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Journal of Child Psychotherapy

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An application of Bion’s theory

of thinking and transformations
in hallucinosis. An experience of
supervision with Dr Donald Meltzer
a
Ricky Emanuel
a
Royal Free Hospital , Pond Street, London , NW3 2QG , UK
Published online: 20 Sep 2012.

To cite this article: Ricky Emanuel (2012) An application of Bion’s theory of thinking and
transformations in hallucinosis. An experience of supervision with Dr Donald Meltzer, Journal of
Child Psychotherapy, 38:3, 284-301, DOI: 10.1080/0075417X.2012.720102

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 Journal of Child Psychotherapy
Vol. 38, No. 3, December 2012, 284–301

An application of Bion’s theory of thinking and transformations in

hallucinosis. An experience of supervision with Dr Donald Meltzer
Ricky Emanuel*

Royal Free Hospital, Pond Street, London NW3 2QG, UK

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I hope in this paper to show how Bion’s theory of thinking and his later theory of
transformations in hallucinosis, enabled psychotherapy in a special school setting
many years ago to be undertaken with a psychotic child who was constantly
hallucinating. The work was carried out under the expert supervision of Dr
Donald Meltzer who managed creatively to employ these theories to help me
make sense of what seemed like incomprehensible communications. Bion’s
theories were indispensable in being able to make sense of non-sense. I hope to
illustrate the nature of hallucination where according to Bion, the sense organs
operate in reverse: showing how the function of hallucination is to provide an
alternative to thought about absent objects or ‘no-things’. The distinction between
thought based on the capacity to bear the frustration about the absence of the ‘no-
thing’ long enough to discover its meaning, is contrasted with the immediacy of
hallucination where the ‘meaning’ is already ‘known’. The nature and function of
naming is explored along with its precursor: the binding of phenomena. I also
discuss how rare it is nowadays for child psychotherapists to treat children like this
as they tend to be medicated and not referred for psychotherapy.
Keywords: Child psychotherapy; psychotic children; hallucination; theory of
thinking

Introduction
Meltzer writes, ‘Bion has given us the possibility for developing instruments for
recognizing and dissecting mental operations within us’ (Meltzer, 1984: 118).
Without Bion’s theory of thinking and the concepts of beta and alpha elements,
container/contained and his description of the formation of the mental apparatus
required to process and think about emotional experiences, we would as child
psychotherapists, have been unable to work with some of the most disturbed
children that we now see. The capacity to undertake psychotherapy with severely
deprived children, now the mainstay of the caseload of child psychotherapists, arose
directly from these theories (Boston and Szur, 1983).

Bion’s theory of thinking and reversibility of the senses

Bion describes how the raw sense data of bodily emotional experience, (the ‘things-
in-themselves’ called beta elements), have to be processed by the apparatus of alpha

*Email: ricky@emanuel1.net

ISSN 0075-417X print/ISSN 1469-9370 online

Ó 2012 Association of Child Psychotherapists
http://dx.doi.org/10.1080/0075417X.2012.720102
http://www.tandfonline.com
 Journal of Child Psychotherapy 285

function and transformed into alpha elements if they are to be stored, dreamt or
thought about at increasing levels of abstraction.
The key determinant according to Bion, of whether an emotional experience can
be modulated through the process of thought, or evaded by means of the range of
defences including the most extreme methods used in psychotic functioning, is the
degree to which frustration can be tolerated. He believed this capacity arises from
both genetic and environmental sources.
In his theory of thinking, the first thought arises from the felt, absent object, the ‘no
thing’. He writes, ‘Sooner or later the wanted (good) breast is felt as an idea of a breast
missing and not a bad breast present . . . If there is no ‘‘thing’’, is ‘‘no thing’’ a thought
and is it by virtue of the fact that there is ‘‘no thing’’ that one recognises that ‘‘it’’ must
be a thought?’ (Bion, 1962: 35). The person has to be able to tolerate the experience of
frustration caused by the absence of an object long enough for him to discover what it
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is that is absent. If the frustration is so intolerable, the no-thing experience is evaded, as

the absent object becomes the present persecutor, which has to be evacuated as a beta
element. ‘Intolerance of frustration could be so pronounced that alpha function would
be forestalled by immediate evacuation of the beta elements’ Bion (1962: 35).
Beta elements, which have not been able to be worked upon by alpha function, can
only be evacuated through somatic innervations as in psychosomatic presentations or
bodily disturbance, acted out in behaviour or basic assumption group functioning or
hallucinated. Bion described how in hallucinatory phenomena or transformations in
hallucinosis, the sense organs can work in reverse. Reversibility as a concept was used
in different ways in his theories, e.g. talking can be a means of communication or the
muscular apparatus of the mouth can be used reversibly to rid the mind of accretions of
stimuli in a evacuative, semantically meaningless way. He described how all the senses,
or for that matter any type of thought or activity using his theory of positive and
negative links, can be employed in the service of processing and thinking about
emotional experiences or its reverse, the evacuation or distortion of mental experience.
Thus the eyes for example can function as cameras to receive sense data to be worked
upon by alpha function so that meaning can be discerned, or they can be used as
projectors to evacuate beta elements which have not been able to be processed. Using
his concept of alpha function operating in reverse, Meltzer describes how an emotional
experience can start to be worked upon by alpha function but the pain this gives rise to
as the meaning of the experience is revealed or the frustration it involves, leads to a
cessation of the processing. The nascent thought is destroyed and its debris evacuated.
However, unlike pure beta elements, parts of the proto-thought cohere. He writes,

We may see something analogous to this when we observe a child trying to build
something with Lego. He starts constructing something and then, at a certain point, he
becomes discouraged or anxious and he smashes it to pieces. But the smashing does not
just disintegrate the construct into individual pieces of the Lego but rather into partial
structures . . . These little pieces are not meaningless primary shapes for they retain
traces of automobile-ishness . . . they are beta elements with ‘traces of ego and superego’
i.e. shreds of meaning.
The debris is then evacuated through the reversal of sensory functions as with
hallucinations. When they are taken in again they are perceived as already having shreds
of meaning bound to them. Therefore the patient does not perceive events and objects
that he needs to think about in order to derive meaning – he perceives objects with the
meaning already contained.
(Meltzer, 1986: 107)
 286 R. Emanuel

The same reversible function can be applied to all the senses. These ideas, whilst
seeming abstract and difficult to comprehend, were essential tools that were needed
to make sense of the emotional experience of working with severely ill children. It is
this that I now want to illustrate.

Max
In my clinical training as a child psychotherapist in 1978, my first post was in what was
called then a School for Maladjusted Children (now SEBD). There was a full CAMHS
team in the school. I worked as a trainee in the school and mostly tried working with
highly disturbed, acting out and violent young people. It was hellish, with the therapy
room constantly under attack from within and without and the most I could do the
majority of the time was to try and protect the setting. And then Max was referred to
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me. He should never have been in such a vicious school environment but no one knew
where else to place him. He was a nine-year-old psychotic boy from an immigrant
family where seeming ‘possessed’ was less odd than in our culture. In setting up
psychotherapy cases in the school, we tried to meet with the parents first in the usual
way. In this setting, most of the parents were, it turned out, so disaffected or uninvolved
with their children that this was in fact a rare occurrence. Consent was obtained via the
school’s psychiatric social worker who would visit the family and gain consent for the
therapy from them. Since the CAMHS team were an integral part of the school staff,
parents knew when their children were admitted to the school that they might be
offered therapeutic interventions. We offered review meetings but I can remember few
parents who would ever turn up for them. It was also extremely difficult to get a proper
history of the child except the usual meagre amount in their files. This did not often
contain much relevant information. Max’s parents did not want to meet with me but
his father agreed for me to see him as part of his school life. I met his father only once
during the whole time I saw him. I never met his mother and she was hardly mentioned
by Max. I knew he had a younger brother. His father was forever studying for the time
he would return to his home country. He was too busy to come to meetings in the
school, let alone meet with me. This is highly irregular in today’s CAMH services and
we probably would not begin a case under these circumstances, but often this was the
only way any intervention at all could be offered. In terms of background information
therefore, we worked in the dark except for occasional information gleaned from the
school social worker about home life. Mostly the parents would not be in when the
social worker visited.
I started seeing Max twice a week. He seemed to live in a constant state of
hallucination. He would scan the ceilings and sky, writing furiously in the air with his
finger or pencil, laughing inappropriately or seeming frightened, crouching in corners, and
at other times lost and bewildered. He was virtually mute, restless and ineducable. There
was no way he could be taught in the class as he roamed about, grimacing or laughing,
again looking up at the ceiling and writing in the air or hiding in the corners. His material
in the sessions was entirely incomprehensible to me. Here is a flavour of his early sessions
with me. I am embarrassed to read them now as I tried valiantly offering him Kleinian-
type interpretations to which he hardly reacted and which I will spare the reader.

Having entered the room for his first session, with a fixed false smile on his face, he
starts mentioning children’s names who come to the school . . . He takes a truck I have
left for him and moves it around in space, then towards me, saying a list of children’s
 Journal of Child Psychotherapy 287

names. He mentions the bus. He takes a pen and writes the first two letters of each
child’s name. On another sheet he writes ‘we are going, [labouring for a long time on the
ing of going] home’. I say feebly, he will see Mummy and Daddy at home. When I
mention the word Daddy he scribbles very hard. I say Max got cross when I mentioned
Daddy. He says, ‘‘Max is cross, Daddy is cross with Max’’. ‘‘Don’t write, don’t write!’’,
he shouts as if this was what Daddy was cross with.

It is noteworthy that he spent most of his time writing either on paper or in the air.

Later he becomes interested in the big and baby crocodile and the big crocodile was going
to bite the baby crocodile. He shows me the mouth biting. I ask why the big one wants to
eat the little one, is this the cross Daddy? Max says, ‘‘No he won’t eat it’’, but a chase ensues
and he intones the word crocodile breaking it up into Croc-o-dile over and over again. I
make another lame interpretation, but this chasing game goes on and on as he names other
children, and says, ‘‘Silly Max’’, ‘‘fucking crocodile’’, ‘‘don’t swear’’, ‘‘fucking hell’’. He gets
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some paper and writes a few names of children, the word ‘fking’ and strange little figures
and scribbles [Figure 1]. He begins making very bizarre body movements, quick staccato
movements with his eyes open wide. He stares just above my head, surveying the room as if
it were peopled all around. He then draws the name Kenny – Winston but the last ‘n’ of
Winston starts to liquefy and has a little tail attached to it. He begins moving around the
room with eyes wide open and grimacing, falling about as if being hit about the face and
body. I say perhaps he feels he is in the middle of a fight between Kenny and Winston and it
is happening inside him in his mind. He said quickly, ‘‘On your mind, on your mind, spell
mind, mmmm, spell mind’’. He got up and came over to me prodding me with a pen,
bringing me a piece of paper and ordering me to spell mind. He writes it out himself, ‘mind’,
then ‘on your mind’ and says it over and over again. He then looks around the room, sucks
his thumb and crumples to the floor. It felt overwhelming and intensely confusing.

He would dismantle words, intoning the word croc-o-dile and sometimes corrupt this
word, saying ‘‘rarorile’’ over and over again laughing as he did so. In another session
later that week he started speaking coherently saying – ‘‘he went to the zoo – Max
was crying – ate no lunch – cake and custard in Rosaleen’s room – see Ricky time’’. I
tried to clarify why he was crying but he did not reply except to say, ‘‘E said slide,
Eslide, E. . . Slide’’. He drew a strange picture saying, ‘‘E slide’’ as if something were
sliding right off the edge of the box of toys into space. This idea of things sliding,
ESlides or he slides, down an edge into space, became comprehensible later on.
O’Shaughnessy writes,

According to Bion, the psychotic personality has its origin in the fragmentation
followed by the expulsion of the means by which the ego knows reality; that is, the

Figure 1. Scribbles from an early session.

 288 R. Emanuel

fragmentation and expulsion of the senses, consciousness and thinking . . . Instead of

beginning to develop a mind for thinking, it is likely that such a psyche has become an
apparatus for ridding itself of bad objects. It does this by minute fragmentation and
projection of incipient thoughts, sensations and also the sense organs which threaten to
bring awareness of internal or external reality.
(O’Shaughnessy 1991: 91)

She goes on to say that for the psyche to function psychotically, it requires both an
inborn disposition and an interaction with an adverse environment. She describes
how the therapist has to tolerate the ‘obscurity of many of the patient’s
communications and the amount of incomprehension’ this entails. This was
extremely difficult for me in my first year of clinical training. I tried to get help
from all the supervision groups and supervisors I had at the Tavistock, hoping that
someone could make some sense of what Max was communicating, often wondering
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if there was sense to make of it or whether I was being bombarded with evacuated
meaningless beta elements in beta screens.
Most supervisors attempted to ascertain some meaning using our usual Kleinian
theories but none of them had any effect on Max as I hopelessly tried them out. Bion
talks of the need to get the meaning exactly correct with the psychotic as they lack a
capacity to intuit the nuanced meaning from a communication in the way that a
more neurotic patient can. A miss is as good as a mile. Most of what I said seemed to
miss the target and Max ignored it.
No one could help me with this boy yet Max loved coming to see me, probably as
an escape from the hellhole that the school environment was for him. He was
mercilessly taunted and tormented as a ‘nutter’ but he hardly seemed to register this.
On one occasion, he was locked by the bullies in the stock room and made to eat a
‘chocolate’ dog faeces sandwich.
Then one day after complaining about the impact of this relentless incompre-
hensibility on me to my analyst, she suggested I contact Dr Meltzer. He had given
some lectures to us on the course but he was not someone I felt I could approach.
She encouraged me to write to him explaining my predicament and asking if he could
provide me with a consultation about Max. To my immense surprise after writing to
him, he contacted me immediately and invited me to come and present Max in a
seminar he was running at his home with qualified child psychotherapists on work
with psychotic children. This in itself was daunting to attend as it contained some of
my senior analytic siblings not to mention him, but nevertheless I went along and
was welcomed into the group albeit as the only trainee. Luckily for me, Dr Meltzer
was fascinated by Max’s material and he asked me to continue to present on a
weekly basis to the seminar as he felt we could all learn a lot from Max.
He would listen carefully to the sessions I would present, which were so
fragmented they were difficult and nearly impossible to write up and he would pore
over the myriad of drawings and lists Max produced. As he listened, he would close
his eyes in intense reverie and gradually he seemed to find a way into the material
unlike anyone else I had encountered. He subsequently wrote about the case in a
chapter in his book, Dream Life (Meltzer, 1984) called ‘The borderline between
dreams and hallucinations’. My descriptions below are derived from some parts of
this chapter and I will not quote it on each occasion. I hope to show now how he
made sense of what mostly I encountered as non-sense.
The initial months of Max’s therapy were filled with sheet after sheet of chaotic
scribbles amidst which there appeared strange little drawings that seemed to be the
 Journal of Child Psychotherapy 289

start of longhand writing but also printed names usually of children, my name, his
name or Daddy (Figure 2). It was notable that Mummy was hardly mentioned and
as I said above, I never met her in external reality either.
I have described how he stared into space or the upper spaces of the room and
this was where my attention was often drawn.
As he got used to being in the room with me, Max began to assign me tasks in
relation to a more systematic listing of children’s names. I had to read out the names
or ask specific questions such as, ‘Who goes on the bus?’. This referred to the special
school bus he travelled on. He would then list the names including the people who
were not there – No Pat. No Tess etc, amongst the list (Figure 3).
Sometimes I had to ask questions like, ‘‘Where is Sharon?’’ when her name was
not on the list of the children in the school bus or in assembly.
He would sometimes list the names of the No Children (Figure 4).
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I would have to answer his question for example, ‘‘Where is Sharon?’’ with the
reply, ‘‘Sharon is in Ireland’’, or ‘‘Where is Eddie?’’ ‘‘Eddie has gone to a children’s
home’’, according to where they were (Figure 5).

Figure 2. A sample listing of names with some disintegration.

Figure 3. Who goes on the bus.

 290 R. Emanuel

Figure 4. Listing of No Children.

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Figure 5. Listing of children incorporating answers to where they were.

 Journal of Child Psychotherapy 291

But it became clear that Ireland would also mean up, as whenever I said where
the child was, Max would scan the ceiling. (Notice the word Mixed Up, with the
words Mixed and Up separated, on the drawing in Figure 5, as I had started to talk
to him about this state of mind.) Alternatively ‘No Anthony’ might be at ‘Building
school’ (Boarding school) and up would go Max’s eyes searching as with ‘No Eddie’,
‘In children’s home’.
As I mentioned, Max not only scanned the air, but he also made writing
movements there, sometimes with his finger but mostly with a pencil in his hand or
directly on the paper. You will remember Daddy’s admonition, ‘‘Don’t write’’!
This list making and hallucinating/writing activity went on interminably until
one day Max brought two books into the session from a reading series in the
classroom, both about a squirrel called Bushy. He would write out sequences from
the book on paper as well. In one book Bushy was bullied by ‘Bully’, while in the
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other he was tormented by the ‘Silly Fly’. This tormentor always says, ‘‘Watch me’’
and ‘‘Look at me’’ and ‘‘You can’t catch me’’ (Figure 6).
In one list the couplet ‘Bushy Fly’, was written and underneath the couplet ‘Bully
You’ (Figure 7).
Dr Meltzer then made the astonishing leap, that the hallucinated objects who
were watched and looked at like the Silly Fly, were connected to the bullying ones, as
it was in fact true that these bullying children like Anthony, (who when he was No-
Anthony was said to be at ‘Building School’) were in the air. It was a fact that very
aggressive children who disrupted the classes and harassed other smaller children
were liable to be sent to boarding school. Bion writes,

To appreciate hallucination, the analyst must participate in the state of hallucinosis . . .

By eschewing memories, desires, and the operation of memory he can approach the

Figure 6. Writing from the Bushy/Bully/Silly Fly books.

 292 R. Emanuel
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Figure 7. The couplet Bushy Fly in close association with Bully You.

domain of hallucinosis and of the ‘acts of faith’ by which alone he can become at one
with his patients’ hallucinations and so effect transformations O!K.
Bion (1970: 36)

I think Dr Meltzer was able to do exactly this, to dwell in Max’s psychotic world and
from the ether or O, transform meaning to me, a transformation in K, which I could
then transmit to Max.
In another extraordinary leap of imagination or what may be described as an
ability to reside in the domain of hallucinosis, Dr Meltzer was able to discern the
source of Max’s hallucinations and state of persecution by the absent children. He
noticed that in writing the names of children, Daddy or myself, there appeared a
tendency for writing to disintegrate into letters followed by a squiggly line. We saw
this in the earlier material I quoted: how when Max enacted being in the middle of a
fight with Kenny and Winston the last ‘n’ of Winston fragmented and Max looked
up at the ceiling. Instead of a list of people or no-people existing on the page, the
writing of the names would start to fragment and becomes letters and squiggles.
Letters would break off names and become little round heads with wiggly tails,
which was followed by Max searching the upper air (Figure 8).
For example, see in the images below how the O from Dino breaks off and floats
off in the picture below. My name intact on the top left is breaking up on the bottom
right and being dismantled into Ric and Daddy and other names liquefying in the
next image. There are also strange symbols with little heads perhaps with legs below
and feelers reminiscent of the drawings in the Bushy/Silly Fly books (Figures 9
and 10).
These letters, took on a life of their own, in the space above us, like the Silly Fly
hovering calling out, ‘‘Watch me’’ which Max obeyed. Whole names including his
own could slide off the line and into the air and presumably become hallucinations
(Figure 11).
 Journal of Child Psychotherapy 293

Figure 8. Names fragmenting or liquefying.

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Figure 9. Letters breaking off names.

Figure 10. Further drawings of names breaking up.

The earlier references to E Slide or he slide, became understandable as a

description of the letters or names sliding off the page into space, like the E slide
down the edge of the box he depicted in earlier sessions.
 294 R. Emanuel

Figure 11. Whole names sliding off the lines.

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Figure 12. A combination of names and Silly Fly drawings.

Dr Meltzer felt that the listings were enabling Max to ‘fix’ or bind his
hallucinated persecutors on the paper, but they had a tendency to lose their
definition and escape from the paper back into the air.
The process would be endlessly repeated, ‘pulling’ them back from the air onto
the paper by drawing or writing them onto the paper or in the air, only for them to
slide off again.
This process was becoming clearer along with an understanding of the link
between the shape of the Bushy and Silly Fly drawings (see below) resembling the
squiggly shapes seen in the combination of children’s names and squiggles (Figures
12 and 13).
These ideas enabled Dr Meltzer to help me formulate the Bushy/Silly Fly/Bully
Stories to describe to Max what was happening to him in his hallucinated and
persecuted or ‘delighted’ states.
I felt like Little Hans’s father acting as a surrogate for Dr Meltzer in the sessions
as there was no way I would have ever been able to come up with these types of
formulation. It requires the capacity to reside in the domain of hallucinosis that few
of us possess.
 Journal of Child Psychotherapy 295

Figure 13. Tadpole like squiggles with some Silly Fly characteristics.
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Figure 14. Tadpole like creatures from drawings in early months of therapy.

As I talked to Max about these things, his behaviour in the classroom changed
noticeably, he became less restless and more cooperative and less often hallucinated.
These formulations also made sense of the earlier compulsive writing in the air,
intended as a process to catch the persecutor and bind it with its name, to be fixed on
the page like a butterfly held by pins on paper. Unlike a butterfly pinned down, his
persecutors escaped their bondage and flew back up, only for the process to be
endlessly repeated. The process also could be recognised in retrospect in the tadpole-
like creatures, which had inhabited his drawings in the initial months of therapy
(Figure 14).
These hallucinated forms were highly persecutory but they also provoked laugher
and grimacing, but now with a ‘borrowed form’ from the Bushy/Silly Fly stories,
they could begin to be described, named and so, thought about.
Bion writes,

‘meaning’, which could not be grasped outside the conditions of hallucinosis, was
perfectly clear in a state of hallucinosis. The ‘meaning’ of a statement in hallucinosis is
not, however, the same as its meaning in a domain of rational thought. Ordinarily,
constellation, constant conjunction and binding (by nomenclature) are a prelude to
exploration of meaning. In the domain of hallucinosis the mental event is transformed
into a sense impression and sense impressions in this domain do not have meaning: they
provide pleasure or pain. In this way the unsense-able mental phenomenon is
transformed into a beta element which can be evacuated and reintroduced so that the
act yields, not a meaning, but pleasure or pain . . . Meaning is lost, pain and pleasure are
 296 R. Emanuel

gained, from a state that is independent of proximity to an object and of the frustration
peculiar to thoughts and their genetic association with the ‘no-thing’
(Bion, 1970: 37)
A name is used to bind phenomena that are in Bion’s terms, ‘constantly conjoined’
and is ‘used to prevent the scattering of the phenomena. Having found the name and
thereby bound the phenomena, the remainder of history, if so wished, can be devoted
to determining what it means; . . . the name is an invention to make it possible to
think and talk about something before it is known what that something is’ (Bion,
1963: 87).
It can be seen with Max, that the binding process or fixing on the page, may be a
necessary precursor for the name to be given so that thought about it becomes
possible. The bizarre objects described above, also contain traces of ego functions
and superego aspects, so the hallucinated, bizarre objects can carry out some of the
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projected ego function, e.g. ‘watch me!’ as the silly fly objects proclaim.
Max was unable to distinguish that the thing that was not there, the no-children,
the absent objects, were different from things that are there. Bion writes,

Where one patient (who is capable of bearing frustration) (my italics) would understand a
word to mark a constant conjunction, this patient (one who is incapable of bearing reality

Figure 15. Naming of emotional experiences.

 Journal of Child Psychotherapy 297
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Figure 16. Controlled dismantling of words.

and frustration) (my italics) experiences it a thing that is not there, and the thing that is
not there, like the thing that is there, is indistinguishable from a hallucination.
(Bion, 1970: 9)
Naming and describing this whole process of binding, fixing and the tendency for
those objects to escape their bondage and become free hallucinations for Max,
enabled him to be more able to clearly define the difference between ‘Is-there’ and
‘wasn’t-there’ in lists, without persecution.
The absent objects did not become present persecutors in the same way, but
became able to be transformed into thoughts that could be used for thinking about
his emotional experiences like the persecuting bullying.
He could think about his identification with Bushy being bullied by Fly, a real
present object, instead of by hallucinated absent ‘no-Silly Fly’ children. He could
think about children hurting each other, rather than enact this or exist in the middle
of them as he had in the beginning. As shown below, he could label aspects of his
experience by means of writing, using the personal pronoun I, to show how he felt he
was getting lost, ‘I am getting lost’, and then more impersonally, ‘Maxwell is getting
lost’ (Figure 15).
 298 R. Emanuel

He was also now almost able to think how about how words could become de-
constructed or split, letter by letter under his control, instead of exhibiting the
fragmenting, disintegrative tendency they had before (Figure 16).

Later work
Max improved significantly so that he was able to be moved out of the school to a
school for moderate learning difficulties. I began seeing him in the local clinic where I
worked and he was brought by an escort to see me twice a week. His therapy became
more like that of a seriously disturbed child, rather than the chaos of work with a
psychotic child. O’Shaughnessy describes, following Bion, how the psychotic patient
attending for therapy also has a non-psychotic personality but that progress is
different from a more normal patient.
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If the patient’s projections are received and understood, he may begin to feel less
isolated and persecuted and his splitting may lessen. This may lead to an attempt to
think, which is an essential part of the repair of his ego. This involves permitting entry to
perceptions and projected bits, a process often experienced as an assault: the patient
feels struck in the eye, or jabbed elsewhere (cf. Max jabbing at me with pens from earlier
sessions), twitches, or may get a headache. Return of some awareness brings a new
condition internally and externally . . . This can gradually lead to the patient sustaining
more human contact with whole objects and an increased ability to think and use verbal
thought in place of action projective identification.
(O’Shaughnessy, op. cit.: 97–8)
Here is a fragment from my session notes with Max aged 13, six years after beginning
treatment with me.

In the room he scrutinised me, commenting, ‘‘You always do that’’, moving his hand from
side to side. I tried to clarify what he meant and finally clicked he meant he was referring to
me sliding the engaged sign on. He seemed muddled today and verbalised – ‘‘I can’t think’’.
He seemed blocked up and I asked if he had something on his mind. ‘‘No’’. He tried to
begin to sort out his old drawings based on the date on them saying they were ‘‘mixed up,
not in order’’. I had noticed a recurrence recently of some of the older symptoms, staring at
the ceiling, looking at his fingers or touching his lips. He tried to sort out the drawings but
not all of them were dated and he asked me continually if he came on such and such a day,
dating back years. I said I did not know unless he had dated his drawing. I found myself
getting increasingly frustrated by the pedantic way he tried to sort his papers out. He
would find a page that was dated and try and sort through the whole pile of papers which
comprised at least four huge folders, to find the next date sequence. He cleared his throat
and spat out into the sink. He tried to get some water from the tap which ran slowly and he
complained it was not working properly. I linked this to how he felt about his mind today.
He found a drawing of a boat and asked me its name. He shouted at me when I said ‘‘a
boat’’. ‘‘It’s not a boat, ship or yacht but a sailing boat’’. He said, ‘‘There is not lots on it’’.
We took a long time to discover what this meant. He said, ‘‘The sailing boat is one, the sea
is two, but there is not lots of sea, he should have put more sea in it’’. There was a general
air of dissatisfaction. He grimaced and made movements reminiscent of the past. I felt
alarmed at his potential regression and pointed out what he was doing saying he was going
back to doing things he had not done for a long time. He was surprised and said he didn’t
use to do that, not like staring at his fingers on the table. His sorting continued and I felt
very frustrated. He said again he was muddled up. I said this made him feel frustrated. He
asked what that meant and then said he did not like feeling muddled up. At the end of the
session I realised he was searching for drawings on days he had missed sessions and so
there were absent drawings. I wondered if these absent objects threatened to become
hallucinations again.
 Journal of Child Psychotherapy 299

Max clearly had developed a rudimentary capacity to think about his emotional
experiences and label them, recognising the emotional difference between being able
to think and feeling muddled. The absent objects still threatened to become present
persecutors if he could not bear the frustration of the absence, felt in the
countertransference by me.
Previously Max was tormented with anxiety about the no-thing described by
Bion but was unable to think about the meaning of its absence. ‘The patient then
may be seen as facing a choice: either he may allow his intolerance of frustration to
use what might otherwise be a ‘no-thing’ to become a thought and achieve
freedom . . . or he may use what might be a ‘no-thing’ to be the foundation for a
system of hallucinosis’ (Bion, 1970: 17).
I do not believe Max had such a choice when I started working with him. No-
children or absent objects were expelled from his mental apparatus through his
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eyes operating in reverse like projectors instead of cameras as Bion described and
became little homunculi pervading the space which he lived. Meltzer writes about
Max.

So exclusively was his attention directed towards these circulating no-things that he
could hardly attend to other aspects of the world. By enlisting his therapist’s
capacity to fix them by name on the paper, where the name and the thing in itself
were quite indistinguishable, the anxiety they engendered by invading his life space
was curtailed for a moment. Yet he had only ‘‘fixed’’ them to the surface of the
paper and not transformed them into representations in his mind so they tended to
struggle free of this bondage to launch themselves once again into his visual field.
Only as they took on meaning and began to couple, fight, bully and become related
to the figures in the world with whom he had began to interact, albeit
masochistically, did the air begin to clear of ‘‘enemies.’’ The threatening no-children
heralded the possibility that he too could become a No-Max homunculus in someone
else’s visual field. Later he could articulate this in a more comprehensible way using
language to think about his anxiety.
(Meltzer, 1984: 121)

After nine years of seeing him, I left the clinic. I offered to transfer his therapy to the
hospital to which I was moving to, but his father refused this saying he wanted Max
to ‘‘focus on his education’’. Here is a fragment of our last session.
I had substantially talked about the ending and I said this was our last session because I
was leaving the clinic. He looks at me and asks, ‘‘Do I know what you mean?’’ Do you?’’
I ask ‘‘Do I’’, he said. ‘‘Tell me another way’’. I try but I do not think either of us could
express or comprehend the emotional meaning of this event.

I did continue to visit Max in his school every so often to keep contact. When he left
school I tried, unsuccessfully again, to persuade his father to let me continue to see
him in the hospital or a local clinic.
A year later, I received the following letter from a registrar in adult mental
handicap services.
I am writing to you about Max who you saw many years ago. He is a 17-year-old boy
with severe autistic features. When I went to see him at home recently, his only
spontaneous remark was regarding you – ‘‘I love him’’.

He went on to tell me Max was deteriorating and hardly left his room. He asked if I
would see him again by contacting his father directly. I wrote to his father offering
 300 R. Emanuel

Max an appointment but he ignored the letter. I tried to get the adult mental
handicap team to encourage his father to allow me to see Max. They too were
unsuccessful.
Many years later, I received a call from a doctor in an adult mental hospital
where Max had been admitted after a psychotic breakdown. He would hardly speak
but spoke my name and said he wanted to see me, as I would know what was
happening with him. I did go and see him on an adult ward, which was very
distressing but it was not possible to resume work with him. He had, though, kept
our experience in mind in a touching way.

Conclusion
Was this later breakdown predictable? Clearly he had developed a capacity to think
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but there was always a threat of a resurgence of psychotic functioning where the
frustration of the absent objects, including me or anyone in his environment who
could contain him would exceed his capability to think about them and he would
become ‘lost’ again. He could keep my name in mind but the tragic abandonment he
experienced and the lack of any understanding in his family meant he probably lost
all hope. Meltzer also believes that the psychotic part of the self cannot be fully
integrated by anyone and does need to be split off in some way or other for normal
functioning.
I think that children like Max who present as childhood schizophrenics rather
than autistic in the early years are hardly seen by child psychotherapists any
longer. In a literature search of our Journal and more widely, there are sparse
references to children who hallucinate being seen in psychotherapy since the early
1980s. I think many of them are medicated and I cannot know how helpful this
may have been for Max. Most children are diagnosed with autism or mental
retardation now and childhood schizophrenia is a term hardly used. In a review
of the literature by Tengen and Maia they state that, ‘childhood-onset
schizophrenia is a separate disorder, different from infantile autism, not only in
terms of conceptual issues, but also in terms of phenomenology, genetics and
associated clinical and neurological issues’ (Tengen and Maia, 2004: S1). The
presence or absence of delusions or hallucinations is a hallmark of the diagnosis
of childhood schizophrenia.
According to Tengen and Maia, childhood schizophrenia has a worse
prognosis than other childhood psychoses. ‘Factors that indicate a worse
prognosis are: early onset, absence of triggering factors, premorbid factors such
as poor social adaptation (including work), autistic behaviour, negative
symptoms, poor family and social support, non-remission within three years,
frequent relapses’ (Tengen and Maia op. cit.: S8). Max clearly had many of these
factors in his life.
Despite the tragic ending, I have no doubt that Max benefitted from the
containing and understanding experience of psychotherapy where he introjected a
thinking object. I think he had some experience, as O’Shaughnessy (1991)
mentioned, of feeling less isolated. I do not believe these formulations and
understanding would have been possible without Bion’s work as understood by
Meltzer. None of this would have been possible had Max and I not had the extreme
good fortune to be able to access Dr Meltzer’s genius in understanding psychotic
processes based on the work of Bion.
 Journal of Child Psychotherapy 301

References
BION, W.R. (1962) Learning from Experience. London: Heinemann.
BION, W.R. (1963) Elements of Psychoanalysis. London: Heinemann.
BION, W.R. (1970) Attention and Interpretation. London: Heinemann.
BOSTON, M and SZUR, R. (1983) Psychotherapy with Severely Deprived Children. London:
Routledge and Kegan Paul.
MELTZER, D. (1984) Dream Life. Perthshire: Roland Harris Trust Library No. 12. Perthshire:
Clunie Press.
MELTZER, D. (1986) Studies in Extended Metapsychology. Clinical Applications of Bion’s
Ideas. Roland Harris Trust Library No. 13. Perthshire: Clunie Press.
O’SHAUGHNESSY, E. (1991) Psychosis: ‘not thinking in a bizarre world’. In ANDERSON, R.
(ed.) Clinical Lectures on Klein and Bion. London: Routledge.
TENGEN, S. and MAIA, A. (2004) ‘Functional psychosis in childhood and adolescence’. Jornal
de Pediatra, 80 (2 Suppl): S3–10.
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