A BRIEF DISCUSSION OF NEVILLE SYMINGTON’S: THE PSYCHOTHERAPY OF A MENTALLY HANDICAPPED PATIENT
I have recently been reading Neville Symington’s (2007) book ‘Becoming a Person’ which is a collection of papers describing his experiences as a psychoanalyst. In this interesting book he outlines how his own experiences undergoing psychoanalysis as well as his experiences as an analyst to people with psychosis, people who are psychopaths and people who are intellectually disabled. The book is a collection of papers written over a period of thirty years which outline how he has developed as a person through different aspects of the analytic experience.
Chapter 8 of the book is a discussion of his experience when acting as a therapist of an adult age 33 who had an intellectual disability. His clients name was not given in order to protect his privacy so a pseudonym was given: Harry Smith. Harry had an IQ of 59. Conventional psychoanalytic wisdom argues that only people who have and IQ at 120 or above can benefit from psychotherapy. So Symington was going against conventional wisdom when taking on Harry.
After reading the case study I decided to write a short blog discussing it. Before proceeding I should note I am not a therapist of any bent. So this blog is the opinion of an interested layman as opposed to a psychiatrist, a psychoanalyst, psychologist or therapist of any kind. I did study psychoanalysis as an undergraduate as part of my philosophy degree. Furthermore my PhD centred on the philosophy of science, mind and language. So I am very familiar with the evidential bases used in all of the main therapies. A few years back I underwent psychoanalysis for a year and a half. So I am familiar with the experience of psychoanalysis from both a theoretical point of view, and from the point of view of an analysand. I have also worked as a care assistant with people who have intellectual disabilities for over ten years. So I am aware from a practical perspective of some of the emotional difficulties which face people with intellectual disabilities throughout their lives. For these reasons I decided to give my perspective on Symington’s discussion of psychotherapy for people with intellectual disabilities.
I found his paper both very impressive and very disappointing at the same time. What I found impressive was his wisdom in helping Harry in the therapeutic setting; however I found his theoretical discussion seriously defective. I will begin with the positive and discus what impressed me about the paper.
According to Symington Harry came from a working class background, both of his parents were hard workers and well presented though the mother was a bit more dishevelled. The father, mother and Harry all lived together in a small flat. However the parents lived separate lives, the father lived in his own room which had a television, armchair, bed and all his own possessions with him. The mother and Harry had their own rooms but spent all of their time together. The father thought that Harry was much smarter than people gave him credit for and wanted Harry to get a full time and paid job. While the mother claimed that she just wanted Harry to be happy. Harry’s father was a former alcoholic and though he had not drank for years his mother took a dim view of the father and Harry was aware of this.
When Harry began his therapy he was obsessed with the question of his intelligence level and anxious about the conflicting opinions on his abilities that his family and careers had of him. He talked incessantly in his early sessions and found it difficult to concentrate on what his therapist said to him. His primary aim was to get his therapist to give an assessment of his abilities which he could file alongside the various different assessments he had already received. Symington instead of offering his own assessment listened to Harry and tried to get Harry to discover his own abilities.
As therapy went on it became obvious that (1) Harry held his mother as an idealised figure who he could not think negatively about. (2) His ego was almost merged with her ego (3) Harry found it difficult to separate fantasy and jokes from reality. Symington didn’t tell Harry these facts but helped him to work to them out himself. After Harry left the therapy Symington discovered from the social worker the following facts: (1) Harry was now unwilling to do any work task at the centre. (2) He stayed at home, but reported to his social worker from time to time and continued to wonder whether he should continue treatment again. (3) It was confirmed that Harry was able to conduct a conversation that would have been quite impossible before the therapy began. He was less pressured by inner anxiety. (4) He was more decisive and had a greater sense of autonomy in relation to life’s choices. (Becoming a Person, p. 137)
Overall then the therapeutic intervention was very successful, in that it helped Harry achieve a greater sense of self understanding and autonomy. Obviously from a single case study it is hard to draw any large scale generalisations. It seems that Symington’s practical wisdom in realising that offering Harry another interpretation to place alongside all of the other ones was vital in the therapeutic success. Likewise Symington’s ability to recognise the unconscious idealisation of the mother and partial inability of Harry to distinguish fantasy from reality were vital. However more importantly Symington was listening to Harry’s stories and helped Harry arrive at the understanding of his situation himself, it was this that gave Harry his greater autonomy. So Symington’s success was a combination of theoretical insight and practical wisdom.
Despite the success of Symington’s analysis of Harry there were aspects of his paper that I was less than happy with. In particular I disagreed with his theoretical explication of therapy for mentally handicapped patients. He explicated developmental delays in people with intellectual disabilities in the following way:
“In the subnormal patient there is an active force blocking the development of intelligence. This means that intelligence presents itself as a threat to the organism.” (ibid, p. 141)
“Now, if there is a regression to the foetal stage in development as Pierce Clark suggests, then to move in a new relation to mother as a result of birth is something powerfully resisted. The hatred of reality and new objects necessarily implies a violent detestation of intelligence. The patient desires to stay in a fixed relation to mother and does not want the emergence of intelligence” (ibid, p. 142)
The above characterisation of intellectual disability is to put it bluntly utter nonsense. Firstly people who have intellectual disabilities do so for a variety of different reasons. If one considers Genetic Disorders like Down syndrome, Fragile X Syndrome, Angelman Syndrome, and Williams Syndrome one can see the absurdity of Symington’s characterisation of the cause of low intelligence in intellectual disability. We understand the biochemical reasons for lower intelligence in all of these disorders to an incredibly detailed degree. The same is true of Neurodevelopmental disorders which occur as a result of birth trauma e.g. and umbilical cord getting wrapped around the babies neck. If this results in damage to the motor control or general intelligence we can trace it to a lack of oxygen in particular areas in the brain. There is simply no need for Symington’s psychological hypothesis in the case of intellectual disability.
Probably the reason Symington was driven to his hypothesis was to explain the change that occurred in his patient which would not necessarily be predicted based on the idea of fixed brain damage. However we are learning that the brain is much more flexible and plastic than it has previously been considered (though it is not near as plastic as some hype would lead one to believe). So Symington’s success can probably be explained in these terms.
In recent times neuropsychoanalyst Marc Solms has been treating patients who have brain damage. Solms is an expert on brain function as well as the human element of psychotherapeutic treatment. Symington showed a real intuitive ability to help Harry with his treatment. It is imperative though that analysts offering such treatment follow Solms example and acquaint themselves with the relevant neuroscientific data to supplement their treatment.