Co-creating safety: symbolic transformation and the recovery of epistemic trust in a traumatised adolescent

This case report describes the inpatient treatment of an 11-year-old boy with neurodevelopmental vulnerabilities and a history of complex relational trauma, who presented with severe aggression, self-injurious behaviour, and profound disturbances in symbolic functioning. At admission, his psychological organisation was dominated by action, fragmentation, and a collapse of epistemic trust – the capacity to experience others as reliable sources of meaning and knowledge. Treatment prioritised the establishment of safety and regulation over premature trauma exploration. Although operationally structured by the ARC (Attachment, Regulation, and Competency) framework, the approach was grounded in Bion’s containment and Fonagy’s account of epistemic trust. Within the containing structure of a child psychiatric inpatient milieu, non-verbal and co-creative interventions, including Winnicott’s squiggle game and the careful tolerance of therapeutic regression, enabled engagement when verbal reflection was inaccessible or experienced as threatening. His symbolic productions were persecutory and catastrophic from the outset – exemplified by the drawing of ‘Pandora’s box’ – and over time moved from this unshared, threatening form towards shared symbolic narratives, culminating in the co-signed image of an open ‘Treasure Chest’. What remained concrete and unrepresented lay not in these drawings but in his body and action: explosive aggression, self-injury, and the refusal to wash. This case illustrates how, in severely traumatised adolescents, symbolic capacity may be present, yet unshared and persecutory, and how the restoration of epistemic trust may be what allows it to become shared and communicative.