Several years after qualifying as a psychoanalyst, I had a patient named Thomas. Thomas was nine years old and had just been expelled from school.
A few months before I first met him, the nurse at Thomas’ school had found belt marks on his arms and legs. She also found bruises and nail marks on his upper arms – parallel injuries, indicating that he’d been grabbed and shaken. Thomas told the nurse that his mother had beaten him – and that he wanted to kill himself. Social services were called. Thomas’ mother told a social worker that she was at her wits’ end; that Thomas never listened to her; he was just impossible. She didn’t know what to do. ‘Everything would be OK,’ she said, ‘if only Thomas tried to be good.’
Thomas’ teacher was asked by the local authority to prepare a report. She described him as ‘distracted’ and ‘in his own world’. He wandered around the classroom during lessons, she wrote; he resisted eye contact, and he had begun describing violent fantasies to his teachers and classmates, easily and often.
Thomas told the social worker who met with his family that he wanted to kill his mother – ‘Cut her open with a big knife, pull out all her intestines, then put her on a torture rack until all her joints snap.’ Thomas told the assessing child psychiatrist that he wanted to murder a little girl in his class – ‘I’d like to chop her head off,’ he said. The next day Thomas brought a large kitchen knife to school – ‘to show her’. He was immediately expelled, and enrolled instead in classes at the children’s psychiatric unit where I was working.
Thomas was seen by a number of doctors – several children’s psychiatrists, a psychotherapist, an educational psychologist and a paediatrician. All agreed that he was suffering from high-functioning autism, or Asperger’s syndrome. One psychiatrist believed that Thomas might also be suffering from Tourette’s syndrome or a pre-schizophrenic disorder; another described him as having ‘manic and psychotic features’. The psychiatrist in charge of Thomas’ treatment prescribed a course of medication and recommended that Thomas be offered analysis five times a week.
Thomas and I met in a small consulting room down the hall from the unit’s classrooms. There was a sink and a cupboard with eight lockers, one locker for each child who was having treatment in that room. Thomas’ locker was stocked with the standard supplies: paper and washable markers, string, tape, plasticine, a family of small cloth dolls, and several small plastic animals. The idea is that a child’s play will be like an adult’s free association, that these supplies can help a child to express the emotions they might not be able to put into words.
During his first session, Thomas told me that he wanted to kill one of his teachers, and then he told me that he wanted to kill me. I suspected he didn’t mean what he was saying, that he was just trying to be disturbing. When I attempted to talk to him about what he was feeling, he responded by going to his locker and taking out his supplies. He ripped up the paper, tried to break the markers, stomped on the cloth dolls and then threw everything into the sink and turned on the tap. I told him that I thought he was trying to show me how angry he was and how tangled up and messy his feelings were. He asked to go to the loo. I waited just outside the door. I heard the toilet flush, water running in the sink, and then the sound of breaking glass. Thomas had smashed a small window above the sink with his right hand. His wrist was cut and gushing blood. He was shocked, and yet he cried out, ‘I’ve been shot, I’ve been shot. I’ve been shot in the Middle East.’
It was difficult for me to get a handle on what had just happened. Thomas was shaken, but his reaction seemed like a performance.
We met the next day, and while Thomas was quieter, he still seemed determined to unsettle me. He spent most of the session calling me ‘big tits’ and ‘fat lesbian’– phrases, he told me, that upset his female teachers. The following week, he drew swastikas on the walls and furniture, goose-stepped his way around the room, and called me a dirty Jew. ‘Sieg Heil, Sieg Heil,’ he shouted.
A few weeks later he began a series of drawings. These pictures, dashed off in a minute or two, showed him standing over me, a meat cleaver in his hand, chopping me into pieces. Some days, he’d then draw another scene: a picture of himself sitting at a table, a napkin around his neck, eating my body parts.
While these sessions were disturbing, I wasn’t too caught up in his various attacks – they were extreme, yes, but somehow they never felt personal. And, little by little, Thomas was telling me about his life. After two months of treatment, his teachers reported that his behaviour in the classroom had improved – he was able to use the therapy room as a place to discharge his anger and confusion.
Then Thomas began to spit in my face. ‘I don’t make rude gestures, do I?’ he’d say, just before giving me the finger. ‘I’m not kicking the door, am I?’ ‘I’m not jumping on the couch, am I?’ ‘I’m not spitting on you, am I?’
One day, we were sitting at the low table in the therapy room, and Thomas told me that he missed his friends. He’d once seen Oliver – his best friend from school – at the supermarket, but Oliver wasn’t allowed to talk to him any more. He sounded sad and I told him so. He immediately spat in my face, twice, then ran to the couch and began to jump up and down on it. I told him that my words – that he sounded sad – had upset him, and that he’d spat at me to get the hurt out of himself.
Throughout our sessions, I tried to describe his behaviour to him in words I thought he could understand and use – I told him that his spitting was a way of getting rid of me before I could get rid of him; a way of controlling the distance between us. I described his spitting as a confession of guilt, an attempt to provoke a punishment from me. Another time I told Thomas that I thought he wanted me to be enraged with him so he’d know for certain that he was the only person in my mind. These interpretations, and others, seemed to have little or no effect. For the next year and a half – in every session – Thomas spat in my face.
Although I was receiving weekly supervision and attending a regular clinical seminar of psychiatrists and psychoanalysts who worked with children – all of whom had been thoughtful and helpful about my sessions with Thomas – I’d reached a breaking point. I began to dread the anger I felt after each of his attacks. It wasn’t just that I didn’t feel I was getting anywhere, I was beginning to lose faith in what I was doing.
I rang a colleague, Dr S., who had practised child and adult psychoanalysis for over fifty years. One rainy evening I left my office in Hampstead and drove to Dr S.’s house across town. Settling in a chair across from her, I began to unpack my files.
‘Set your notes aside,’ she said. ‘Just tell me about him.’
For the next half-hour, I told her Thomas’ story. I tried to describe the atmosphere between us, what I felt was going on. She listened, and asked a number of questions about his birth and early childhood, his parents and younger sisters, his psychiatric diagnosis and school reports. Then she asked, ‘How do you feel when he spits on you?’
‘Angry,’ I said. ‘Despairing too – but mostly angry, and guilty about my anger.’
‘There are a number of children at the unit who spit. Does it always affect you like this?’
‘No,’ I said. I described a six-year-old boy diagnosed with autism. A few weeks earlier, we’d been kicking a ball back and forth in the playground; he’d become overexcited and, running up to speak to me, had spat on me instead. ‘He didn’t make me feel angry. On the contrary, I wanted to reassure him that he hadn’t done anything wrong – I wanted to put my arm around him.’
Dr S. was silent a moment. ‘I’m wondering if you have an expectation that Thomas can control his spitting. Maybe he can, maybe he can’t. But because you think he can control his spitting, you’re angry when he doesn’t. You might consider the idea that he needs you and others – his mother, his teachers – to have this expectation. He needs you to be angry with him.’
Dr S. was right. Calling me a fat lesbian, a dirty Jew, giving me the finger, kicking the door – how hard Thomas had worked to find something that would make me angry. It had taken three months, but eventually he’d found the thing that would disturb me – and then he’d done it over and over and over again.
‘But why are we stuck here?’ I asked her.
‘Think about the impasse,’ she said. ‘You know that when there’s a deadlock it’s usually because the impasse serves some function for both the patient and the analyst. Think of this deadlock as an obstacle that the two of you have created. What purpose does it serve you?’
We carried our coffee cups into the kitchen. I thanked her, and left. On the drive home, I was haunted by her question.
The next day I collected Thomas from his classroom, and he ran ahead of me to the therapy room, yelling, ‘Broken, broken, broken!’ When we reached the door, he turned and looked at me: ‘Well, do you have anything to say about that?’ Before I could answer, he spat in my face.
We went inside. ‘When you spit on me,’ I said, ‘you want me to get angry with you, because if I’m angry with you, it means I believe you could be different than you are. If I’m angry, it means I still believe we can fix what’s broken.’
He was silent for a moment, and then I asked him, ‘Can you tell me what’s broken?’
‘My brain’s broken, stupid.’
He walked over to the small chair I was sitting on. ‘My brain doesn’t work, not like other people’s.’
Sitting down next to me at the low table, he described looking out of the bus window on his way to the unit that morning. Everywhere there were children in school uniforms, with book bags, gym kits and footballs. He recognised many of the boys and girls from his old school. They were growing up, doing new things. ‘I don’t have a book bag. I’m crap at football. I do baby stuff at school. Did I tell you that my sisters practise their multiplication tables on each other? They’re younger than me but they can do all these things I can’t do ’cos their brains work. Mine’s wrecked.’
He looked me in the eye. ‘It’s really sad. Isn’t that really, really sad?’
‘Yes, it is really, really sad.’
There was a great stillness in the room.
Two days later, he spat at me once more, and then never again.
Looking back, it is clear now that Thomas and I were at an impasse because neither of us could bear the thought that he was irreparably damaged. And it was only when we were both able to be sad, to despair because we couldn’t fix what was broken, that his spitting stopped serving a purpose for us and we were able to move forward.
Thomas is now a grown man. He lives in the countryside with one of his sisters, and he has a job in the mailroom of a small company.
Several times a year, usually when his psychiatrist is away, he rings me. He begins by asking me if I remember when his psychoanalysis began. I say yes. And then he tells me the exact time, the day of the week, and the date, of our first session. Then he asks me if I remember when his psychoanalysis ended, and I say yes. And then he tells me the exact time, the day of the week, and the date, of our last session. He’ll tell me that was a long time ago, ‘but it was an important time’. Sometimes he tells me about something that has happened to him recently, but more often than not he wants to talk about something that happened to him when he was a boy. And then, just before hanging up, he always asks, ‘Do you think about me, do you remember what we talked about?’ And I always reply, ‘Yes, I do.’