MONROE WAS THE KIND OF CHILD FROM WHOM USUALLY LITTLE IS expected therapeutically. A member of a disadvantaged ethnic minority, he lived in the poverty of a big-city slum ghetto; as do so many children from such circumstances, he had as presenting problems marked intellectual retardation, a nearly psychotic degree of withdrawal, impoverished affect, and episodic difficulties with impulse control (Meers, 1970), (1973). The fact that his treatment ran dramatically counter to the usual pessimistic expectations makes the fascinating adventure it turned out to be especially worth reporting. It also is worth reporting because it serves as an example of the therapy of several dozen similar children treated by the Cornerstone method, all of whom have been helped.

The Cornerstone Method (Kliman, 1968), (1969), (1970), (1975), (1978) is an attempt, in the context of a community clinic, to integrate psychoanalytic therapy with the therapeutic nursery education of preschool children in order more fully to exploit the properties of each. A child psychoanalyst or psychotherapist works in the classroom alongside two teachers for about two of the daily three hours of class time, four to five days each week, with seven or eight children. The psychoanalyst or therapist treats the children individually right in the classroom, in sessions of 20 to 25 minutes; each child receiving three or more such sessions weekly.

The teachers simultaneously conduct a therapeutic nursery program. By means of affection, example, limit setting, guidance, and stimulation, they work to promote the children's interest, skills, and talents; aim at taming their "drive" behavior in order to divert it into play, learning, and work; and encourage their gaining independence from primary objects by helping them to establish other relationships (Edgcumbe, 1975). The teachers also provide guidance for the children's parents. Where possible, each child's parents are seen once weekly by a teacher, except for once every fourth week, when the therapist sees them.

The teachers and therapist also become involved in complex interactions with one another and with the children (Kliman, 1968), (1975), aspects of which can only be touched on in this paper. It is important to bear in mind, however, that a consistent effort is made to maintain the roles of therapist and therapeutic teacher separate: the former adhering as closely as possible to the interpretive stance of the psychoanalyst; the latter, to the stance of the therapeutic educator of the preschool child.

CASE PRESENTATION

Monroe was the second of three sons born to an impoverished black couple. When he was 2 1/2 years old, his mother suffered a psychosis following the birth of her third child, who was born with a defect requiring a chronic tracheotomy. The mother's psychosis-about which no more than the most fragmentary information was ever gained-included delusionary fears a man would enter her window and attack her. She was hospitalized for nine months and then treated by drugs, the dosage level of which induced her face to take on a masklike appearance and caused her to become grossly obese and slow in her movements. While she was in the hospital, Monroe and his brother, older by 2 years, were cared for by their father and paternal grandmother. The baby was placed in permanent foster care. When Monroe's mother returned home, his father moved out for good, and remained out of contact with the family, except for occasional visits. Throughout Monroe's treatment, neither his mother nor anyone associated with the case knew where his father lived, nor were they able to meet with him. The combination of father's absence and mother's condition made it impossible to gain information about Monroe's early development.

Monroe was referred by a daycare center as a result of his obvious profound developmental lags and grossly atypical behavior: he had little ability to relate to peers and adults; very sparse use of language (limited to occasional phrases such as, "I don't know" or "Thomas hit me"); grossly deficient capacity to learn; a withdrawn, detached appearance, interrupted only by occasional outbursts of obstreperousness; overall, a joyless lack of vitality. On intake, he was described in terms of wandering gaze, lax facial musculature, paucity of expressive interchange, impoverished affect, and scored an IQ (WISC) of 53. However, the examining psychiatrist (G.W.K.) noted some positive features. Monroe's receptive comprehension of verbal communication was at a higher level than his active linguistic expression: he readily brought a toy elephant and a yellow truck when asked to, finding them in the middle of a cluttered floor. On request he built an excellent tower of blocks with some 25 pieces. And he seemed very pleased at the examiner's admiration and encouragement.

Monroe began what were to be two years of Cornerstone method treatment at age 4. Prior to it, he had been seen individually by Mrs. H. Baskerville of The Center for Preventive Psychiatry in educational psychotherapy (Stein and Ronald, 1974)-an approach similar to that discussed by Weil (1973)-for some ten months, three sessions weekly. Educational psychotherapy, though it may have enhanced Monroe's response to treatment in the nursery, brought about no appreciable improvement in his functioning.

A "homemaker," a woman employed by the county, spent eight hours of each weekday with the family to help care for it. A "therapeutic companion," a female graduate student, was provided by the Center to spend time with the family, one day of each weekend.

THE FIRST YEAR OF TREATMENT

When Monroe arrived at Cornerstone, accompanied by his seemingly barely ambulatory mother and the homemaker, he fully fitted the description of him at intake. His eyes appeared glazed; his visage, like that of many institutionalized patients, blank; his affect flat.

However, in the very first session, when, in an attempt to make emotional contact with him, I1 cautiously rolled a toy truck to him, a somewhat livelier facial expression immediately developed. More important, Monroe rolled the truck back! I suggested we were getting to know each other. Monroe managed to smile through his sad vacant look and actually seemed delighted. Then he smiled broadly and rolled the truck to other people in the room: to the teachers, to his mother, and to other mothers, present because it was the first day of school. He responded to my remarking on his discovering other people eager to play with him with an almost uncanny show of ecstasy: he squirmed about the floor, seemingly trying to rub as much as he could of his body on it. A thing as good as this, I commented, ought be made contact with by as much of one's being as possible.

Monroe quickly became more active. In the second session, he jumped off a table into my arms, declaring he was a baby and I his mother, and assigning to me the task of his caretaker. By the end of the first week, when another child was in possession of something or someone he coveted, or when the day's class session had come to an end, Monroe shrieked in a deeply pained, almost unearthly manner, though without tears. At the end of one session, he attempted to destroy the watch on a teacher's wrist, seemingly in an effort to halt the passing of time. Within two months, Monroe cried and wept continuously during the greater part of three sessions immediately following the three-day interruption of school.

Within a month of entering Cornerstone, Monroe became very difficult to cope with. He would kick, bite, spit, punch, scratch, and make a shambles of the classroom, create chaos and drive the teachers to near despair. He would ingest great quantities of food, storming the cupboard where it was kept or attempting to appropriate all of what had been set out for the entire class. When he was stopped and scolded, his frenetic activity might well dissolve in a flood of tears, as he would fervently hug and kiss his scolder, ask to sit on her lap and be cuddled by her. As infuriating as Monroe might be one moment, as lovable he became the next. In one session, he bit a very attractive female psychologist who had come to administer tests. Then he stuffed himself with pretzels and potato chips. My verbalizing that the recipient of his bite was a "yum-yum" brought forth ecstatic nods of agreement from Monroe. He then declared a wish to go camping with her in a nearby forest.

Despite the turmoil there was a general feeling that Monroe's condition was improving. Following his morning session in Cornerstone, he continued to attend the daycare center, where he was functioning better: he was following his teachers' instructions and getting on better with the other children. It appeared that the attention, tolerance, and affection-and, of course, the food-Monroe was receiving from the nursery were enabling him to feel more nourished and intact outside of it (Kohut, 1971), (1977). Confirmation came from a most unexpected source and for reasons that were astonishing: Monroe's mother, her pitiable appearance unchanged, volunteered that her son was improved because he seemed more lively and troublesome at home! While it was difficult to know to what extent she was suffering from mental illness, and to what extent from her drug treatment, it was clear that she was no longer actively psychotic. We failed in our efforts to prevent continuing overmedication to which she was subjected by a nearby aftercare clinic, but we were able to engage her in nearly weekly parent guidance.

Within three months, Monroe was affectionately feeding a dog outside the school; playing at being a fireman at the local fire station which we often visited at his request; proudly presenting Ms. Balter, one of his teachers, with splendid phallic structures made of blocks; affectionately hugging her while wearing a mask he had cut out of paper to disguise himself as a grown man; and once playfully urinating on her hand when she helped him with his trousers in the toilet. He emerged as the most competent among the children at cutting designs from paper, and radiated a charisma which made him very popular among his peers.

Nevertheless, Monroe's ego limitations were glaring. His thinking was so stimulus - or context-bound (Goldstein, 1939); (Werner, 1940), (1957), he was unable to engage in conversation because he could not, at will, call up relevant ideas within himself. For example, to deal with the fact that waiting for him to produce material relevant to therapy invariably resulted in little more than his ignoring me, I would at times begin work with Monroe either by throwing him in the air and catching him, or by holding him by his feet upside-down-activities which delighted Monroe. When asked which he preferred, however, Monroe was unable to verbalize his choice, simply saying "yes" when I did so.

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Dr. Gilbert Kliman, won the International Literary Prize for Best Book concerning the Well Being and Nurture of Children, "Responsible Parenthood" and is the recipient of grants from over 50 private foundations and The National Institute of Mental Health. His research interests include the Psychological Trauma and Treatment of Severely Disturbed Children and their families, in-classroom psychotherapy.

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