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UNEXPECTED GAINS
Tavistock Clinic Series
Margot Waddell (Series Editor)
Published and distributed b y Karnac Books

Other titles in the Tavistock Clinic Series

Acquainted with the Night: Psychoanalysis and the Poetic Imagination
Hamish Canham and Carole Satyamurti (editors)
Assessment in Child Psychotherapy
Margaret Rustin and Emanuela Quagliata (editors)
Facing It Out: Clinical Perspectives on Adolescent Disturbance
Robin Anderson and Anna Dartington (editors)
Inside Lives: Psychoanalysis and the Growth of the Personality
Margot Waddell
Internal Landscapes and Foreign Bodies:
Eating Disorders and Other Pathologies
Cianna Williams
Mirror to Nature: Drama, Psychoanalysis, and Society
Margaret Rustin and Michael Rustin
Multiple Voices: Narrative in Systemic Family Psychotherapy
Renos K. Papadopoulos and John Byng-Hall (editors)
Psychoanalysis and Culture: A Kleinian Perspective
David Bell (editor)
Psychotic States in Children
Margaret Rustin, Maria Rhode, Alex Dubinsky, HClene Dubinsky (editors)
Reason and Passion: A Celebration of the Work of Hanna Segal
David Bell (editor)
Sent Before M y Time: A Child Psychotherapist's View of
Life on a Neonatal Intensive Care Unit
Margaret Cohen
Surviving Space: Papers on Infant Observation.
Essays on the Centenary of Esther Bick
Andrew Briggs (editor)
Therapeutic Care for Refugees: N o Place Like Home
Renos K. Papadopoulos (editor)
Understanding Trauma: A Psychoanalytic Approach
Caroline Garland (editor)

Orders
Tel: +44 (0)20 8969 4454; Fax: +44 (0)20 8969 5585
Ernail: [email protected]
www,karnacbooks.com
UNEXPECTED GAINS
Psychotherapy with People
with Learning Disabi Iities

edited by

David Simpson & Lynda Miller

KARNAC
LONDON NEW YORK
 Firstpublished
First publishedin
in2004
2004byby
Karnac
H. Kamac Books Ltd.Ltd.
(Books)
6118 FinchleyBuildings,
Pembroke Road, London NW3
London 5HT6RE
NWlO
Copyright 8 2004 David Simpson & Lynda Miller
The rights of editors and contributorsto be identified as the authors of this
work have been asserted in accordance with % 77 and 78 of the Copyright
Design and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior written
permission of the publisher.
British Library Cataloguing in Publication Data
A C.I.P. for this book is available from the British Library
978 1 85575 964 0
ISBN: 1-85575-964-0

Edited, designed, and produced by Communication Crafts

CONTENTS

ACKNOWLEDGEMENTS ix
SERIES EDITOR'S PREFACE xi
ABOUT THE EDITORS AND CONTRIBUTORS xiii
INTRODUCTION xix

CHAPTER ONE
The psychotherapy of a little girl with a severe learning
disability and a history of deprivation and neglect
Maria Kakogianni
CHAPTER TWO
Therapeutic dilemmas when working with a group
ofchildren with physical and learning disabilities
Sally Hodges and Nancy Sheppard
CHAPTER THREE
Some thoughts on psychotherapeuticwork
with learningdisabled children and their parents
from orthodox religious communities
Judith Usiskin
vi CONTENTS

CHAPTER FOUR
Facing the damage together: some reflections
arising from the treatment in psychotherapy
of a severely mentally handicapped child
Louise Emanuel

CHAPTER FIVE
Learning disability as a refuge from knowledge
David Simpson

CHAPTER SIX
Adolescents with learning disabilities:
psychic structures that are not conducive to learning
Lynda Miller

CHAPTER SEVEN
The creative use of limited language in psychotherapy
by an adolescent with a severe learning disability
Annie Baikie

CHAPTER EIGHT
The question of a third space in psychotherapy
with adults with learning disabilities
Pauline Lee and Sadegh Nashat

CHAPTER NINE
When there is too much to take in:
some factors that restrict the capacity to think
Elisa Reyes-Simpson

CHAPTER TEN
An exploration of severe learning disability
in adults and the study of early interaction
Lydia Hartland-Rowe

CHAPTER ELEVEN
The endings of relationships between people
with learning disabilities and their keyworkers
Victoria Mattison and Nancy Pistrang
 CONTENTS vii

CHAPTER TWELVE
Ensuring a high-quality service:
clinical audit, quality assurance, and outcome research
in the Tavistock Clinic Learning Disabilities Service
Nancy S w a r d , Sally Hodges, and Marta Cioeta

REFERENCES
ACKNOWLEDGEMENTS

w e would first of all like to acknowledge the enormous

debt of gratitude that we and all the contributors to this
book owe to the people with learning disabilities, and to
their families and carers, on whose experience this book is based.
We would also like to thank all those people-staff, students, and
other colleagues-who have over the years contributed to the
development of psychotherapeutic services for people with leam-
ing disabilities at the Tavistock Clinic. We would particularly like
to thank Nick Temple and Margaret Rustin for the loyal support
that they have given to the Tavistock Learning Disabilities Service
over the years and for their encouragement to write thisbook. We
would also like to thank Margot Waddell, Series Editor, for her
helpful advice with manuscripts. We are, finally, particularly
grateful to Maria Fake, our team secretary, for all the work she has
done in this production.

Authors of individual chapters would like to acknowledge the

following people who have made helpful contributions: Lynda
Miller (chapter one); Valerie Sinason (chapters three and four);
X ACKNOWLEDGEMENTS

Margaret Rustin. Gianna Williams (chapter four); Maria Kako-

gianni, Edna O'Shaughnessy (chapter six); Barnado's staff for their
constant support (chapter seven); Isabel Hernandez Hatton (chap-
ter nine).
SERIES E D I T O R ' S PREFACE

S ince it was founded in 1920, the Tavistodc Clinic has devel-

oped a wide range of therapeutic approaches to mental
health that have been strongly influenced by psychoanalysis.
It has also adopted systemic family therapy as a theoretical model
and a clinical approach to family problems. The Clinic is the largest
training institution in Britain for mental health, providing post-
graduate and qualifymg courses in social work, psychology, psy-
chiatry, child, adolescent, and adult psychotherapy, as well as in
nursing and primary care. It trains about 1,400 students each year
in over 45 courses.
The Clinic's philosophy is aimed at promoting therapeutic
methods in mental health. Its work is founded on the clinical
expertise that is the basis of its consultancywork and research. This
series aims to make available the clinical, theoretical, and research
work that is most influential at the Tavistock Clinic. It sets out new
approaches in the understanding and treatment of psychological
disturbance in children, adolescents, and adults, both as individu-
als and in families.
Unexpecfed Gains describes the Tavistock's pioneering work
with children, adolescents, and adults with different degrees of
xii S E R I E SEDITOR'S P R E F A C E

learning disability and associated mental and emotional problems,

nearly a decade on from Valerie Sinason's vastly influential book,
Mental Handicap and tht Human Condition, which drew so signifi-
cantly on her work at the Tavistock over a number of years. The
chapters in this volume draw on, elaborate, and further explore
this centrally important tradition of bringing psychoanalytic con-
cepts to bear on the opaque, puzzling, and painful states of mind of
the leaming disabled referred for psychotherapeutic help. These
concepts are drawn from a range of professional experience-in
particular, that of insight into the nature of early mother-infant
interactions and their special complexities where learning disabil-
ity is concerned.
The various chapters movingly and challengingly emphasize
the impressive changes that can be achieved within the general
framework of psychodynamic practice. The approach demon-
strates how, through adaptations and innovations of technique,
people and institutions can move towards a greater understanding
of the almost unbearable difficulties of this group of patients, and
also of their potentialities. This is true not only for those individu-
als who have often suffered abuse, abandonment, trauma, failure
of care, and long-term institutionalization, but also for groups of
children and the organizational settings where they are cared for.
The "unexpected gains" of the title result from the work of an
extraordinarily dedicated multidisciplinary and mutually support-
ive Service and offers clear and sensitive evidence of the ways in
which it is possible to improve the quality of life of even the most
deeply disadvantaged.
Margot Waddell
Series Editor
ABOUT THE EDITORS AND CONTRIBUTORS

Annie Baikie trained at the Tavistock Clinic. She currently works

as a Child Psychotherapist at the Royal Aberdeen Children's Hos-
pital, where, as well as working for the Department of Child and
Family Psychiatry and Psychology's generic teams, she works in
both the Specialist Learning Disability Team and the Specialist
Looked After, Adopted and Accommodated Children's Team. She
teaches locally based courses in the Grampian region for the Scot-
tish Institute of Human Relations. Having previously worked as a
drama/movement therapist, she maintains an interest in work
with children and adults with limited language and is particularly
interested in the interplay of non-verbal communication with
the transference-countertransference relationship. She supervises
creative art therapists as far apart as London and Orkney. She was
recently involved in a series of films at the Glasgow Film Theatre,
where issues of childhood were explored from a psychoanalpc
perspective.

Marta Cioeta trained as a Psychologist in Italy and in Psychoana-

lytic Observational Studies at the Tavistock Clinic, where she is
currently training as a Child and Adolescent Psychotherapist and
xiv ABOUT THE EDITORS AND CONTRIBUTORS

working in the Child and Family Department. Her experience

includes working with people with learning disabilities, those af-
fected by eating disorders, and those who suffered abuse. She has
worked as counsellor in primary schools, currently within the
Tavistock Outreach Project in Schools (TOPS).

Louise Emanuel is a Consultant Child and Adolescent Psycho-

therapist, working in the Department of Children and Families,
Tavistock Clinic, where she runs the Under Fives Service. She has a
special interest in working with children with learning disabilities
and staff consultation. She is a visiting lecturer in Ireland, South
Africa, and Italy. She is currently co-editing a book on therapeutic
work with pre-school-age children.

Lydia Hartland-Rowe is a Child and Adolescent Psychotherapist

working in a psychotherapy service for adolescents and at the
Tavistock Clinic in a teaching capacity. She has worked within
services for children, adolescents, and adults with learning dis-
abilities for nearly 20 years, initially as a music therapist and as a
residential social worker. She then provided training for staff
working within voluntary-sector services for people with learning
disabilities as a staff development officer. She has worked as a child
psychotherapist with young people with learning disabilities and
is currently a tutor on the Tavistock Clinic course relating to
psychotherapeutic approaches to learning disability.

Sally Hodges is a Consultant Clinical Psychologist in the Learning

Disabilities Service and autism team of the Tavistock Clinic. She
has ten years' experience working with children and adults with
learning disabilities. She is the organizing tutor for the Tavistock
Clinic's postgraduate diploma in psychodynamic approaches to
working with people with learning disabilities. She has published
papers and book chapters on a range of topics, including autism,
child protection, child development, and feeding difficulties, and
she is the main author of Counselling Adults with Learning Disabili-
ties, published by Palgrave in 2002.

Maria Kakogianni is a Psychologist with the Psychiatric Hospital

of Athens currently working in rehabilitation services for people
 ABOUT THE EDITORS AND CONTRIBUTORS XV

with learning disabilities and psychiatric disorders. Maria also

works for the Hellenic Centre for the Mental Health of Children
and Families: "Perivolaki", a therapeutic unit for children with
autism and pervasive developmental disorders. Maria worked
with the Learning Disabilities Service of the Tavistock Clinic from
1995 to 1999. She is currently studying part-time for a PhD, doing
research on gender and the emotional development of adolescents
with learning disabilities.

Pauline Lee is a Consultant Clinical Psychologist who has special-

ized in two main areas: the mental health of people with learning
disabilities and the clinical psychology of children and adolescents.
She trained and worked originally in Canada, where she was
jointly responsible for developing the assessment and treatment
protocols for a specialist mental health and learning disability team
in Vancouver. Her current assessment and therapeutic work in-
cludes a combination of psychiatric, psychotherapeutic, and behav-
ioural approaches. She is currently head of clinical psychology
services for people with learning disabilities at the Cheshire and
Wirral NHS Partnership.

Victoria Mattison is a Clinical Psychologist working with adults

with learning disabilities in Tower Hamlets, London. Since com-
pleting her clinical training and specialist learning disability place-
ment at the Tavistock Clinic in 1998, she has worked with children
and adults with learning disabilities, and young people at risk of
exclusion from school. Victoria has recently returned to the
Tavistock to complete a diploma in Systemic Work with Families.
She has published two papers about working with adults with
learning disabilities and has co-authored one book, Saying Goodbye:
When Keyworker Relationships End (with Nancy Pistrang).

Lynda Miller is joint Head of the Tavistock Clinic Learning Dis-

abilities Service and Consultant Child and Adolescent Psycho-
therapist in the Adolescent Department of the Tavistock Clinic. She
also works as Principal Child and Adolescent Psychotherapist in
the Child Guidance Service in Enfield. She teaches on preclinical
and clinical training courses at the Tavistock and in Bologna, Italy,
and has published papers in the United Kingdom and in Italy.
xvi ABOUT THE EDITORS AND CONTRIBUTORS

Sadegh Nashat is a Chartered Clinical Psychologist who initially

trained at the University of Geneva. He has done further training at
the Institute of Psychology in Paris in personality assessment and
projective techniques and has a particular interest in ethno-cultural
issues in psychotherapy. He is currently working at the Tavistock
Clinic in partnership with the Camden Local Education Authority
Behaviour Support Service, working mainly with children who are
at risk of permanent exclusion and with their families.

Nancy Pistrang is a Senior Lecturer in Clinical Psychology at

University College London. She obtained her PhD in clinical psy-
chology from UCLA, after which she worked as a clinical psycholo-
gist in the British National Health Service before taking up her
present position. Her research focuses on psychological helping in
everyday relationships, including communication in couples, non-
professional helping, and mutual support groups. In addition to
publishing in a range of psychological journals, she has co-
authored two books, Research Methods in Clinical Psychology (with
Chris Barker and Robert Elliott) and Saying Goodbye: When Key-
worker Relationships End (with Victoria Mattison).

Elisa Reyes-Simpson is an Adult Psychotherapist and a Senior

Lecturer in Social Work at the Tavistock Clinic. Following a degree
in psychology and experience of working with adolescents, she
undertook a masters' degree at the Centre for Contemporary Cul-
tural Studies at Birmingham University. After training in social
work, she worked in adult mental health. She also has a private
psychotherapy practice.

Nancy Sheppard is a Clinical Psychologist working in the Learn-

ing Disabilities Service and Children and Families Department at
the Tavistock Clinic. She has worked with adults and children with
learning disabilities since qualifying as a Clinical Psychologist in
1996 and currently organizes the learning disabilities module on
the University of East London Doctorate in Clinical Psychology
course. She is also involved in the Post-Graduate Certificate in
Working Psychodynamically with People with Learning Disabili-
ties set up and run by the Learning Disabilities Service at the
Tavistock Clinic. She is course organizer for specialist placement in
clinical psychology and has published several papers and reviews
relating to working with people with learning disabilities. She has
contributed three chapters to Counselling Adults with Learning Dis-
abilities, published by Palgrave in 2003.

David Simpson is joint Head of the Tavistock Clinic Learning

Disabilities Service. Following a background in paediatrics, he
trained in psychiatry at the Maudsley Hospital. He is a Consultant
Child and Adolescent Psychiatrist and Programme Director for
Specialist Training in Child and Adolescent Psychiatry at the
Tavistock Clinic and is Honorary Senior Lecturer at the Royal Free
and University College London Hospital Medical School. He is a
Member of the British Psychoanalytic Society and works in private
practice as a psychoanalyst.

Judith Usiskin trained as a Child and Adolescent Psychotherapist

at the Tavistock Clinic. She has been a member of the Learning
Disabilities Service since its inception, and she has lectured and
taught widely, both in the United Kingdom and abroad, on work-
ing with people with learning disabilities. She divides her time
between the Tavistock Learning Disabilities Senrice and the Young
Abusers Project, a forensic psychotherapy resource offering assess-
ment and treatment for children and adolescents with sexually
hannful behaviour.
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