Adolescent sex offenders present a therapeutic problem in that they are both victim and perpetrator. As perpetrator they present a social problem and need containment while the underlying victimization needs treatment. A special unit has adopted an integrated model of systemic, cognitive-behavioural and psychodynamic frame works. To take into account both victim and perpetrator, psychoanalytic psychotherapy needs to be modified by (a) the incorporation of child protection measures and (b) a continuing focus on the offending behaviour. Given this structure the psychodynamic work helps to support a sex offender safely in the community and also produces dynamic material that illuminates the pathological processes from abuse to abusing. Themes that emerge in the treatment include sexualization of attachments, re-enactments of the abuse and a constant testing of the boundaries of the therapeutic relationship. Working actively with these issues can be seen to strengthen creative capacities in the young person as well as to help prevent recurrence of abusive behaviour. Clinic material is presented for illustration of these points.

This paper investigates how it is that a child has become an abuser, and by what means that process may be deconstructed. We know that abusers generally have a childhood history of abuse, though not necessarily sexual. Since not all children who have been traumatised repeat those patterns, and inflict abuse on others, then something must have happened for these particular children in response to their abuse. The author elaborates the view that there is no such thing, to paraphrase Winnicott, as ‘an abused child’ – no such child, that is, separate from the world of the relationships that formed him. He draws on the conceptualisation by Bentovim of an interlocking set of roles described as a ‘trauma organised system’; this notion reflects the fact that the child is a product not just of his specifically traumatic experiences but of a milieu in which power and control is exerted by someone who has typically succeeded in neutralising any caring function in a family in order to bring about the exploitation of a child. Clinical material is presented from the intensive psychotherapy of a nine-year-old boy, who happened also to be a refugee, for whom abusive family dynamics dominated his internal world. He was found to have identified with the abuser, his own father, in order to escape the pain of his victim self and was threatening to act this out in the treatment, making the therapist into a victim. Management of the treatment setting by the inclusion of a benign parental figure enabled the acting out to be contained. Symbolisation of the child’s inner conflicts became possible through play. As the abuser self was contained so the child’s victim experiences could be processed. The conclusion is drawn that engaging therapeutically with the residues of trauma from the beginning of treatment is essential in working with young people who have abused

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It is now widely recognised that families represent a hidden and largely unacknowledged resource to the NHS in the day to day management of long-term disabilities, particularly severe mental problems like schizophrenia. It is most likely that 50–60% of first admission schizophrenic patients will return to some type of family environment and a significant number will remain with the family for a considerable time. The current trend towards community management of mental illness, hampered by the lack of community provision, almost inevitably means discharge to families and is likely to continue and increase further.