by Sarah Hall
Case Study 2:
· Recognition of the Self ·
Referral and initial presentation
Christopher Surname Unknown
Born 22.02.2004
When Christopher arrived for his first assessment there were elements of ‘wildness’ to him – long unstyled hair, signs of tooth decay, brown patches on his skin from ringworm. Nor did he behave like a normal eight-year-old boy. He oscillated between stony emotional blankness and moments of high energy, when he prowled around the room, picking up objects and examining them with almost forensic scrutiny – he seemed especially drawn to the collection of ammonites and geological specimens I kept on the shelf. He had no concept of basic social restrictions and rules – for example he found the shoes he was wearing uncomfortable so he took them off and began to chew at one of his heels. When he spoke he used a fascinating and unorthodox mode of verbal communication, lacking the first person singular. ‘We want to go back to Lea’ was one of the first things he told me. Christopher was referred for treatment after hospitalization due to extreme weight loss. He was at that stage living in temporary foster care after removal from his home – a mountain commune called Brant Lea, near K-town, which is an isolated fellside settlement in Northern England.
Background
Christopher had been discovered wandering the upland moors by a hiker, disoriented and suffering from mild hypothermia, and was admitted to the paediatric ward of the local hospital. He was 18 kg (80 per cent of his expected body weight) and alarmingly cachexic – staff described him as ‘looking like a child from a concentration camp’. He also had lice and fungal nail infections. There were no dental or immunization records. He displayed a highly restrictive eating pattern and when questioned he described his diet as consisting of produce grown or gathered by the commune – legumes, lettuce, wild snails, rabbit, and crayfish. The site was eleven miles from K-town, an old, part-ruined farm property on common land that the group had squatted in and taken over. Christopher had spent all his life to date there. After a programme of in-patient weight restoration (sedation and nasogastric tube were unnecessary) Christopher began to eat moderate portions of food. He was discharged and placed in foster care, while Social Services assessed the case. After four weeks his foster carer took him to see the family physician, concerned about repeated weight loss. She suspected that Christopher had been using food avoidance tricks, like hiding bits of meat in his clothing and under his bed. There were also boundary issues – he kept walking in on her while she was in the bathroom, even after instructions not to, and he did not respect her personal property.
Assessment
At the intake session Christopher did not mind being weighed but had trouble engaging with the assessment process for any length of time and found it difficult to answer questions about himself. The first thing he voluntarily said was, ‘We want to see the snail farm.’ He did not refer to his mother as ‘mum’ but would respond to her given name of Amber. While able to recognize meaningful and familiar individuals, Christopher had an incoherent and fragmented sense of self; he could not distinguish his identity from that of others, particularly those in the commune. There was some growth retardation and his reading skills were well below average. However, he showed no signs of possessing a distorted body image or suicidal tendencies. On the Eating Attitudes Index he obtained low scores on the perfectionism and maturity fear subscales. He did, however, hold a set of strong beliefs about controlling his food intake, his role in the community, and the importance of pleasing the ‘Firsts’ (original commune founders). When I asked if not eating very much would please them, he replied, ‘When we fast we have spinny dreams. Pascal and Jan say our dreams make us special. They see between us.’ (Pascal was one of the Firsts and seems to have had a pseudo-shamanic role and influence over the group.) ‘Isn’t it the job of adults to make sure children get enough food to grow up strong?’ I asked. Christopher seemed confused, as if the notion of hierarchy and responsibility had not occurred to him. ‘We always eat the snails,’ he said. He then, quite animatedly, described a system he had created for detoxifying snails – three days in a box sprinkled with oatmeal, followed by starvation for two days. ‘We punch holes in the lid,’ Christopher told me, ‘or they die. If they still have dirt inside they give our tummies an ache and we throw up.’ ‘How many snails do you usually eat?’ I asked. ‘Two,’ he replied. ‘Two a day? Can’t you have more? I bet there are lots of snails around?’ Christopher shook his head and became agitated. ‘We mustn’t, we mustn’t, we give two to us all,’ he repeated. When he had calmed down again we discussed what was an appropriate amount of food for each meal. I showed him the food pyramid chart, which he took some interest in. He then became restive, got up from the chair and took from the shelf one of the South Dakota hoploscaphites that I’d unearthed during my last Rock Soc trip to America. He did not seem to understand that the object belonged to me or that his request to take it might be inappropriate. I was keen to develop the therapeutic alliance, and I said it would be fine to borrow the fossil if he promised to return it at the next session (I was rather nervous about the arrangement). Christopher agreed, but it was clear he did not really understand the notion of ownership.
History of presenting problem and family history
In the next session, the hoploscaphite was returned. Christopher asked me what the rock was surrounding it. ‘Pierre Shale,’ I replied. ‘Is it rocky where you lived on the mountain?’ Christopher thought for a moment. ‘Limestone, granite, no sandstone.’ I was impressed by his knowledge of the area around K-town, which I am also familiar with. He then said, ‘Hamish knows about bad soil.’ ‘Who is Hamish?’ I asked. ‘Hamish does sex with us.’ The use of the plural pronoun on this occasion was particularly disconcerting but by then I was more used to Christopher’s enmeshment terminology. ‘Who do you mean by us?’ I asked. Christopher simply nodded. ‘We don’t like him better than Sam and Pascal though,’ he said.
After the weigh-in, I asked Christopher to draw pictures of the people at the commune and name them. I asked again about Hamish’s sexual relationship and he pointed to Amber. He was able to separate out the identities of fellow communers when encouraged to do so, but his immediate response was invariably to assume a position of naïve unification with other individuals, hence ‘we had sex’, ‘our tummies ache’.
It is important to relate the environment in which Christopher was raised, and the chaos of his upbringing. Records and interviews revealed that there were about nine or ten people at the commune, who had been living for over a decade in prefabricated barns and yurt-like tents, with no electricity, except that intermittently provided by a diesel generator. The primary members – Firsts – were as follows: Christopher’s mother Amber, Amber’s brother Noel and her former boyfriend Sam, and Pascal (for visual reference see genogram, figure 1.1). Christopher had an older sister, Liana (age approx. fifteen), who left the commune a year before Christopher’s hospitalization and removal into care. I shall return to this point as it is of significance. There were no formal structures demarcating filial or platonic roles, Christopher was regarded as a ‘community child’: he was not obliged to sleep or eat in Sam and Amber’s yurt, and his basic functions were not monitored with regularity. His home schooling appears to have been sporadic, though some of his practical skills were astonishing, for example he could tie fishing flies and knew how to work the generator, probably learned from watching those around him. Much of his time was spent autonomously, rather than with Amber, who was an unreliable figure and reacted to Christopher’s needs erratically. For example, he related an incident where he fell through a barn roof and seriously injured his arm. When he approached Amber crying she continued singing the song she was playing on the guitar and ignored him. There were often extended periods when she was away from the commune with her brother Noel, trading at fairs. When I asked Christopher who he usually sought comfort from or help with a problem he said, ‘We go to sleep and just wake up bett
er. Sometimes Pascal sends a stroking dream.’
Figure 1.1 Genogram of Commune
The community’s ethos seems to have been one of brutal honesty and freedom. Meetings were held where everyone spoke, airing grievances, and disclosing feelings – both good and ill – towards other members. Secrets were regarded as damaging, as were positions of status and labels, though the Firsts seem to have held a certain prestige. Christopher told me that Pascal had originally seen the site in a ‘flying dream’ (perhaps under the influence of narcotics?) and the others had trusted him to find it. Christopher was excited by one genesis story in particular. Two of the commune’s barns had been built by the Firsts. Complaints were made (one suspects architectural innovation was an excuse for people to complain about the group of settlers) and planning officers investigated. Since, one assumes, no permission had been granted, orders were given for the structures to be dismantled. The Firsts chained themselves to the doorframes. ‘We stopped the diggers bashing our barns down,’ Christopher told me proudly. ‘But this all happened before you were born?’ I suggested. ‘Maybe Liana remembered it happening and told you about it?’ But Christopher proved unresponsive to this character differentiation. He would often end the sessions prematurely, dead-eyed and without much emotion. On this occasion though he went to the shelf of fossils and lifted up a piece of fulgurite. After a few moments he said, ‘It’s too light.’ I explained that fulgurite is created by lightning hitting sand, turning the sand into another substance. I asked him if he would like to take it home with him and bring it back again at the next session and he seemed pleased.
In the following assessment sessions the complicated and unboundaried nature of relations at the commune became more clear, as did the lack of stable and predictable parental care. Prior to Christopher’s hospitalization there had been a period of intense disruption. First his sister chose to leave (he had no contact with her after her departure). Then Hamish (a recent widower) and his daughter Kiki (aged ten) joined the group. The loss of his sister, and the new arrivals, caused Christopher to feel agitated and confused. Soon after his arrival, Hamish formed a sexual relationship with Amber, which Christopher witnessed first-hand on several occasions: ‘We didn’t have to go outside if we didn’t want to while there were the noises.’ When I asked Christopher if Kiki liked living on the commune and was his friend, he said, ‘No.’ ‘Why not?’ ‘Kiki doesn’t share books and clothes. She doesn’t come in the bath.’ Christopher then described a large communal clay bath, which several members of the group used at the same time. The structure appeared to be primitive and was heated underneath by a wood fire. It seems Kiki also felt uncomfortable with the levels of nudity on the site and would remain clothed in Christopher’s presence. On one occasion she had thrown sawdust in his eyes when he’d walked in on her using the toilet (there were no proper doors on the latrines). ‘Our face stung,’ he told me. The unstructured environment was rendered increasingly confusing by the arrival of father and daughter, whose general habits were not in keeping with anything he recognized as ‘normal’. It was during this period that Christopher began controlling his food intake. He described eating a precise number of wild snails per day and avoiding meal times by hiding on the moors or pretending one of the other commune members had given him food. That Christopher was left to his own devices much of the time meant his condition either went unnoticed or was ignored. The Child Protection Enquiry report shows his mother’s response to his hospitalization as follows: ‘He’s just a bony kid. He runs around so much. And he knows where the eggs are kept if he’s hungry.’
Due to the complexity of the case, I felt it would be helpful to speak to Christopher’s mother myself in order to assess his perception of life at the commune against hers, and to discuss the possibility of her attending treatment sessions. There is a contact mobile number but the first few times I rang no one answered. (There is a poor signal in the mountains around K-town.) Finally, I was able to reach Pascal. I introduced myself and asked to speak with Amber. Pascal was initially hostile and uncooperative, saying, rather defensively, ‘What right have you got to interfere? You want to criticize our lifestyle, but what’s your own life like? You can’t see into him like we can. What do you know about children?’ When I assured Pascal that talking to Amber would be of benefit to Christopher, and that Christopher’s condition might permanently damage his health, he relented. It took a few minutes for Amber to be found and then she came on the line. ‘I don’t want to talk about Christopher,’ she said. ‘He made his choice and I respect that. But he’s away from us now.’ I tried to point out that her son was, at the time of leaving the commune, terribly underweight, sick, and disoriented, and his condition and age meant that he was far from being able to make rational decisions. I told her Social Care had intervened as a matter of routine. ‘Intelligence isn’t about age, those are just society’s concepts,’ she said. ‘Christopher knows all about the environment and love. You want him to be selfish and a machine that only thinks about itself. You want him to be like you, but he won’t ever be like you.’ The conversation was deeply frustrating. Amber would not answer questions directly and obfuscated her points, either deliberately or because her thought process was disordered. When I asked, ‘Aren’t you interested in helping your child?’ she replied, ‘But he’s not mine, he’s ours.’ When I asked if Christopher’s father might care to attend the sessions, she hung up.
At this stage I found the case particularly difficult and stressful and asked my supervisor to review. I should note that I had recently separated from my partner over issues relating to starting a family – we were unable – and I felt that some of what was being discussed in the sessions was too close to the bone. Christopher was painfully thin. He had no physical inhibition and he would often sit on the floor against my legs or touch my arms or my hair. It was distressing to think of his own mother being wilfully neglectful, and I found Amber’s arrogance maddening. I was granted two weeks’ leave, after which I resumed my work with Christopher.
Initial formulation
My impression of the commune was poor from the beginning and much of what was disclosed by Christopher and the conversation with Amber verified my suspicions. There was little privacy or coherence, and the culture, ‘all of one mind and all free’, which abdicated responsibility and parental leadership, and prized sexual openness and unboundaried sharing, provided an unstructured upbringing for Christopher. The inconsistent behaviour of his mother (and in fact all ‘caregivers’ he was exposed to) and her low levels of expressed emotion resulted in a highly ambivalent attachment style which was reflected in his ways of relating to both his foster carer and myself within our sessions. Never knowing what to expect from Amber and with a complete failure of consistent emotional recognition and mirroring, he was not able to know his own emotional state, wants and needs, or have them validated. I suspect that Christopher’s perception was that, because those around him reacted purely in the moment to their own individual wants and needs, he had very little control over the external world. Such an inconsistent and confusing environment is likely to have had a highly detrimental effect on Christopher and at a young age he had no choice but to collude in the maladaptive schemas of the commune. His sense of self in large part failed to develop and my hypothesis was that he used methods of food control in an attempt to create order due to a chaotic internal state.
The aim of our sessions was therefore primarily to separate the individual self from the collective, to recognize personal and societal boundaries and to break the restrictive eating patterns. In essence, Christopher needed re-parenting in order to learn to recognize and understand his own internal state and develop a more functional attachment style now that he was to be integrated into mainstream society.
Initial treatment sessions
In the early sessions Christopher was often emotionally void, ignoring me or dismissing the conversation if he did not want to participate. He also spontaneously attempted to take his clot
hing off several times, kept opening and closing the window and disrupting the proceedings in other ways, and repeatedly expressed a desire to be sent back to the commune. He often wanted to curtail the early sessions, but as he became more engaged he began to throw tantrums. As I was drawing later sessions to a close, he occasionally needed to be forcibly removed by his foster carer.
Over the weeks of treatment he began to respond well to the environment of the foster home, with its predictability and boundaries, and over a five-month period his weight stabilized. He was able to follow simple house rules like knocking on a door before entering, and not attempting to get into the bathtub with other house members. The exercise of lending my fossils, though rather unorthodox, worked well as it encouraged a relationship of trust between us, while also illustrating the nature of ownership and personal possessions. I told Christopher where each fossil had been found – Syria, Argentina, North Wales – and why each was meaningful to me. Towards the end of treatment his carer indicated that Christopher had himself started to remember to return the items without her prompting. During my two-week leave I had travelled to Morocco, and on one paleo-mineral tour I found a beautifully preserved mid-Ordovician trilobite, which I decided to give to Christopher. The following session he brought it back. This time I had to explain that it was a gift, and now belonged to him.
