Case Study 2: Recognition of the Self

Illustrations by Klone Yourself

REFERRAL AND INITIAL PRESENTATION

Christopher [surname unknown]
Born 02.22.2004

When Christopher arrived for his first assessment he was not like a normal eight-year-old boy. There were elements of wildness to him—long unstyled hair, signs of tooth decay, brown patches on his skin from ringworm. He oscillated between stony emotional blankness and moments of high energy when he prowled around the room, picking objects up and examining them with almost forensic scrutiny—he seemed especially drawn to the collection of ammonites and geological specimens I kept on the shelf. Nor was he age appropriate with respect to his behavior, having 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 personal pronoun, and transposing “I” with “we.” “We want to go back to Lea,” 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 (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 pediatric ward of the local hospital. He was 18 kg (80 percent of his expected body weight) and alarmingly cachexic—staff described him as “looking like a kid from a concentration camp.” He also had lice and fungal nail infections. He displayed a highly restrictive eating pattern, and when questioned, he described his diet as comprising produce grown or gathered—legumes, lettuce, wild snails, rabbit, and crayfish. There were no immunization or dental records. The site was 11 miles from K-town, an old, part-ruined farm property on common land where the group had squatted and taken over. Christopher had spent all his life to date there. After a program of inpatient 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—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 Test 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, “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 pseudoshamanic 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 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 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 keep it might be inappropriate. Keen to develop the therapeutic alliance, 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 appreciate 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. 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. “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 first response was invariably to assume a position of naïve unification with other individuals, hence “We had sex” and “Our tummies ache.”

To understand this particularly unusual case, 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; her former boyfriend Sam; and Pascal (for visual reference see genogram, figure 1.1). He had an older sister, Liana (aged approximately 15), who left the commune a year before Christopher’s hospitalization and removal into care. There were no formal structures demarcating filial or platonic roles, Christopher was not obliged to sleep or eat in Sam and Amber’s yurt, and his basic functions were not monitored with regularity. Consequently, he was regarded as a “community child.” His homeschooling 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 her, 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 whom he usually sought for comfort or help with a problem, he said, “We go to sleep and wake up better. Sometimes Pascal sends a stroking dream.”

The community’s ethos was one of brutal honesty and freedom—meetings were held where everyone spoke, airing grievances and disclosing feelings, both good and ill, toward other members. Secrets were regarded as damaging, as were positions of status and labels. 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 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?” I attempted to talk further about this character differentiation, but Christopher proved unresponsive. He often ended the sessions prematurely, dead-eyed and without much emotion. On this occasion 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 clearer, 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. This loss and the new arrivals caused Christopher to feel agitated and confused about the entity to which he believed himself part of. Soon after his arrival, Hamish formed a sexual relationship with Amber, which Christopher witnessed firsthand 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 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. 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 outsiders, 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 wilfully 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 was a mobile number, but the first few times I rang, there was no answer (perhaps switched off or no 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 began. “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, far from being able to make rational decisions and that Social Services 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, and when I pointedly 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 instead, she hung up.

At this point, I found the case particularly difficult and stressful and asked my supervisor to review. I had recently separated from my partner over issues relating to starting a family, and I felt that some of what was being discussed in the sessions was too close to the bone. 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 his mother 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 which prized sexual openness and unboundaried sharing, provided an unstructured upbringing for Christopher. The inconsistent behavior 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 he had very little control over the external world, where those around him reacted purely in the moment to their own individual wants and needs. 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 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 and almost complete lack of boundaries.

The aim of our sessions was 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 reparenting in order to learn to recognize and understand his own internal state and develop a slightly 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 clothing off several times, kept opening and closing the window and disrupting the proceedings in other ways, and expressed a desire to be sent back to the commune. As he became more engaged in the proceedings, he also suffered fits of anger—whereas he had often wanted to curtail the early sessions, he began to throw tantrums toward the end of the later ones as I was drawing them to a close, occasionally needing to be forcibly removed by his foster carer.

He responded well to the environment of the foster home, with its predictability and boundaries, and over a five-month period, his weight stabilized. Christopher began to look and act less like the feral child I had first encountered. 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 in relation to separate individuals. I told Christopher where each fossil had been found—Syria, Argentina, North Wales—and why each was meaningful to me. Toward 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 traveled 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. I had to explain again that it was a gift, and that it now belonged to him.

More difficult was encouraging Christopher to use the personal pronoun, to begin to ask, “Who am I?” and understand “I am me.” Progress in this area was painfully slow. Christopher believed himself to be somehow joined with the commune, and could not identify the single entity of himself, at least not consciously. Encouraging him to say “I” instead of “we” created high levels of anxiety—he often shouted, “No, we aren’t alone,” and he would scratch at his arms or hit his head. His fear of individuation was profound. It was as if he felt I was trying to convince him that he was becoming a new person, unknown, a stranger to himself, rather than acknowledging his existing state.

As an intermediate stage, I began to get him to use his name to describe himself, thereby gradually demarcating his identity. “How’s Christopher today?” I would ask. “Christopher watched television last night,” he would reply. A breakthrough came during a project to replicate the snail farm. I was keen to have Christopher teach me how the process of detoxifying worked and thereby demonstrate his unique skills. As Christopher was punching holes in the lid of the margarine box, I asked, “Where will we get the snails from?” “I can always find them hiding under leaves,” he told me. The moment passed without his noticing the self-referencing language, but it had a remarkable effect. In the following session his mood leveled, he became emotionally consistent, and he was able to use the personal pronoun with greater ease.

OUTCOME AND UPDATED FORMULATION

Though seemingly physically healthy and responding well to psychological treatment, Christopher was found unconscious in his room in the foster carer’s home on 01.25.2013. He was pronounced dead after two hours of attempted resuscitation. Autopsy results were inconclusive, showing no sign of illness, trauma, or suicide. While the initial formulation was not wholly incorrect, it is possible there was an underestimation of the strength of Christopher’s attachment to the collective. Due to the rare nature of the presenting case, it was always my intention to publish it as a paper in the Journal of Contemporary Child Psychotherapy, and I felt that the tragic outcome should not deflect from this intention. On reflection, perhaps treatment proceeded too rapidly and a full range of risk-influencing factors was not identified and taken into account. The case is currently being reviewed as part of an ongoing Severe Untoward Incident investigation.

On a personal note, though uniquely fascinating, working with Christopher was also extremely challenging and often disturbing. At times I felt particularly angry toward his mother, my supervisor, and even my own limitations in helping him. I wondered whether this was ultimately influenced by my childlessness, a state that I had until then believed myself to be reconciled with, and feelings of attachment to Christopher. I found his sudden, unexplained death extremely distressing and have since restarted my own personal therapy. Christopher’s was my final case. I was granted six months’ leave of absence, but following this, I made the decision to retire from practice.

Sarah Hall’s collection of short stories, The Beautiful Indifference, was published by Harper Perennial in January.

More from the 2013 Fiction Issue:

The Mare

Jailbait

Miami