Book review ‘Finding a Way to the Child: Selected Clinical Papers1983-2021’ by Margaret Rustin (eds Kate Stratton,Simon Cregeen). Routledge 2023

Meet Vorjat from Kosovo. He is 15. His father had been kept prisoner and beaten by Serb soldiers, his older brother – a clever law student and political activist – disappeared, his disfigured dead body later discovered by mother. Then paramilitaries burst into the family home and raped mother in front of Vorjat and his younger sister. Father, by then back home, rejected his wife. The family home was burned to the ground. They fled to London.

Vorjat is “a tidy, very clean, polite boy in school uniform” who tells his psychotherapist, Margaret Rustin, that everyone in his family is sick. He and his sister have to take responsibility for their parents. At school he is often abused for being a refugee: “go home, you are taking our houses, why does your father not work?” He is provoked into fights. When asked if he can talk to anyone he says “nobody knows about me”. He is very tense and says he felt sick on the bus coming to the clinic. The next week is half term, and he misses his session because of his confusion about that. During that week the Home Secretary announced that asylum seekers who have been here for more than three years can stay.

At the next session 25 minutes have passed before he can tell his therapist this news; but the letter confirming the family’s changed status has not yet arrived. Mrs Rustin links feeling sick on the bus to his frightening journey across Europe under a tarpaulin in the back of a lorry, always at night. Now we are beginning to meet the therapist too, as she wonders to herself if his failure to attend the second appointment reflected his doubts about her reliability. “To my surprise” she writes, “as he left he said ‘see you next week, if you haven’t forgotten me’ which exactly expresses this point”.

“When good news arrives, it seems to offer an opportunity for a part of himself that has gone into a kind of hibernation to reappear. But that is a very dangerous moment”. A few weeks later the Home Office letter has arrived and Vorjat happily describes how his father woke him to give him the news, yet at the same time he had a terrible stomach pain; “the unbearably painful quality of taking in something that might lead to growth and change.” We get to know more of Margaret Rustin as the work proceeds. There were several cancelled sessions; “when Vorjat did not come ... I am put in touch with the sort of experiences he has had in recent years of not knowing what is going to happen to him ...The dread I am aware of in the mornings of his session is intense”.

For readers unfamiliar with psychoanalytic therapy these may seem exaggerated reactions. Surely the task is to support the patient, and not be overwhelmed by his terrors. Yet what Rustin is doing is attending as carefully and deliberately to her own emotions as to the patient’s, on the grounds that she may be more aware of what is shared between them than he is. “I had to ask myself the question as to whether his absence was related to unconscious anger which could only be expressed in this passive way”. She is not overwhelmed, and comments candidly on her own surprising animus against her colleagues “what intrigued me was my irrational anger with my colleagues who of course were playing their part in looking after this distressed family but appeared to me as competitors for the opportunity to do any effective work”. Had she not understood the actual source of her irritation, this reaction could have led to conflict with her team and others involved in this case. Such partitions in professional networks are most likely when they are dealing with trauma or abuse that cannot be thought about, reflecting splits in the patient’s mind. Colleagues may then unwittingly find themselves acting parts in the family’s drama (Britton, 2005). Instead, Rustin obtained valuable information about Vorjat’s inability to show any negative feelings towards her.

Why need he express negative feelings towards his psychotherapist? Because if there is to be real therapeutic progress it is not sufficient to leave the harm done to the patient ‘out there’ in Kosovo, or even at home or at school. The psychoanalyst Wilfred Bion, a dominant figure in the pre-NHS Tavistock, coined the term ‘nameless dread’ for experiences that are too awful to contemplate. If they can be named, the dread is, as Rustin puts it, “defused of some of its power and can then be investigated”. Psychoanalysis aims to bring such matters into the room where they can be felt, here and now, yet “the pressure on the therapist to focus too much attention and feeling on external problems was continuous”. After enduring such merciless cruelty and loss, how could anyone expect Vorjat readily and wholeheartedly to trust an offer of help, however attentive it may be?

Vorjat “faced me with a state of depressed inertia, which I would describe as a psychic failure to thrive. The perpetual threat of the death of the therapy was the core clinical issue… I believe what helped me was the effort to describe – to find words for my thoughts and observations, the majority of which were private to myself, part of an internal conversation. Without this process of thinkability, such young people are vulnerable to dangerous degrees of violent emotion”. Rustin notes that “two of the would-be bombers in London on 21 July 2005 had fled as young adolescents from horrific civil wars in Eritrea and Somalia.”

This is the first of over twenty case presentations, some in great detail, in a selection of Margaret Rustin’s clinical papers from 1983 to 2021, all from NHS practice. The narrative carries the reader along; these are real life accounts of work between two people, written from the point of view of one who is determined to understand the other, in order for them to understand themselves. The seemingly simple idea that you need another mind to make sense of your own is the basis of modern psychoanalysis, the training for which begins long before any patient is seen. Infant observation (which will feature in a later volume of Rustin’s writings) was devised in the 1950s in the Tavistock Clinic by Esther Bick (1902–1983), who realised that observing one’s own emotional response to another person – especially someone who cannot speak – was a necessary condition for becoming a therapist. Infant observation is now a foundation of psychoanalytical psychotherapy trainings around the world, for all ages of patients. The immediate contact that infants make with their caregivers is a highly evolved and life-saving force (Hrdy & Burkart, 2020), and remains fundamental in our most important relationships throughout life. It is this form of communication that is privileged in psychoanalysis.

In her preface Margaret Rustin describes the transformative experiences of her own analysis and of her training at the Tavistock Clinic by the brilliant first generation of child psychotherapists, including Esther Bick, who had been appointed to set up the training by John Bowlby, the first post-war director of the children’s department. “Encountering the inner lives of my child and adolescent patients … led to an awed realisation of the immense potential for development which rested in the transference relationship”. Under Rustin’s leadership from 1985 to 2009, together with many other gifted colleagues on the Tavistock staff, later generations of child psychotherapists have followed her out of the therapy room into active participation in CAMHS teams and into consultations with colleagues in the community, while always returning to the clinical encounter where most learning takes place. Though far from universal, child and adolescent psychotherapy is, thanks in large measure to the Tavistock training in earlier decades, a recognised and evidence-based part of the CAMHS workforce (Midgley et al., 2021). It is one of the core psychological professions in the NHS, five hundred strong - and growing - with another 230 in NHS-funded trainings and yet more working with looked after children, early years and schools, youth justice and in the voluntary sector. The training is regulated by the Association of Child Psychotherapists. More than any other child and adolescent mental health profession, child psychotherapists have the capacity to stay with the child’s experience when others are diverted by diagnostic or systemic matters, however important these may also be.

Margaret Rustin can be critical of prevailing principles, such as the notion of ‘partnership’ in therapy, which she says may “avoid recognising dependence on the therapist”, adding that “the right of patients to be fully informed is sometimes interpreted in such a way as to reduce the right to be understood”. In a powerful dissection of the short life of Victoria Climbié (1991–2000), tortured and murdered by her great aunt and her boyfriend (as described by the Laming Report, chapter 9), Rustin notes how often professionals did not register their “gut feelings” and thus failed to tell anyone else about them. “It was very rare in this case that two people got together to think about what was going on … the whole system ended up as powerless as Victoria”, a tragic example of professional re-enactment.

Without the ethical obligation to pay attention to how we are made to feel, important information will be missed, and errors of judgement are more likely. It is possible to learn to respect our reactions to both colleagues and patients without going through intensive psychoanalytical training, but there is little encouragement to do so. Reflective practice (Kraemer, 2018; Rustin, 2009) and group relations experience (Wallach, 2019), all pioneered in the Tavistock Clinic, promote powerful learning from which all mental health professionals can benefit.

These fourteen chapters by Margaret Rustin provide unique access to the life’s work of a national and international leader in the field of psychoanalytical psychotherapy for children and adolescents, following her thinking as it has developed over four decades. There is more to come.