McLean, D. (1989). Assessment of a Latency Boy With Obsessional Symptoms. Bul.

Anna Freud Centre,

12:265-280.

(1989). Bulletin of the Anna Freud Centre, 12:265-280

Assessment of a Latency Boy With Obsessional Symptoms
Duncan McLean

Michel was 11 when he was referred to the Anna Freud Centre by his mother, Mrs S.
About two years previously he had developed great anxiety about going to sleep at
night. He would often be awake until late and spend some time in a variety of rituals.
Mrs S had already approached two other agencies to get help for Michel. The first, the
child psychiatric department of her local hospital, had prescribed night-time tranquillizers
which had been of little benefit and had made Michel rather drowsy the next day. The
second, the local child guidance centre, had suggested that Michel had been sexually
abused and should be sent away to boarding school. Mrs S had disagreed both with the
diagnosis and prescription from this agency and had come to us for a further
assessment.
The possibility that Michel had been sexually abused had arisen out of the fact that it
had been discovered three years previously that his sister Joan, four years younger
than himself, had been sexually abused by mother's younger brother. At that time the
child guidance centre had had a disclosure interview with Joan and subsequently there
had been a number of family therapy sessions. Mrs S said that in these sessions the
social worker and the psychiatrist were very explicit about what had occurred during the
abuse. Apparently this had included penetration into every orifice. Michel had refused to
talk, so it was not known either whether he was abused or had been witness to the
abuse. Mother was at a loss to know how the abuse had occurred, as although Alex, her
brother, had been a frequent visitor to the house, she could not see how he might have
had the opportunity. Joan was 8 at the time of Michel's referral and the abuse had
occurred roughly between the ages of 2 and 4. This had been ascertained
retrospectively, since during those years Joan had had constant vaginal thrush and
cystitis as well as loose bowel movements. At the time, the cause of this had not been
suspected and the abuse only came to light when mother was in hospital because of a
stomach ulcer and the children were being cared for by a female relative who
discovered Alex having intercourse with Joan. The police were called and Alex was
removed from the house. He was never convicted of the offences because of some
technical difficulty with the evidence. However he was never allowed back to the house,
though mother admitted that despite what had happened she still felt much love for her
brother.
It was two years after these events that Michel's obsessional symptoms started. The
details of his rituals are unclear since he tries to hide them from everyone. They occur
only at night when he is about to go to bed. They seem to involve a routine which
includes looking in cupboards and under his bed as well as walking in a particular line
from the bathroom to his bedroom. He also touches things in a certain order, and the
wheelchair of the maternal grandfather, who shares the house with them, has to be
positioned in an exact spot. Frequently he is unable to get off to sleep, and when he
does he often has nightmares.

Background
Michel has a 16-year-old brother, John, who is often out until the early hours of the
morning at discos. Michel often asks when John is getting home and will stay awake till
he arrives. On Friday nights when Mr S has to work a shift during the night, Michel,
together with Joan, go into mother's bed. This is partly because of Michel's anxiety but
also because mother does not like to be on her own. Mrs S was unconcerned about
this, despite Michel's age, though realized he would have to stop doing this soon.
The family is a relatively settled one. Mr S is Spanish and came to this country in 1967,
looking for work, after he had lost his job in Spain for political reasons. He is now 50
years old and works as a machinist in a factory. He does shift work and is often on a
very early shift which means he keeps very odd hours and which limits the time he can
be with his family. He is a quiet, easy-going man, and keen on sport, particularly
football. He is fond of his children but a little dissatisfied with his marriage since his wife
tends to dominate. He would like to take the family back to Spain where they usually
visit each summer. Mrs S is against this and it seems unlikely they will go.
Mrs S herself comes from Scotland. Her parents came to live with the family five years
ago. The maternal grandmother died two years later. The maternal grandfather is now
quite ill, having had a series of strokes, so that he is senile, needs a wheelchair and a
great deal of care and attention. Mrs S is the main provider of this, though he goes to a
day-centre during the day. Mrs S is a hardworking and conscientious person. Besides
looking after grandfather and the children she also works as a counsellor with a
voluntary agency which helps families where there has been sexual abuse. She took
this on soon after her experiences with her daughter Joan. Mother has had a number of
physical illnesses and is somewhat preoccupied with ill health. She has had both gastric
and duodenal ulcers and also, during her last two pregnancies with Michel and Joan,
she has had to inject herself with an anti-coagulant as she had a thrombosis with her
first pregnancy. On one occasion Michel witnessed her injecting herself when pregnant
with Joan, and was quite upset about this. Mrs S has had a difficult life and, though the
strain shows, she is a survivor. She somewhat idealized her own upbringing in Scotland,
minimizing the amount of violence involved. She has two brothers, both of whom have
fared badly. Alex, already mentioned, has been diagnosed as schizophrenic and has
been in and out of institutions all his life. He is currently in prison for an unspecified
offence. Her older brother Michael is divorced, unemployed and now an alcoholic. He
visits the family quite frequently. He, together with Alex, would often arrive in the house
on Friday nights, drunk, and violent and upsetting scenes would often be witnessed by
the children. On one occasion Alex pulled mother's hair. On another occasion Michael
introduced Michel to a friend who was so drunk that he had wet himself. On occasions
the police would have to be called to eject them from the house. Despite this, Mrs S has
retained a deep attachment to her brothers and this has caused some friction with her
husband.
Michel was born by caesarian section, mother staying in hospital only five days after the
birth. He was breastfed for 4-6 weeks, but because he seemed unsatisfied he was
changed to the bottle after this. He later took to solids satisfactorily. Mother had all her
babies in bed with her for the first few months since she found this easier. She could
give few details of Michel's development and had not found him a difficult child. Walking,
talking and toilet training she thought were within normal limits. When Michel was 3, she
lost twins at 5 ½ months. Mrs S had been on a three-monthly contraceptive injection
and although she had reported that she felt pregnant she was given another injection
and later lost the babies. At 3 years 6 months Michel started playgroup and went
mornings for a year. He settled well and then began going full-time before making the
transition satisfactorily to infant school. When he was 4 Joan was born by a further
caesarian section. This was a difficult experience for mother since her scar became
infected, she haemorrhaged, and she still has problems with it.
Michel had some difficulties at his first infant school, making poor progress in reading.
Mrs S had him assessed by a psychologist who said that he was either being badly
taught or he was dyslexic. He was moved to another school, and within six months he
became a good average reader. Since then he has got on reasonably well at school;
that is, until just over a year ago, when he became excessively fearful of his form
teacher. Mrs S commented that the teacher bore a close resemblance to his Uncle Alex.
His teachers see him as being a little restless and attention-seeking, but he is well liked
and thought to be potentially quite bright. He moved to secondary school two terms ago
and appears to have settled in quite well. He is particularly passionate about football,
and as well as playing in the school team he is also in the team of the local community
centre where he often goes in the evenings. He is a popular boy who has a number of
friends, both in and outside school. In fact his daytime behaviour is very unlike his night-
time behaviour before going to bed, and he is generally seen as being cheerful, lively
and energetic.

Assessment Interviews
I saw Michel on two occasions for his assessment and he was subsequently seen once
by a psychologist. He is an attractive looking boy of a slim, athletic build. His hair is dark
and he has an olive complexion which makes him look much more Spanish than
Scottish. He carries himself well and moves gracefully, though there is something rather
restless about him, so that he finds it difficult to sit still. Initially anxious and a little
withdrawn, he rapidly relaxed and became lively and engaging, with occasional displays
of humour. He is a very likeable boy and one is not surprised to hear that he is in
considerable demand as a friend. He related to me in a warm friendly fashion, with an
engaging mixture of shyness and cheek. In my first interview with him I asked him why
he thought he was coming here. He said straight off that it was because he used to
check beneath the bed, but went on to say that he no longer did this, and grinned
broadly when I said he did not seem to think there was much the matter with him. I went
on to ask him to tell me something about himself, and he started talking about his
school. It was clear he was not too happy about this. He said that it was all right, but in a
rather flat fashion, and I wondered what he did not like about it. He told me about a
female language teacher who could not keep order in the class, and as a consequence
they could not get on with their work. He felt she was stupid. The other teachers he
liked. He also told me that the people did not care about you at this school. If you fell
over and cut yourself no-one would pick you up and take you to the nurse. There were
some subjects that he enjoyed. He mentioned crafts and design. He seemed quite
excited in talking about the machinery they used to make things in plastic and wood. He
also loved sport, especially football for which he clearly had a great passion.
He went on to tell me about the community centre near his home and that they had a
football team for whom he played. They had matches on Saturday afternoons and
Friday evenings, and he played in the centre of the field. When I asked if he was any
good he showed a reluctance to sing his own praises. The community centre was open
every night of the week and he usually went there after he had done his homework, so
that he would be out from 5 p.m. until 7 or 8 at night, or even later on Friday nights. He
knew everybody there and clearly felt very at home and had some good friends. He
indicated that having mates was very important to him. He talked with some regret
about how some very good mates he had had in his previous school he no longer saw.
The family moved house at the time he started at his secondary school. He now found
himself playing matches against his previous friends, and found this very confusing,
often passing the ball to them though they were now on opposite sides. He proudly
listed the achievements of the football team he had played in with his previous friends
and how they had won the double: winning the cup and the league in the same season.
I went on to ask about his family. I said I understood that his father was a machinist. He
agreed, and said his father had to work rather strange hours as a consequence. For
most days of the week he returned home from work at about four in the afternoon and
then went to bed for two or three hours until he got up for supper at seven or so. He was
then up for a few hours until going to bed at eleven. He would have to be up very early
in the morning to start an early shift. Because of these irregular hours, Michel did not
see a great deal of his father during the week and the main contact was at weekends.
He thought his father would get angry with him if he played about at times of going to
bed. If he kept on fooling around his father would eventually get into a rage and might
even hit him. He minimized this, saying that his father did not hit him too hard, and I
found it difficult to judge how frightened or saddened he might be by this. Father shared
his interest in football and they would go to watch football matches together. His father
used to be a football player himself when he was in Spain. Sometimes father could be
quite funny. He mentioned how once, when Uncle Michael had taken the dog for a very,
very long walk, father had pretended to be the dog, hanging his head and complaining
about how tired he was.
Michel did not have a great deal to say about his mother, saying she did not get as
cross as his father, but she would control him. She had once caught him climbing on the
roof of a building and grounded him for the week. He ruefully recounted how he had had
to bear all his mates going off to play football matches without him during that time.
Of his brother John, he said there were often arguments because he stayed out late at
night. His father did not like this since John was unemployed and had not gone on to
any further education. He and John got on well though and he liked him because he
would play football with Michel sometimes. From discussing his brother he got on to
talking about a gang of delinquent youths who operated near his home. He described
how once when he was looking out of his window he had seen them breaking into a car.
They had smashed the window of the car and the alarm had gone off, so they ran away.
However the alarm stopped and they came back and took out the stereo. The alarm
then started a second time and they again ran off, but later came back and took out the
speakers. He had not wanted to get involved and call the police, because if the youths
had found out he would have been called a sneak. He complained though that several
adults had walked past while the youths were doing this to the car, and no-one had
taken any notice. He then went on to talk about not liking Saturday nights, saying this
was because his younger sister would go to sleep and his parents would go to bed. His
older brother would be out and he would find it difficult to get off to sleep. Once he had
slept in his brother's room and been amazed at the way his brother had fallen asleep so
quickly. Sometimes on Saturday nights he would wait up until John got home but would
be worried by noises he heard while waiting. When I tried to get him to elaborate on his
worries he retracted, saying it no longer really bothered him and there wasn't anything to
worry about.
However he did say that at times he had nightmares. He described one of being chased
by somebody and then tripping and falling over and waking up just before his face hit
the ground. In another he described being caught by someone who had a knife. He said
that if he watched horror movies then he would not get nightmares. Sometimes the
nightmares would turn into dreams, as when falling over he might find he had a
parachute or even that he could fly. He then went on to talk about other things that had
frightened him. He mentioned the faces of killers he had seen in newspapers. He talked
of two he had seen recently. The first was of the man who had killed a paperboy. The
man had abused the boy and then killed him by crushing his head with a stone. Michel
himself had been a paperboy for a time in the summer about three months ago, and his
mother had stopped him doing this because of her worry about him at that time. There
had been some rather dark places he had to go into when delivering newspapers. He
also mentioned the boy of eleven who had murdered a little girl by smothering her in
mud. Though admitting he was anxious, he did not seem overtly worried when talking
about these things. We then got on to his sister Joan. He said they often fought
together. He felt that she was a pest and frequently provoked him. Each would try to get
the other into trouble with the parents if they could. He would be infuriated if she
managed to do this to him but gleeful if he got her into trouble. He described too how
sometimes he would waylay her on the way to the toilet and jump on her and really give
her a fright. Rather ruefully he said he could not actually attack her because he might
hurt her and put her into hospital.
I said I had heard he had been to the child guidance centre sometime before. He told
me this had had to do with his sister. At first he said he could not remember why this
was. Then he said he could, and that it was about having family meetings because of
what had happened to his younger sister. There had been a man (Alex) who had
touched her in places he should not have, and they had all had to go along to talk about
it. He had not minded going, it had been all right, it was quite good to get off school for
half a day. I did not press him for any further details at this point and he left the first
interview in a cheerful fashion.
When he came to his second interview he had a great deal to tell me. He said he had
been off school for a few days as the school was closed for reasons he did not
understand. Yesterday he and a friend had gone off exploring. They had come across
this place, it was like a factory. There were lots of different places there for making
things. There was one place that looked like an arcade where there were lots of lights.
They had gone in to have a look around. By way of making an excuse, so that they
could stay there, they had asked where the dress shop was, and had been told that it
was up the stairs somewhere. They had stayed and looked around, but after a while
they had got rather bored and had been about to leave when a man jumped out and
grabbed hold of Michel. The man wanted to drag him into his office, saying he was
going to call the police. He had managed to get away from the man by slipping out of his
coat, though the buttons of his shirt had been pulled off. He had run home and told his
mother, and she had called the police. They were going to go round to the place
together today to see if they could find the man. I said this must have been a very
frightening experience and he agreed that it had been. Though he gave me this account
with some animation he did not really convey how frightening it was. There was a
dreamlike quality to his recitation.
He then moved on to say he had not told me about his grandfather last time. He was in
hospital at the moment and had gone in on the day we had last met. He had been to
see him that evening. Hospital was probably the best place for him to be as he was
quite comfortable there. When he was at home they had to have a district nurse to get
him up in the morning since mother had to get them off to school. He thought his
grandfather was rather funny when he talked without having his teeth in. He then
sucked in his cheeks like his grandfather. He had worried that he might die like his
grandmother who had died two or three Christmases ago. He had cried a lot when this
had happened and he still missed her at times, particularly at Christmas.
I then asked him about his mother's brothers. Michel said there was Michael, whom he
saw quite often. He told me he was coming that evening, although he seemed
uninterested in this. There was also Alex, the one he had told me about last week who
had interfered with his sister. He said he was now in prison, as far as he knew, and
supposed it was because of what he had done to Michel's sister. I asked if he had
witnessed anything of what had happened and he said ‘no’, the first he had known of it
was when he had gone to the hospital to have the family meetings. He did not seem
unwilling to talk about it but could not remember a great deal since it had happened
some time ago. I then went back to ask him about his night-time worries. He was very
reluctant to talk about this and was dismissive, saying he no longer had any trouble
getting to sleep. He did eventually admit that he had a compulsion to look under his bed;
that is, he would do so once and then he would lie in bed and feel he had to do so
again. He would keep telling himself that it was silly and he need not do it, but then he
would have to. He also had a particular routine, of looking under the bed, in the
cupboard and behind the curtain, which he would have to do a number of times.
However he contradicted himself by saying he no longer had to do these things because
he now said his prayers instead. I wondered how long these prayers took, and he said
about fifteen minutes. I asked him about his grandfather's wheelchair. He said he
sometimes had to turn it round because he would get an image of someone sitting in it
with an evil face. Later on I wondered about girl-friends. He said he did not have one at
the moment although he had had lots in the past. He particularly liked tomboys, girls
who liked to do things like climbing trees, running and jumping, things that boys did. He
was somewhat uninterested in the subject, seeming to suggest that only if they were as
good as boys would he be interested in them. I asked him what he would like to do
when he grew up. He first of all said he wanted to be a professional footballer, then said
he did not know if he really wanted to do that. He knew someone who was, and this
person had to move around from one club to another and leave his friends behind,
which he did not like. Michel had at one time thought he might like to be a doctor, but
was not sure he could stand all the blood and guts.
I then suggested he might like to draw something, which he agreed to. He drew a series
of faces with different expressions, like the faces he had drawn at school in a language
class to put names to feelings. He drew an angry and a sad face, then a shocked one, a
bored one, and a face with bags under the eyes. I asked him to tell me when he would
feel these things. He said once he had got chopped down in the penalty area when he
was about to score a goal and the referee had not taken any notice. He had restrained
himself from retaliating, but if really pushed into a fight with another boy he would
certainly defend himself. About sadness, he mentioned his grandmother again and her
dying. In connection with the shocked face he talked about how he and some friends
had found a cupboard down a corridor in one of the blocks of flats near him. A caretaker
had agreed they could use it to camp, and there was a light switch with a timer so that
the light would turn itself off after a few minutes. They had pushed a screwdriver into the
side of the switch to try and keep it on, and he had got an electric shock. It had made
him cry. About the bored face, he mentioned not having been allowed to go out that
morning. He had wanted to go and see a friend of his who also was not at school. This
friend had been expelled because he had had a fight with another boy, although it had
been the other boy's fault. He thought his friend was going to a special school now. This
friend earned a lot of money by doing a paper round. As he had had to stay in the house
he had become fed up as there was not much to do. He hoped to get a computer soon
and would then be able to play by himself. This ended our second interview. Michel left
a little sadly, as if regretting that our meetings were over.
Michel was next seen by a psychologist who administered an intelligence test and
projective tests. The WISC showed Michel to have the full scale IQ of 104. This came as
something of a surprise. Both we at the Centre and his teachers had thought he was
probably of above average intelligence. However there was quite a large scatter on his
scores in this test and his performance may have been adversely affected by anxiety.
His projective tests were quite revealing. He tended to give full and imaginative
responses to them. I will reproduce two examples here. The first one is done in the
dramatic form that he used for several of his responses:
Card 4: (a woman is clutching the shoulders of a man whose face and body are averted
as if he were trying to pull away from her).
Lady: ‘Oh my love, don't leave me.’ [smiles]
Man: ‘Sorry, I have to.’
Lady: ‘But why?’
Man: ‘Two months ago I left the army. I have to go back there and fight for my country.’
Lady: ‘Oh please don't. What happens if you die?’
Man: ‘Don't worry. I'm send you a letter.’
Lady starts crying.
Man: ‘Don't cry, I won't be gone for long. I am leaving tomorrow morning.’
Lady: ‘I'm pack your things.’
Man: ‘Thanks, darling.’
Next morning:
Man: ‘I am going now, Julie. ‘Bye.’
The lady cries. The man kisses her goodbye. He fights for America. They win the war
against the Japanese and he comes home. There is joy once more.
The second example, again quite a dramatic response, perhaps reveals some of his
deeper anxieties.
Card 8 BM: (an adolescent boy looks straight out of the picture. The barrel of a rifle is
visible at one side and in the background is the dim scene of a surgical operation like a
reverie image).
Response:
‘Quick, quick! Get the emergency machine out! He's got a low blood-pressure. I don't
think there is any chance for him living. He has been shot in the heart. We are cutting
his belly to try to get the bullet. It's deep. His heart-machine has gone weaker and
weaker…tick…tick…tick… tick…he is dead.’ [Question: Who shot him?] ‘A German
spy.’ [Question: ‘Who is he, the boy?’] ‘A detective, trying to find out the case. Oh, he is
a boy, he is a young detective.’
I will come back to the projective tests, particularly when discussing Michel's drive
development.

Some Aetiological Considerations

In considering the background to this case there are a number of environmental
features which stand out as possible significant contributors to Michel's disturbance.
Firstly there is the sexual abuse of Joan and the possibility that Michel was abused at
the same time. Though this cannot be ruled out with certainty, the evidence points
against it. Michel generally seems very at home in his body. He relates well in the
interview situation and is neither over-fearful nor compliant, nor is he seductive. A more
open question, perhaps, is whether or not he witnessed the abuse. There is his account,
in his interview with me, of witnessing a crime which the adults ignore. Also there is his
clear preoccupation with and fear of child sexual abusers and murderers. However
these things can be as well explained by other factors, such as the effects of the
disclosure of the abuse and the subsequent family interviews. There is, too, the fact that
Michel repeatedly witnessed his uncles coming to the house in a drunken, unruly and
sometimes violent state. It seems that this happened repeatedly over the years and it
would appear that Michel's need to check before he goes to sleep, and his particular
anxiety at weekends, when these scenes are most likely to have occurred, are directly
related to this.
Michel's relationship with his parents seems potentially difficult for him. Mrs S has had a
very busy life and one wonders how much time she has been able to devote to Michel.
She gives a rather sketchy developmental history which may indicate her relative lack of
time for him. She appears to be the dominant force in the family and still has Michel in
her bed on occasion. Both these factors may make for difficulties, particularly as he
approaches puberty. Although Mr S has a good relationship with Michel, he does not
see a great deal of his son during the week and he is somewhat passive, dissatisfied,
and dominated by his wife, thus possibly making him a poor model for male
identification.
The current situation in the family is also complicated by the presence of the maternal
grandfather who is very ill. Constantly seeing a man in such a state may cause Michel
some anxiety.
Apart from the sexual abuse of Joan there does not seem to be a great deal in the past
of particular significance, though the miscarriage of the twins when Michel was 3 ½ may
be significant. His story, in the diagnostic interview, about the double theft from the car
might be a screen for this event.

Developmental Assessment
In assessing Michel's drive development one must suppose that he is still in latency. He
enjoys an active social life with a same-sex peer group based upon latency-type
interests and sublimations. There is no evidence yet of the fears and preoccupations of
adolescence. Although he talks about having girl-friends he really has no interest in
them if they cannot act as surrogate boys.
As far as component drives are concerned, there is little evidence of strong oral
fixations. Michel is, for the most part, an active and independent child. However, there is
an interest in delinquency that might be an expression of early passive wishes. His
account, in the diagnostic interviews, of entering the factory complex has a delinquent
flavour to it. There is also his account of seeing some youths rob a car. In his projective
test, too, there were a number of references to thefts. Though the interest in
delinquency may be related to fixations at a later developmental level, they may also
represent some unmet dependency needs in Michel. There was one reference to
dependency wishes, in his complaint that at his secondary school one was not easily
looked after and taken to the nurse.
Anal components, too, seem relatively absent. This is somewhat striking, given his
symptomatology. Outside the area of his anxiety there is a spontaneity and self-
assurance about him that suggest a harmonious balance in relation to his drives. He is
neither fastidious nor compliant, nor is he over-controlling in a manner that might
suggest anxiety over anal drive derivatives. This would seem to rule out an obsessional
character structure, and his obsessional symptoms are probably a regressive attempt to
deal with anxieties at a higher developmental level.
The phallic narcissistic phase appears to be well established. There is some
pleasurable exhibitionism and pride in his achievements, such as his skill at football.
The oedipal level too has probably been achieved. I think it is at this level that the main
conflicts lie. In his responses to the projective tests, as in Card 4 quoted above, he is
interested in the love relationship between a man and a woman. In this card there is a
reluctance to be with a woman and a suggestion that he is more interested in
establishing his male identity.
For Michel in the oedipal position there seem to be dangers from all sides. In one of the
projective tests, the maternal figure is seen as bossy and dominating. The positive
oedipal position is thus fraught with dangers and this is probably reinforced by mother
having Michel in her bed. In addition, castration anxiety appears to be severe. This can
be seen in his response to the projective test Card 8 BM quoted above. The castration
anxiety has probably been reinforced by a number of factors, such as witnessing his
uncle's violence, as well as the steady physical deterioration of his grandfather. Also in
the positive oedipal position he is potentially identified with a sadistic molester and
abuser, and guilt would cause a retreat from this position. However, a move into the
negative oedipal position puts Michel at the mercy of just such people. It seems that
fantasies about this are what he mainly defends himself against when he is going to
bed. His nightmares are about being attacked, and many of his rituals are related to
ensuring that his bedroom or the house is secure. It is interesting, in this respect, that he
provokes an attack by a man when he gains entry to the factory complex. I think this can
probably be seen as a counter-phobic mechanism. He identifies with the aggressor by
entering the factory. Presumably, though provoking potential male authority figures, he
had hoped to get away with this and allay his anxiety, though in the event things went
badly wrong. The night-time rituals probably involve a further regression to the anal level
as a means of controlling his anxiety over both passive and active sexual wishes.
When considering Michel's aggressive drive, one can see that this is intimately bound
up with his conflicts. Outside the area of his difficulty he can be lively and assertive, and
there is no marked inhibition. However he can be aggressive towards girls, and this
particularly shows with his younger sister Joan. His aggression towards her is mainly
conducted at a verbal level, although he can go as far as to jump out at her to give her a
severe fright. Here again one sees an identification with the aggressor, though guilt
prevents Michel from taking this too far and he cannot allow himself actually to hurt her.
Presumably the delinquent interest, too, allows some discharge of aggression as well as
dealing counter-phobically with his fear of being attacked.
In considering Michel's libidinal cathexis of himself, one must suppose him to possess a
considerable degree of healthy narcissism. His very likeableness and popularity with
most people suggest a basic sense of self-worth. When he has overcome his initial
apprehension, it seems he has an expectation that others will like him, and there is no
doubt that he feels he is quite good at some things, such as football, and is proud of his
achievements. However there are areas in which his self-esteem is precarious. For
example, his mother reports that if he is not the best at something he can feel it is the
end of the world. In addition, he can at times adopt a ‘don't care’ attitude when he feels
he might be failing. One could see these areas of fragile self-esteem as related to the
irresolution of his Oedipus complex.
At a conscious level, Michel's object relations seem largely uncomplicated. Like many
latency boys he has little to say about his mother, whom he takes for granted. He is fond
of her and a little rueful about her control over him. However, as stated above, at an
oedipal level she is perhaps seen as a rather threatening and dangerous figure. In
addition there is probably a complaint against his mother, seen in the first diagnostic
interview when he talks about the teacher who cannot control the class. This may well
be displaced from the frequent occasions when mother has allowed her brothers to
intrude violently into the home.
As with mother, Michel's father is also seen as a benign figure. Michel appreciates his
sense of humour, and they share interests, such as watching football. In being relatively
absent from the home, and dominated by his wife, he seems a somewhat insubstantial
figure in Michel's life. Set against the figures of his violent uncles, this may have
weakened Michel's male identifications.
Michel's older brother John does not appear to be a very important person in his life.
There are several years between them, and though they get on well enough, there is no
particularly close tie. John is now becoming increasingly peripheral to the family as he
establishes his own independence. It is probable that Michel sees him in a parental role
when he uses John to allay his anxiety at night.
With the younger sister Joan there is a great deal of hostile rivalry. He will go out of his
way to get her into trouble, and there are constant arguments between the two. He
clearly has to restrain some very strong aggressive wishes in relation to her. This is
indicated by his talk in the diagnostic interview about putting her into hospital. His
aggression towards her could be due partly to envy, that she is a girl and the youngest,
but it may also be anxiety-driven if there are any sexual wishes in relation to her. These
would put Michel in the position of feeling he was the molester, and any impulses would
seem highly dangerous to him.
Michel's relationship to his grandfather appears to be an understanding and protective
one. Grandfather has been living with the family for some years and during that time his
disabilities have gradually increased, so that he has deteriorated both mentally and
physically. The constant sight of his grandfather's severe incapacities seems to have
strengthened Michel's castration anxieties.
Other important relationships for Michel have of course been his uncles Michael and
Alex. He now no longer sees Alex, but of course he remains an important figure
because of the past abuse of Joan, and also because on many occasions Michel
witnessed Alex, together with Michael, being aggressive and sometimes violent. In one
of his projective tests, Michel identified himself with a man in prison, and this
identification with a violent man must be a particularly disturbing one for him, increasing
both his guilt and castration anxiety. A further impetus would be his being named after
his Uncle Michael. The linking of the abuse with these aggressive images of his uncles
will make negotiating puberty, and any sexual wishes, particularly difficult.
It has to be said that outside his family relationships Michel appears to get on with
people. He has at times been somewhat fearful of authority figures, but generally he is
well liked. He has a large circle of friends with whom he gets on well. It seems in this
respect a very healthy development.
Michel's ego development is assessed as generally sound. He is a fit, healthy, athletic
boy. He is also lively, perceptive and imaginative. His IQ results have already been
referred to. Although he comes out as average, he might have the potential to achieve a
higher score than this if he were not so anxious.
The defences Michel's ego employs appear well balanced and modulated. Within the
area of his pathology, anxiety appears to produce regression with consequent
projection, reaction formation and undoing manifested in his obsessional rituals. At
these times his defences fail him and he is often unable to sleep, and even when he
does, he has nightmares. In more general terms, the defences of turning passive into
active, and denial, may be rather over-used in his character structure. He is at times
restless and over-active and will attempt to deny some obvious difficulties, such as his
symptomatology or his learning difficulties. These defences, however, do not interfere
too greatly with his life, from which he seems to gain a great deal of pleasure.
Michel's superego development appears well structuralized and internalized. He wants
to contain his aggressive feelings, and indeed does so to a large extent, and his
adoption of social norms is not just based on compliance. His superego is also aim-
giving in what appears to be quite an appropriate fashion. He has ideals to succeed on
the football field and to grow up to be like his father, in a not unrealistic fashion. There
may be some lacunae in his superego, in his tendency to delinquency. The dangers that
Michel's ego faces are therefore primarily those which relate to the oedipal situation, in
particular guilt, castration anxiety and loss of love. His conflicts can be seen now as
internalized ones, though on occasion they are secondarily externalized, as when he
entered the factory in a provocative fashion. As such, they have probably become
relatively independent of the environment, and this can be seen in the fact that his
symptoms persist, though in many ways the family situation is now better than it has
been for some time. Of course there are current factors which may be playing into this
conflict and exacerbating it, for example, as mentioned before, the presence of his very
disabled grandfather in the home.
Michel's general adaptation seems to be a good one. He can tolerate frustration well,
and has some areas of good sublimation potential. He has a number of practical abilities
and skills which give pleasure and satisfaction. In his attitude to anxiety he seems very
much to want to master those things that he finds potentially overwhelming, and there
seems a definite push towa rds his completing his development.

Conclusion
When assessing obsessional symptoms, the phenomenology cannot of itself give an
indication of the diagnosis but has to be set within a developmental context. A whole
variety of psychiatric disturbances, from neurosis to psychosis, can have obsessional
symptoms as an element of their psychopathology. In Michel's case, the obsessional
symptoms do appear to warrant the diagnosis of an obsessional neurosis. Michel
appears to have clearly entered into the oedipal complex and has internalized conflicts
between his oedipal wishes and impulses and his superego. This leads to regression to
the anal phase in relation to his symptomatology, where there is a continuing battle
between his superego and his projected sadistic impulses. What is interesting in
Michel's case is the almost total absence of obsessional character traits and the impact
and influence of the sexual abuse within the family. If anything, Michel's character
structure shows mild delinquent traits rather than an over-rigid superego, and this may
point to some relative lack of maternal care in the early years, since his mother has
been very over-stretched by all the obligations she has had to meet.
The fact that Michel has developed obsessional symptoms within such a character
structure relates, I think, to the intensity of the environmental factors as well as to his
developmental stage. I think it is significant that the symptoms have appeared in the
pre-pubertal period and it is probably the upsurge of the drives that has brought about
the onset of the symptomatology. However, over the years there have been many
environmental factors that have hindered the resolution of his oedipal conflicts. Some of
these seem more certain in their impact than others. A possibly significant early event
was his mother's miscarriage when he was 3. This may have made positive oedipal
wishes appear dangerously aggressively. Next, there was the sexual abuse of Joan
when Michel was between 5 and 7. As I have stated, I think it most unlikely that Michel
himself was abused, though whether he witnessed the abuse is an open question.
However, the disclosure of abuse in itself may well have added to Michel's worries
about dangerous male sexuality and its consequences. These particular disclosures
happened within the context of the continuing intrusions of his uncles into the house
each week in a violent and often aggressive state. This must have greatly intensified
castration anxiety as well as intensifying guilt over his sexual impulses. A further
environmental factor is that his mother continues to have him in her bed. Other factors
already mentioned are his father's relative absence, weakening positive male
identifications, and the sight of his disabled grandfather. All these environmental
influences appear to have pushed Michel into a flight from the oedipal position. His
obsessional symptomatology in the evening seems a regressive attempt to deal with the
anxiety over his drives which are mobilized by going to sleep.
With this assessment, it was felt that Michel's further development was greatly
jeopardized. His symptoms had persisted despite the fact that some environmental
factors supporting the neurosis had somewhat lessened. It was felt that he had many
characteristics that made him very suitable for psychoanalytic treatment, witnessed in
his ability to make good use of the diagnostic interviews. Analysis was therefore
recommended as the treatment of choice.