A personal site of professional interest
Discuss or Comment

Getting Better Makes It Worse

Obstacles to improvement in children with emotional and behavioural difficulties

Sue Kegerreis

Introduction

Every teacher has at some stage faced the frustration of seeing a child who has been showing great improvement suddenly relapse or a child who is doing good work deliberately spoil it. This paper is an exploration of some of the difficulties children face when ‘getting better’ in an attempt to understand why this happens. To open, I would first like to give some illustrative vignettes from a school for children with emotional and behavioural difficulties. Much of the material in this chapter comes from work in such a school although similar problems could well have occurred in mainstream schools.

  1. Peter, 13, had been really successful and much liked at special school, rarely in trouble. Plans were made for him to return to mainstream school. One week before he was due to start, he was caught shop-lifting, apparently a first offence.
  2. Wayne, 14, had been working up to start a trial period in mainstream school, but after only a short while he gave up, saying it was ’too much for him’ although nothing had really gone wrong.
  3. On a smaller scale, Carol, 15, was congratulated effusively by the head teacher for having had a really good morning. At lunch-time she ‘flipped’, and had one of the worst confrontations with her teacher that he could remember. She later complained to the head that he had ‘jinxed’ her.

The Problem

What is it that makes change for the better such a desperately difficult challenge for these children? As reasonably mature adults, we tend to assume that improvement is simply improvement, clearly visible as such to the children, and as clearly desirable to them as it is to us. We can become baffled by the resistances that the children bring up to thwart our best efforts to help them to change, and often despair in the face of self-destructive behaviour of the sort illustrated in the examples given above.

Negative Therapeutic Reaction

One term for this kind of problem is ‘negative therapeutic reaction’. This is a useful formulation as it underlines that this is a negative response to something helpful, part of getting better that causes destructive reaction. This is familiar to all of us, both as therapists and teachers (in any setting) and also individuals. We all know how hard grievances can be to give up, even when we experience a longed for change, and we all know how complicated our reactions can be when a problem disappears. For children negotiating all the stress of growing up, in mainstream as well as special schools, each bit of progress calls for a complex letting go, and can bring into play some of the difficulties described in this paper.

Children in special schools have to face the fact that improving probably implies leaving to return to mainstream school, which carries with it all the problems familiar to primary school children on secondary transfer magnified many times. From being a special, cared-for success they have to become an odd and threatening newcomer, managing all the ordinary problems of school life with far less support. They also have to deal with complex feelings about leaving a place which simultaneously symbolises both their problems and the kind of nurturing they needed. They also have a great deal more to lose now. It is far worse to fail a second time around. Whether in special or mainstream school, children who make a move away from their ‘problem’ status have to wrestle with the burden of having real hope for their own future. They are leaving behind their dreadful but safe despondency and are now newly in a position to let themselves and others down. Carole in the opening vignettes illustrates how doing well can create such anxiety over ‘keeping it up’ that it feels better to ‘blow it’ straightway. A public schoolboy I saw recently had very nearly been expelled. Once he got in touch with how much he did not want to fail, he found it tremendously hard to fight an impulse to push himself over the brink, to get away from the terrible new feeling of responsibility.

Avoiding the Fear of Loss and Damage

Many children with emotional and behavioural difficulties can be understood as being caught up in a psychic state dominated by persecutory anxieties. By this I mean anxieties of such a primitive and basic nature that the children feel their existence is under threat. This is in contrast to depressive anxieties caused by internal conflicts between loving and hating feelings. If persecutory anxieties predominate a child will tend to deny any bad parts of himself, projecting them into others and so experiencing himself primarily as the victim of outside maltreatment. He has no secure sense of self-nurturing, internalised from a sustained sense of being nurtured. The idea of something stable and good, whether inside or outside himself, is constantly under threat and often quite absent. He may feel that his inner world is irretrievably in ruins, and may do his utmost to reduce his outside world to an equally devastated state.

There may seem from this description no possible incentive to stay in this state of mind. Yet the children so often cling to it despite its so apparent self-destructiveness. What could it be that is so much worse?

If one leaves this state behind, in the jargon if one begins to establish a good internal object, one has to encounter the fear of losing it. If you live in an entirely loveless world, you have nothing to lose in your destructive rages, but once you allow yourself to care, then you have to bear the fear of spoiling something worthwhile. Thus a child I see repeatedly said, ‘But I don’t care. I don’t want to care. If I did I’d have to MIND.’

For many children it is more comfortable to be engrossed in a fight than suddenly to wonder what one is fighting about and face sadness instead of anger. Thus Rod, seen for individual psycho-therapy, after spending half the session physically threatening and attacking me, finally stopped and had a miserable, depressed second half, saying with an air of discovery, ‘it’s silly, isn’t it, hitting you’. He was having to face the painful, dawning realisation that he had both with me and elsewhere in his life been fighting something helpful.

From this, we can see why one possible reason for the children resisting the transition to what, in our eyes, looks so obviously a better way of being is that they simply cannot afford to. To do so puts them in so painful a position that it sends them rebounding back into the ‘sicker’ yet, in a sense, less immediately agonising state from which the healthy part of themselves is struggling to escape.

Internal Eenvy: Tthe Envious Voice Within

One powerful cause of negative therapeutic reactions of the kind described here is the presence within of an envious internal figure who cannot allow the child to break free. We all have within us a ‘cast’ of internal figures, with whom we unconsciously relate and who influence both our actions and how we feel. These might include an internal judge who makes us feel guilty and watches us critically, the internal good parent, who helps us take care of ourselves, or the voice inside which undermines our confidence by always stressing our shortcomings. Each of us will have our own distinctive collections of these ‘internal objects’ depending on our experiences and what we have made of them. If there exists in a troubled child a vocal envious internal object then improvement will be fraught indeed. One girl I see is plagued by anxious, guilty feelings whenever she feels she is making progress or even having ordinary good luck. For her, it seems, the world is populated by deprived, fiercely envious people who are only waiting for her downfall. The more her life improves the more anxious she feels as she waits for what feels like the inevitable crash.

As another example, a boy who recently left special school for mainstream school spent a good deal of his time telling me how he despised the children who remained behind. He claimed he wanted to be like a computer tape that could be wiped clean of any association with the school and with them. In one session he climbed onto the very highest bit of furniture in the room, balancing on a chair up there very precariously. He then told me that the chair was an aeroplane and that he was shooting down all the ‘special school kids’ who were themselves desperately trying to shoot him down and topple him. They would, he said, be so pleased to see him fall. Here he is externalising his problem onto the other children, but we can see how precarious his progress is if he is embroiled in a battle with an internal envious figure who cannot allow him to succeed.

The problem for this boy of being the envied one are acute; but do not completely preclude progress. Some others have an even more powerful voice in their minds telling them: ‘It won’t last, what right have you to put yourself forward, you’re too bad to do well, who do you think you are?’ This can lead to total paralysis, or to the all too familiar pattern of progress followed by self-sabotage, as illustrated by the introductory examples.

Envy: Difficulties over Forgiveness and Gratitude

Another problem is illustrated by an adolescent I see. She apparently developed well and happily until puberty, at which she suddenly fell prey to a series of phobias and fears that led her to retreat almost totally from normal adolescent life, being unable to leave her mother. In treatment, when in fact a good deal of improvement was taking place, she told me that if she was, then she certainly wouldn’t tell me, because then I would think that I had done it and she didn’t want me to have that pleasure! In saying this, she was giving me a clear indication of what had been part of the cause of her failure to develop smoothly into a successful young lady. To grow successfully was to give her parents the great gift of taking pleasure in her, in the fruit of their creativity. Such was her anger and envy of her parents that she could not allow this. They, like me, were not to feel they were able to be really fruitful, so she would punish them and me by being an unrewarding baby/patient.

‘Getting better’ is also giving pleasure, affirming the creativeness of those who have tried to help. For some the unconscious rage against the parents make such a gift impossible to make. Their only weapon is the spoiling of their own lives. In a sense, getting better implies forgiving. In an unpublished talk, Dr Robert Hale, who has done a great deal of work with drug-addicts, emphasises this as a reason for the addict’s persistent refusal to save their own lives. Underlying much self-destructive behaviour is this refusal to forgive what seem to be unrightable wrongs, unrelievable grievances, over what has gone on in the child’s past. Indeed, many of the children have much to forgive, and it is unsurprising that this is difficult.

‘Getting better’ not only implies forgiveness, it also implies gratitude. This in its turn necessitates an acceptance of vulnerability and neediness. It is against the psychic pain of this vulnerability and dependence that so many of our children’s symptoms have been developed as defences, especially when such states are rendered infinitely worse by parental unreliability and failure.. But the potentially terrifying state of independence has to be accepted before the gratitude, the feeling of having received something good from outside themselves, can be felt. Often, the children would rather maintain their far from splendid isolation than face the reality of their position and needs, with the ever-present possibility that they will again feel let down. The apparently simple psychic manoeuvre of feeling grateful involves many of the areas of most acute difficulty for the children and can add to the load holding them down in their illness.

External Factors Inhibiting Progress

It has to be acknowledged that some parents may in reality be ambivalent or even destructive towards their child’s progress, which may put extra pressure on him/her at the point of possible success. For example Wayne (no. 2 in the opening illustrations) is the ‘baby’ of his family and his mother has consistently treated him as being much younger than he really is. Her fear of what his growing up will bring has led her to reinforce his own fears with statements that he was not yet ready to return to ordinary school and to meet his anxieties with encouragement to give up, rather than reassurance to continue.

So ‘getting better’ can bring additional burdens in terms of the child’s relationship with parents and peer group. In the extreme cases, if his milieu is a very disturbed one, then improvement can often mean isolation for the child. For Martin (14) who is struggling to keep in touch with the softer, more caring side of himself, when violent ‘macho’ behaviour is the hallmark of his family, to be different implies a determined breaking out of their mould and maybe out of their world.

It is to be hoped that greater mental health in a child would improve relationships at home, but it also has to be acknowledged that in some households the child may be the only one well enough to break out of a destructive family system. There can be terrific conflicts of loyalty for a child in this position.

Improvement can also be a family ‘minefield’ for children whose progress arouses envy in the parents towards the people who have helped him. The parents of the children have their own guilt and feelings of inadequacy to face, and it can be full of conflict to see one’s child being helped out of difficulties that one has been unable to help them with and maybe partially caused. The parents therefore may have their own problems in allowing the child to get better, even if these are entirely unconscious and at odds with all their love and concern. They, as well as the children themselves, may be unable to allow the teacher or therapist that amount of potency.

Children can also be held back in their progress by a fear of being of less concern to parents and teachers if they give up their attention-getting troubled behaviour. It can seem to them that their parents are only really mobilised as forces in their lives in activities centred around their difficulties. So, despite the fact that they know that they provoke much negative feelings in their parents and teachers, they do at least feel that they exist for them, and this can seem better than what feels like being quite forgotten.

Concluding Remarks

When there is the possibility of improvement, all these motivations to self-destructiveness are potentially activated. Before this, when the child seems stuck, it may not be apparent quite how powerful they are. One’s attention is often on the more striking features of the child’s difficulties, such as his inability to share or his hatred of anyone challenging his omnipotence. But when hope begins to dawn, the child can be thrown into a most painful state. Mental health is not the absence of psychic pain, far from it. It is the ability to encounter it, tolerate it and develop through it. The children’s difficulties are not caused solely by the overload of such pain, but rather by the attempt, for whatever reason, to avoid it.

In a very real sense, getting better does, some of the time, make it worse. We need to be aware of what we are asking of the children when we offer them the chance of improvement. We are setting them no easy task, and the pain on the way may be enough to drive many a child back into the comparative safety of his illness. Understanding what they are going through should help us deal better with the despair and frustration engendered by their resistances, to contain their anxieties and therefore to steer a straighter course ourselves. It can help us more meaningfully to talk to the children about their fears, thereby making them more comprehensible and less uncontrollable. One hopes that we would be better able to avoid unrealistic expectations or over-enthusiasm in the face of progress if we can always hold in mind the anxieties aroused and the probability of there being set-backs. This will strengthen us and help us strengthen the children against giving up hope when things get difficult. It will perhaps take many periods of progress followed by failure before the necessary inner strength can be built up. There is no escaping the pain of this process, but an understanding of what is at stake will help the children negotiate the difficult path through the worst, on to a state where being ‘better’ brings its rewards of stability, creativity and peace of mind.

From “The Emotional Needs of Young Children and their Families” Eds. Trowell, J and Bower, M (Routledge 1995)