. The B. family was helped by casework with Mr. B., whereas it was the group which supported Mrs. K. in h a emerging depression when her son began to improve. Two families had joined the group when their daughters were admitted because of increasingly violent bchaviour at home. The R’s were sensible of the problt$ms facing them, but found it very difficult to use the group at first, partly because of Mrs. R’s intense fear of crying as she spoke of her daughter’s problems, partly because Miss R. had forbidden h a parents to talk in the group. They were tenrified of what she might do if they disobeyed her in this, just as they had been teirified of her physical attacks on them and her little brotha before she was admitted. The T. family, on the other hand, refused to admit to anyone that physical violence on the part of Mr. T. or his daughta was a threat, and they spent 2% months in the group before any of the other families knew why they were there. With the group’s support, Mrs. R. gained courage first to describe the intense s t r a i n she was under, and then to face the group again after leaving in tears. Her daughter was encouraged, even provoked, by the group to say what it waa she thought was so hateful and damaging in her feelings about h a family. Miss R. had refused to consider going home even for Christmas day, and the group had spent some weeks m discussing the pros and cons of th is and trying to discover how accurate were Miss R’s fears of what she might do to her family. Finally Miss R. burst out with her terrible secret “I hate my fatha and brotha and I don’t like my mother.” I remarked to her that I thought she was brave to have said it, as she had been so frightened of the effect she would produce, and other members of the group then pointed out that h a parents wae st i l l sitting there unharmed and not particularly surprised. The following week Miss R. shyly told the group that she had decided to spend Christmas day at home. Through all these weeks the T’s had sat unmoved, despite repeated staff efforts to involve them with the R’s situation, such as their nurse saying “I think you may have experienced some of thae feelings too.” On the evening of Miss R’s final outburst, however, it was Miss T. who went over to her where she

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sat sobbing on the floor near the door and tried to comfort her. It was only when the nurse appealed to the R’s to help the T’s confront their dtuation that the T’s began to talk and thus we learned again that the patients and parents could sometimes do more to help each other than we could, as long as we provided a safe setting for it. Even more important than our learning this was its effect on the parents’ feeling of failure and guilt. They regained a sense of knowledge of themselves and their own children which freed them to take care of each other, and to approach their wishes to love and take care of their children again.

It was at th is moment, a month before Christmas, that I announced to the group that I would be leaving at Christmas. When the group asked why, it felt appropriate to explain that the hospital and I were x-organising my work so as to allow me to be at home with my baby. This aptly reinforced some of the work we were doing around the adolescents’ difficulty in expressing wishes to be taken care of by their parents and the parents’ conflicts ova their continuing responsibiity to and for their children. My approaching departure did not seem to have more effect on the group than that of any other member had throughout the year. I had been concerned from the beginning over the problem of how much I would be a transference object for the patients and the parents. The parents had been asking for a doctor before I joined the group: they had wanted an authority figure, a therapist who would make interpretations and function as a magical parent - what they got was a child psychotherapist who did not make interpretations. I felt that, in the last few months, while the nurses and I had continued to listen differently to the m a t e d of the group, we had learned to respond interchangeably, i.e., that the division of function we had noticed early in the year had gradually worn away. For all of us, the techniques we had evolved for working in the parent-adolescent group had become internalised and we saw our work in the group as distinct from the other clinical work we did separately, with such different techniques and styles. Thus it was surprisingly easy to leave - I did not feel that the group would suffer or be so different once I was gone, although I hoped that it would continue to change. Another factor was the sense I had that the burden of work had shifted from the staff to the whole group. From being leaders or taskmasters, the nurses and I had become facilitators, who shared in the work of the group. I found it harder to leave the staff group, when OUT mutual learning and support, and our struggles had been great; similarly, I had found it harder to say goodbye to the nurses who had left during the year than to the patients and parents who had left the group. The less06 of those feelings seemed to be that our staff work together had been a crucial element in whatever we had achieved in the group, and that the equal time spent in working together was worth it.

Looking back over the year I am impressed by how much there was to lcarn and by how rich in possibilities the setting of the parent-adolescent group was and is. The major lesson for me, as a child psychotherapist, was the extent to

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which m y training in psychoanalytic work in the one-to-one setting W~LI

applicable both to working with other staff and in a large mixed group. The theory underlying my therapeutic work with individual patients held true with the group, both in the area of the dynamics of the material and in the area of technique. It was not the technique itself which could be transferred directly for, as I said at the beginning of this report, interpretation remained a rarely used type of intarention. Rather it was m y training in considerations of technique which applied, ic. the idea fkst that technique mattered, and then the ability to consider timing, wording, and level of intervention.

Another way of understanding the contribution that I could make as a child psychotherapist is in terms of m y basic assumptions. The general aim of m y individual work and the purpose of the techniques I UK in the one-to-one petting arc to help the patient towards awareness of his own feelings and wishes in th; service of an increasing autonomy and responsibility for himself, which in turn will allow him as0 to depend on othm and take responsibility for others. The work the nurses and I shared in the parents' group also had thee aims, and I felt that we, as staff' grew in our ability to foster them in ourselves and in the patients and their parents.

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