The conceptual framework helps with thinking, but this thinking needs to be differentiated from a way of working, from the actual techniques of intervention. While I still continue to think within a Kleinian framework, years of clinical experience have taken me away from a strictly Kleinian way of working to a position that embraces a less interpretative and more playful approach. (Location 226)
The conceptual and technical tools used by current child therapists are the legacy of previous generations of therapists, who have shared their thoughts in publications and supervision. To understand, and more importantly, to challenge these historical wisdoms, it is imperative to know how they evolved and in what context they were formed. (Location 247)
While Freud was hearing about this early sexuality from his patients, he believed it was not the sexual phantasies as such that were the problem, but the repression of such feelings that lead to neurotic symptoms. Such thinking implied that all human beings have sexual feelings in childhood. To explore this view, Freud observed his own children, and asked colleagues and friends to observe their children, to see if any signs of childhood sexuality could be discerned. These observations, along with his clinical material, led to the publication of The Three Essays on the Theory of Sexuality (Freud 1905a), in which Freud put forward his ideas about the nature of childhood sexuality, and proposed the various stages and vicissitudes of these instinctual drives. (Location 266)
What is important in this case is the serious consideration given to the child’s behaviour. It is not thought to be naughty or silly. For Freud it had meaning, a meaning that confirmed his theory about child development and sexuality. Hans was struggling with sexual feelings towards his mother, and rivalrous feelings towards his father, but such feelings had to be repressed for fear of a retaliating castration from his father. This case also highlights Freud’s appreciation of the need for close and detailed observation. While one may now disagree with Freud’s interpretations, it is in this case that we can see the beginning of what would now be called a psychoanalytic attitude—that behaviour (even a child’s behaviour) has meaning and can be determined by unconscious factors. (Location 276)
Sigmund Freud died in 1939, but the hostility between the two groups, now in the same city, came to a head in a series of scientific and administrative meetings at the London Institute of Psychoanalysis. The meetings took place between 1941 and 1945. These later became known as the ‘Controversial Discussions’ (King & Steiner 1991). The purpose of the meetings was to examine the contention that Klein’s ideas were incompatible with Freudian principles, the implication being that they could not be considered proper psychoanalysis. Was it a deviant form of analysis or an extension of Freud’s ideas? Should they be excommunicated, like the followers of Jung, Adler, Rank and so on, or could they stay within the kosher confines of the International Psychoanalytic Association? In the end, despite many personal attacks, the London Institute remained intact, eventually agreeing to a tripartite subdivision of Freudians, Kleinians, and Independents (those members who were not willing to take sides). (Location 431)
To overcome this problem, she felt it was necessary to settle the child into feeling comfortable and positive with the therapist. Only with this trust could the disturbing work of analysis proceed. To be able to look at negative feelings about themselves, children had to feel positively about the analyst and themselves. (Location 445)
Anna Freud did not consider this introductory period to be part of proper analytic work. It was merely preparing the ground for the work of interpretation that was to follow. (Location 454)
Anna Freud saw this technique of engaging the child as a necessary modification of the classic technique used with adults. She did not believe you could immediately interpret to a child. This would be too disturbing. The child’s inability to process his or her ‘revealed’ feelings, and the inability to morally manage them (a weak superego), would be damaging to the child’s sense of self. Klein felt that not only could you interpret immediately, but it was absolutely necessary to do so if you were to engage the child’s cooperation and interest in the analytic work. (Location 460)
favorite psicoanálisis infancia interpretación klein anna freud
While Klein never really changed her thinking about engaging the child through interpretation, Anna Freud did discard her technique of an introductory phase in favour of interpreting the child’s initial defences in therapy. Thus she did use interpretation to engage the child, but such interpretations were directed to the child’s conscious awareness. She would talk about the need of a child to puff himself up, to act in a superior and arrogant manner, as a way of defending against feelings that he may be no good or not wanted. This stayed ‘on the surface’. It was directed to feelings the child could readily grasp. Klein felt it was necessary to go to the ‘base’, that deeply unknown ‘feelings’ needed to be exorcised, allowing the roots of the anxiety to be revealed. This would free the child from primitive anxieties and guilt and enable development. (Location 471)
One of the reasons Klein would interpret in the early sessions with the child was because she believed that the child could immediately have a transference reaction to her. Anna Freud felt this was not possible, as the child could not transfer thoughts and feelings from the past onto the therapist because there was no past to transfer from; that is, the child did not have a past in the sense of a past relationship with its parents. (Location 481)
Klein was proposing that the infant was socially wired to relate from the very beginning. Klein was aware how fleeting and primitive this relating could be, but nevertheless felt the infant was capable of discerning pleasure and pain, and at times such states were related to the outside world, or to ‘not me’ experiences. (Location 486)
Initially this world is the mother—that is where the blueprint is formed. But all later relationships, both human and nonhuman, would be influenced by these primitive gestalts. In this way all relating is a transference for Klein. The application or transferring of this blueprint to all other situations throughout life makes Klein’s concept of transference much broader and more ever present than Anna Freud’s use of the term. (Location 494)
Anna Freud did not believe that all reactions of the child to the therapist were evidence of transference. Some reactions were responses to the current reality of the therapist. (Location 513)
Current child psychotherapy practice has been heavily influenced by the growing appreciation of the systemic forces within the family, and the developments in family therapy, as well as the strong recognition of the importance of parenting, especially in the early years. From 1960 on, both the Hampstead Clinic and the Tavistock have included working with parents as an important part of their training. (Location 525)
From a technical point of view, one of the greatest differences between Anna Freud and Klein was in their thinking about the role and meaning of the child’s play. These were important differences, and profoundly affected how they worked with the child. Klein believed that the child’s play, in a free play situation, was the equivalent of the adult’s free association; that is, if you followed the sequence of the play, you would come to an understanding of what it may mean. (Location 534)
Klein conceptualised the child’s mind as a place full of phantasised objects that have relationships with each other. Anna Freud held to her father’s view that the child’s mind was full of powerful impulses that had to be managed by the child’s reality sense (ego) and moral sense (superego). Because of these differences, they had different ideas of what i n sight mea nt for the child. I nsig ht for Klein meant that the child became aware of his or her primitive phantasies, and was able to integrate these thoughts and feelings into the rest of the psyche. For Anna Freud, insight meant the child had a greater understanding of how his or her own mind functioned. The child would be more aware of the strategies he or she employed to manage their instinctual forces. (Location 566)
Ernest Jones, in his paper (Location 581)
‘Some Problems of Adolescence’ (1922), examined the link between adolescence and early childhood. He proposed that the problems arising in adolescence were a reworking of difficulties experienced in earlier years (two to five years of age). This is a strongly held belief in analytic circles to the present day. (Location 581)
After World War II, a major analytic influence came from the work of Donald Winnicott, a paediatrician and child analyst. Although influenced by Anna Freud and Klein, he gave less emphasis to interpreting and more to the therapeutic value of play. For Winnicott play was more than a diagnostic tool. While it undoubtedly revealed the child’s unconscious, it also had a healing effect in its own right. This profoundly affected the way child therapists worked (Lanyado & Horne 2006; Lanyado 2004). (Location 631)
infancia psicoanálisis juego donald winnicott psicoterapia
The 1970s saw the development of the family therapy movement. A greater appreciation of the systemic forces of the family on the child led to the practice of seeing the whole family rather than the individual child. This broader perspective also affected the practice of child therapy. The growing understanding of projective identification, particularly from the work of Bion, enabled Kleinian child therapists to work with the dynamics of the unconscious processes within the family (Box et al. 1981). Bion’s concept of containment extended the idea of the unconscious out of the individual and into the interplay of how unconscious forces can move around within relationships (see chapter 2). (Location 640)
A clinician observes, thinks, and at some stage, intervenes. These three activities define the work. They are the basic building blocks of the clinical process. (Location 684)
To make sense of our observations we need to think about them: to gather, organise, and relate different sets of data to each other so they start to form a pattern. Only then can we begin to make sense of the data. This enables us to ‘do’ something with this information. (Location 690)
there is also the danger of being led by theory. Too much theory can bias perception. Ideally the clinician makes observations, then finds a theory that fits, rather than the other way around. (Location 693)
The broad theoretical orientation of this book is Kleinian. This is how I was trained, and how I was taught to think clinically. But it is 24 years since I left my training in London. Being 12 000 miles from this theoretical base has given me enough space to develop my own way of working. It may be ‘loose’ according to Kleinian orthodoxy, it may be internally inconsistent or even contradictory (as my philosophical friends may say), but it is mine. If we are trying to help people feel authentic, it is crucial that we feel this ourselves. (Location 702)
I say what I say and, as Meltzer (2003) says, I hope the person hearing it may be curious and interested in what I am saying. I do not think, this is projective identification, or counter-transference, and so on. If this were happening in the room then I would worry about my ‘observational distance’ being too far away. (Location 717)
Such splits are likely to occur in the earliest years of life. The small child who is forgotten, neglected, or emotionally abused is not in a position to express his or her rage, despair, and humiliation. If such interactions occur before the child has words, then there is little ability to process such emotional states. Even if the child is able to speak, he or she may have few carers, people who can provide a model for processing these traumatic experiences. (Location 737)
It needs to be noted that if the somatic conversion is really effective, it is going to make no sense whatsoever to say to a person that his or her physical pain has something to do with feelings of irritation. The client will not know what you are talking about. In this way the concept of the unconscious can be thought about clinically as someone having a ‘feeling’ without feeling it. (Location 779)
All this has implications for technique. To quote Mollon (2000, p. 6), ‘a psychoanalytic interpretation that goes quite beyond the patient’s potential awareness so it could only be accepted on faith, would be quite useless’. Not all child therapists would agree with this (especially classical Kleinians). I will discuss this later in the chapters on therapy. (Location 785)
Freud proposed that the ideas that were repressed involved sexual and aggressive feelings, and that these feelings were fuelled by instinctual drives. In more recent times, some schools of analytic thought have moved away from this biological emphasis, and have viewed repression in more relational terms; that is, certain feelings or attitudes have been repressed because to feel them would threaten the relationship. (Location 788)
An example of an unfelt feeling that is managed by making someone else feel it can be seen in adolescence. An adolescent may feel uncertain about his future, but cope with this by staying out late and not telling his parents where he is. It is the parents who are to feel uncertain and worried. The adolescent’s behaviour has transported his worries into them. Another example can be the young child who is frightened of being weak and vulnerable, but cannot allow him- or herself to feel this. Such children attempt to cope with these feelings by bullying others so that others feel these feelings of fear. This way of managing emotional distress, by transferring it into others, raises the whole question of the nature and geography of mental pain. It also raises the question of relationships, both within the individual and with others. This mechanism of making others feel your feelings leads to the concept of projective identification. (Location 793)
These last two examples highlight another aspect of projective identification, the state of mind behind the projection—what is the aim or purpose of the projection? Rosenfeld (1987) believes projective identification can be in the service of evacuating the unwanted aspects of the self, so it is used as an attack on the other, while at other times the projection may be in the service of communication, to let the other know, in a felt way, what is unbearable, to seek some sort of processing containment. I felt my interaction with Marion was of an attacking kind, and this had something to do with the violence and intensity of my feelings. With Paul the interaction felt painful, but more thinkable, and in this sense felt as if it was seeking understanding. (Location 837)
Bion developed the concept of projective identification especially in relation to its role in communication and his ideas about containment. The importance of containment cannot be overestimated. It is fundamental to all my analytic thinking. It is the concept I use in every therapeutic endeavour. (Location 851)
Bion (1962) postulated that projective identification is an important method of identification and communication in the early infant–mother relationship. This is seen in infant observation where the mother ‘feels’ the baby’s anxiety. It is a primitive form of identification. Bion suggests that the infant’s early ‘emotional’ states, pleasurable as well as painful, are experienced concretely and are not known as emotions as such. Because of this they are not available for mental growth. These states cannot be thought about, imagined, or remembered until they have been transformed into some form of abstract experience. Bion is proposing that the infant’s immature system is full of powerful sensations, and the infant can only deal with them by evacuating or projecting them out. These projections are caught and held by the mother. The model is like a spillout system in which the sensational spill is taken up and held by the mother. There is a concept of a container and a contained. (Location 853)
A mind is created when the individual’s inner world meets with the outer world of the container. unlike Freud’s instinct drive theory it is not only the power of the projection but also the strength of the containment that will determine the state of psychic functioning. (Location 862)
The relationship between infant and caretaker is placed at the centre of mental development. The real outside world is now viewed as vitally important. (Location 866)
At position A, the infant is unable to hold the powerful sensations—as adults, we may name this sensation as distress due to hunger. The infant’s system rejects and evacuates this sensation; for example, a burning throat or pulsating gut (Bion calls these sensations ‘beta elements’). In position B these sensations, what we would call distress, reach the mother. There is now the crucial situation of whether the mother is able to recognise and take on board this distress. This is not an intellectual process, for to truly accept this distressing state of being, the mother must actually feel the distress. She must experience, to some degree, its overwhelming and frightening quality. It must blow her system for a moment for her to really feel what it is like. Bion refers to this unthinkable experience for the infant as nameless dread. (Location 868)
I want to stress the importance of this process at position B. If this distress is only accepted in some intellectual way and not really felt by the potential container, then this is the equivalent of not being accepted. What I have in mind is the experienced mother who never gets overwhelmed. Here the infant has no real experience of knowing another human being who knows what it feels like to have these horribly overwhelming sensations. This is also applicable to therapy. I am thinking of the experienced therapist who may have the correct understanding or interpretation, but over the years has not allowed him- or herself to really feel the distress. Being able to feel this distress, and not be overwhelmed by it, is probably the most important capacity a therapist can have. This saves a lot of us who are not especially clever or intellectual. This capacity to feel and contain is not a cognitive exercise, although some cognition is involved. The capacity to think under fire, to use Bion’s military metaphor, is what is needed. This is not easy. Ask any parent who is up all night with a screaming baby. Ask anyone who is around small babies for any length of time. In these situations, you are in the firing line of powerful primitive emotions. In therapy, seeing a very disturbed child or adolescent can take its toll emotionally. This is one of the occupational hazards of doing this work. It also highlights why it is so important for therapists to have a good support system both in and outside their work. (Location 879)
Sustained exposure to this lack of containment leaves the infant bereft of psychic equipment to manage his emotions. As this infant develops into a child he will have little or no space for thinking about his sad or anxious feelings. Such feelings remain unexpressed. Being unexpressed, they can seek expression in the transformed and disturbing states of hyperactivity, phobias, obsessions, and so on. (Location 902)
I think when you are physically attacked in therapy it is often the case that not only are you not accepting a projection, but you are also pushing it back into the patient. The only thing left for patients in this situation is to try to annihilate the person they feel is attacking them. (Location 924)
In Richard’s case, the question of timing is of fundamental importance. Feeding back the projection too early can be disastrous. An important part of clinical work is judging when, how much, and in what form the projection can be given back. It may take some time before the infant/patient feels that the overwhelming feeling has been felt by the mother/therapist. This needs to be long enough to make him or her feel it is safe to begin to experience these feelings again. (Location 936)
In this process, the mother/therapist transforms the terrifying sensational states into something that can be thought about. The infant can begin to build up a realisation that ‘there is somewhere in which the unmanageable can be made manageable, the unbearable bearable, the unthinkable thinkable’ (Isaacs-Elmhirst 1980, p. 87). This containment is not just a passive receptive activity but also an active process, which involves feelings, thinking, organising, and acting. (A further discussion about when and how this is fed back can be found in (Location 940)
By hearing the child’s story we try to gauge the disturbances to containment that the person may have experienced. We carefully listen to events such as traumatic separations or other difficulties that may have impaired the parents’ ability to think about the person emotionally. (Location 950)
Transference is a cornerstone of analytic work. It distinguishes it from all other forms of therapeutic intervention. By transference I mean the feelings that are transferred from past relationships on to the present, immediate relationship with the therapist. (Location 954)
This awareness profoundly affected his thinking about the therapeutic process. Actually encouraging and studying the feelings the patient had for the therapist shifted therapy from being some historical exploration to something that was emotionally alive and present. It involved the therapist and patient having an intimate relationship, a relationship that needed to be carefully observed and understood. This emphasis on the past has been one of the criticisms of analytic work. What is past is past. However, the transference changes all this. Analytic work, with its focus on the transference, is not about the past, but how the past is alive in the present, and nothing is more present than the relationship between the patient and the therapist. (Location 964)
While these discussions may appear theoretical, they do have important implications for how you actually work. How you think about the transference will influence if, when, how and what you say to a child. (Location 983)
When I am seeing a child, be it for an assessment or in therapy, I am always thinking developmentally. I am wondering what has gone wrong in this child’s past, and how might these events be related to his current difficulties? I think about this in relational terms. What happened in the child’s earlier relationships that caused his development to be disturbed? In regards to the transference, if this difficulty in relating is causing problems in the child’s current life, be it at school or at home, then how are these relational difficulties manifesting with me? (Location 990)
This example highlights how one has to wait for the transference. It is rare in my experience to feel the transference in the early sessions with a child. This is not to say that one shouldn’t look for it, even at the very beginning. While the child is playing or talking I am trying to get a sense of how he is relating to me. Is he feeling I will be bored or uninterested in him? Is that why he is so entertaining? Is he feeling frightened of me, that I am going to be angry with him? Is this why he seems so nervous or timid? Is he feeling I am going to humiliate or belittle him? Is that why he is so controlling? Does he think I am going to think he is stupid? Is this why he wants to impress me with his knowledge? (Location 1017)
Freud coined the term countertransference in 1909 (Freud 1909a). He used it to denote a feeling the therapist transfers from his or her past and applies to the patient. It was seen as an impediment to analytic work, a blind spot of the therapist. If the therapist were very anxious about aggression, this may not allow him or her to see or experience any aggression from the patient. If the patient was starting to get angry with the therapist, the therapist may subtly change the subject so the anger is avoided. For this to be true countertransfer-ence, the therapist would (Location 1037)
not know that he or she was doing this. In this sense, true countertransference is never a problem for the therapist. The therapist is not aware of it! This is one of the reasons analytic therapists need to have their own analysis. under the scrutiny of the analytic gaze some blind spots can be revealed and resolved. But no analysis is complete. Some blind spots remain (Renik, 1993). (Location 1041)
Despite these difficulties, I use this concept daily. I am always asking myself what am I feeling when I am with a child. I try to go beyond the words or the play and monitor my feelings. I don’t want to pretend that this leads to great insights or understanding about the child. Most of the time it is difficult to articulate what I feel. However, this question is helpful when I find myself having a strong response to the child. Most often these powerful responses are of a negative kind. I have a strong dislike of the child, or I feel extremely tired, or intellectually or emotionally battered or drained. (Location 1074)
It is also possible to have strong positive feelings towards the child or adolescent. Most commonly this is discussed in the context of an erotic countertrans-ference to adolescents. Feeling some sexual arousal towards the adolescent can feel quite frightening to the therapist; it can evoke fears of being a paedophile. While such feelings need to be seriously considered and taken for discussion in supervision, it is not helping the adolescent to dismiss or deny such feelings. Obviously such feelings are not to be acted out, but recognising such feelings may be important, for they may be communicating that this adolescent may be coping with anxieties about relationships by sexualising them. The adolescent may fear that the other may not be interested in him or her, and may attempt to arouse sexuality in the other to try to keep the other engaged. (Location 1079)
While there can be debate over who really owns the countertransference and how one should work with it, there is no doubt that it is important to monitor your feelings towards the child. The days of the therapist treating the child, in a one-way process, along the lines of a medical model, are long gone. It is now recognised that analytic therapy involves two people mutually influencing each other. It is our responsibility as a therapist to consider both sides in this intersubjective experience. (Location 1123)
The term ‘opacity of memory and desire’ is used by Bion (1970) to describe a state of mind that will allow the immediate emotional reality with the patient to evolve. The term comes from a letter from Freud to Lou Andreas-Salome. Grotstein quotes Bion quoting this letter, ‘When doing analysis, one should cast a beam of intense darkness into the interior so that something that has been hitherto hidden in the glare of the illumination can now glow all the more in the darkness’ (Grotstein 2000, p. 687). I think of trying to see a particular star in the sky when observing from the glare of city lights. In the darkness of the country this may be possible. The glare or illumination in psychotherapy is what we know about the child. If you know there is a long history of sexual abuse in a child’s background, it is nearly impossible not to look for this in the child’s material. In this case memory can prevent seeing beyond the abuse. It can blinker. Memory throws us into the past, while desire moves us into the future. Bion states, ‘Every session attended by a psychoanalyst must have no history and no future’ (Bion 1967, p. 272). (Location 1127)
Not getting lost in the past or future can allow one to stay in the now, to truly be with the child in a real psychological sense. I think of this in terms of leaving enough space for some authentic and spontaneous experience to occur. In this sense it is similar to Winnicott’s description of transitional space and the importance of spontaneity. Another way of thinking about this is to avoid becoming mentally and emotionally stale. Each time you are with a child it is important to be as open and as fresh as you can. (Location 1140)
This example highlights the dangers of memory. It is so easy to habituate, to go stale, to stop noticing and thinking. Bion’s call for an opacity of memory and desire suggests it is important to see the child anew each time. In my experience I am never so open and raw as when I first meet the child. It is hard to retain this openness week after week, but it is something I aim for. Bion’s suggestion of trying to train your mind to think you had never seen this child before can be helpful. (Location 1155)
This means I do not read my notes of the previous session. This is not easy to do, especially when you are seeing a child once a week. There is pressure to think, ‘Now where were we? What did we talk about? What was the name of his dog?’ But it helps to remind myself that, in rereading my previous notes, I am placing myself back seven days ago. This will make it harder to be with the child now. In assessments I write detailed notes at the end of each session. I do not reread these notes each time I see the child. Normally, after three sessions with the child I meet back with the parents. It is only before this meeting with the parents that I reread my notes. I try to allow each session to be separate in my mind. Reading the notes of the three sessions for the first time often enables me to see common themes, of which I was unaware. Bion relates memory, desire, and understanding to sensual experiences. Thinking about the past or the future involves our senses, especially seeing and hearing. We remember what we were told, or in our mind’s eye we can see or remember what the child was doing. This sensual orientation makes it more difficult to experience nonsensual psychic reality. This psychic reality can only be intuited. (Location 1159)
Bion does not see memory and desire as different things; rather, memory is the past tense of desire. Both attitudes hinder being open enough to allow something that is unknown to evolve. The desire to have a ‘good’ session may prevent you from experiencing a bad one. It may be very important to experience a ‘bad’ session, to experience the mismatch, the misattunement. It may only be in this way that you can experience what it is like to be with the child in this uncomfortable state. (Location 1177)
The above concepts, in their different ways, influence how I organise and think about my clinical experiences. They affect the way I behave with a child. But consciously I do not think about them. What I do consciously think about is the child’s anxiety. This thinking involves four questions. • What is the child anxious about? • How is the child managing that anxiety? • What level of anxiety can the child tolerate? • How can I help? In attempting to answer these questions, Klein’s thinking about emotional development and its relationship to psychopathology can be particularly helpful. Fundamentally Klein’s theory is a theory of anxiety. It focuses upon the development and interplay of different forms of anxiety. It adds another dimension, a deeper understanding of emotional life. It helps to go beyond the emotional headlines of sad, angry, anxious, and so on. Its emphasis is on the very earliest period of life. It speculates about the nature of the inner world in this preverbal period. This enables one to think how an individual could have experienced this early period. Klein’s theorising goes to the very bedrock of personality development. Klein’s concentration on internal phantasies emphasises the subjective. Her critics argue that this is given too much weight in relation to outside reality. While this may be true, this internal focus helps to get right inside the child, to hypothesise how the child experienced the event. Klein’s thinking can also be a guide to wondering how the subjective, deeply personal experience can reverberate throughout life. (Location 1198)
Klein talks about five broad types of anxiety: (Location 1212)
• unintegration/disintegration • paranoid • paranoid-schizoid • depressive • Oedipal. (Location 1212)
Klein suggests that as the infant develops, and the environment is consistent, there is a growing capacity to sort out this chaos. Experiences are now primitively grouped into good or bad, satisfying or painful. However, maintaining this split is an achievement. Slowly moving away from unintegrated states, it is easy for the infant to confuse good and bad. At times the split between them is not sufficient to separate them. What may be good could be bad. Because of this confusion there is no trust or belief in goodness. Anxieties are of a paranoid kind. This can be readily seen in some children’s play, in which the goodies are fighting the baddies. But as the play continues, the goodies become the baddies and the baddies become the goodies. There can be confusion as to who is who. Clinically this is often accompanied by feelings of being tricked, or being highly suspicious. This confusion is particularly worrying for development, as there is no sustained belief in anything good. Good is just a cover up for bad. (Location 1230)
At this early stage, although differentiation is becoming more stable, it is still crude and primary: either all good or all bad, all black or white, with no greys. The anxiety now moves from states of fragmentation and paranoia to concerns about persecution from the outside bad. Projecting badness outside may get rid of it, but there is always the concern that it will come back. Klein uses the term paranoid–schizoid position to describe this internal state: paranoid, because there are concerns the outside bad will attack, and schizoid, because the main way of viewing the world is in this split of good and bad. She uses the term position rather than stage, as she believes this is not a stage we pass through, but rather a way of experiencing the world, the psychological glasses we wear when observing our interaction with the world. In this sense, the paranoid–schizoid position is in all of us. (Location 1250)
person who satisfies him is the same one who frustrates. Similarly, there is an increasing appreciation that the person who loves is the same as the person who hates. These developments usher in a new set of glasses. Now ambivalence, both from the infant and from the other, can be perceived. Things are no longer black and white. There is a mellowing of extremes. Now self and other can be viewed as being capable of both good and bad. In this way, perception is much closer to reality. Klein calls this perspective on interactions the depressive position. Rather than fear of being attacked, the anxiety shifts to concerns that the one you love can be damaged by your hate. There is a move from self to other. Now the infant is capable of experiencing gratitude as well as feelings of guilt. Also arising from this guilt can be feelings of wanting to repair the damage that has been done. (Location 1269)
This concern about our impact upon the other leads to a feeling of being responsible for our actions. If we have done something wrong, we need to face up to this and try to make it better. The problem in this position occurs if the concerns for our actions towards another are disproportionate to these actions. (Location 1278)
Klein suggests that if these depressive concerns become too powerful the person may regress to a more paranoid–schizoid position. This would keep the good and bad apart. Alternatively, this view of the world may be managed by going into a manic state. In this position, concerns over offending or hurting the other are denied. Rather than getting involved with people and being worried about this, the manic position denies any dependency on others. Responsibility cannot be tolerated. Things are not repaired while holding on to a sense of guilt. Manic reparations rule. Magic and omnipotence abound. Things are fixed by magic, not by long, hard, and slow work. (Location 1291)
It is important for the analytic therapist to develop his or her perception so that it is as open and acute as possible. It is crucial to be able to tolerate an attitude of ‘nothing is irrelevant’, and also to be able to bear the chaos that arises from this attitude. (Location 1344)
Theoretical implications Observing in this manner can enliven theoretical constructs that can sound vague or esoteric. For instance, the idea of ‘unintegration’ can be readily witnessed when the newborn moves about in an uncoordinated manner. Watching an early infant feed, and witnessing its struggle to integrate his or her looking and sucking at the same time, gives an observer a much greater experiential knowledge of this construct. Observing how the baby appears surprised when his or her floating arm haphazardly enters his or her field of vision adds a further dimension. Ideas like falling apart and feeling disorientated can be observed as the infant screams, flails about, breaks into a sweat, or begins vomiting. (Location 1411)
More than anything else, infant observation shows how the body talks, how emotional states are expressed by the body. Freud’s statement that the ego is first and foremost a body ego makes perfect sense in this context. Witnessing a baby suddenly getting a rash when the mother begins to think about weaning, or seeing a baby develop diarrhoea when the mother returns to work, one is struck by the validity of Freud’s comment. Indeed, it would not be possible for me to think about the presentation of some bodily complaint in the consulting room without immediately thinking about this as an expression of some infantile state of mind. (Location 1446)
Observational training can have an influence on therapeutic practice. It can make it easier to wait and to feel the value of creating a space so thinking has a chance to develop. Generally this means interpreting less. This is something Winnicott (1971) was calling for many years ago. Lanyado echoes this Winni-cottian attitude when she calls for a greater appreciation of the therapeutic value of the regularity, reliability, the interested thinking, and the nonjudg-mental, non-intrusive presence of the observer (Lanyado 2004). Experiencing this in infant observation allows for its greater practice in the clinical setting. It has led to child therapists being much more able to bear knowing a lot less. (Location 1462)
Training in observing infantile states of mind reveals a great deal about emotional life in the earliest years. It is clear that infants have a rich and complex inner world. People may argue theoretically about this, but I continue to be surprised by observations of stable patterns of reactions and consistent expressions of emotions in very young infants. I remember being sceptical when I first read Mrs Klein’s papers, and her attribution of complex phantasies to small infants. I still have some reservations about some of her particular hypotheses, but I have no doubt that babies live in a powerful emotional world. It is amazing how early these emotions can appear, if only we have an open mind and are prepared to look in an ongoing and detailed way. I remember one baby of four weeks who would scream consistently whenever her mother and father embraced! (Location 1501)
Looking back over my observations, it is my impression that no other event has a greater impact upon the infant’s emotional life than weaning (Blake 1988). It stands out like a beacon when thinking about development. It is the mother’s and baby’s first developmental task. It represents the first transition they have to face. It will bring with it all the negatives and positives of any transition. Indeed, it is the prototype for all later transitions. It is the first sustained No, and both parties have to negotiate it. This normally is a period of regression and progression for the baby. It is not uncommon at this point for the baby to get sick, develop digestive problems, have sleep disturbances, be more overtly aggressive and jealous, and regress in communication, mobility, and relating. But it can also be a time of great development. Often weaning is accompanied by a developmental spurt, be it in mobility, communication, play, or relating to others. It is the necessary but painful push to allow mother and baby to evolve to another, more complex level of relating. (Location 1535)
A psychoanalytic assessment has the focus of trying to understand the inner world of the individual. It aims to understand a person’s subjective experience, his or her expectations, fears, phantasies, coping mechanisms, and ways of relating. Consideration is then given to how this inner world interacts with external events. The assessment is based on the belief that behaviour is the result of a complex interaction between the inner and outer worlds of the individual. (Location 1558)
What is essential in an assessment is the capacity to maintain a psychoanalytic attitude, a conviction of the existence of an inner world, as well as a certainty about its power to influence behaviour, thoughts, and feelings. There has to be a belief that this inner world is constantly expressing itself in all sorts of ways. If this attitude is held, then the mechanics of the observing process follow. This attitude enables an openness to different levels of communication with a belief that nothing is irrelevant. (Location 1579)
Psychoanalytic assessment involves the use of the subjective. It is important to remember that your greatest potential assessment tool is yourself. Words or play may be occurring in front of you, but what you are feeling is a vital component in any analytic assessment. It is important to ask the question, ‘How did my moods or thoughts and feelings change while I was in the presence of this child?’ Tuning into (Location 1602)
one’s feelings can be an important source of information about the child’s dynamics. (Location 1605)
A collegiate attitude with the parents is stressed, so that they feel part of the assessment. Parents approach a child therapist because of his or her expertise, and the therapist invites the parents to share their expertise about their child, so that the assessment process becomes a joint experience. This invites the parents in to the assessment process. In this way they feel included and are less likely to feel judged. (Location 1626)
I allow two and a half hours to see the parents. This allows at least one and a half hours to see the parents and one hour to write my notes. (Location 1772)
I begin by asking, ‘Could you tell me about your concerns?’ (Location 1783)
The child’s history The next section of the interview is devoted to the child’s development. In investigating this area, one is trying to get some sense of how the child and those around him or her have traversed the normal developmental and transitional periods of growth. This is also the time to examine significant traumata or disturbances that may have occurred in the child’s life: • pregnancy • what sort of baby? • feeding • weaning • sleeping • physical development • toilet training • milestones • daycare, preschool, school • reactions to change • peer relationships • siblings • interests and hobbies. (Location 1812)
I state that I work in a very unobtrusive way. I will not be firing questions at the child or getting him or her to do various things. I will be following the child’s lead. I tell them that the child will be invited to play with the things that are in the room, and what the child chooses is up to him or her. I then explain the sorts of toys I have. (Location 2062)
Structure of the assessment It is at this time I say that I see children for three sessions, once a week for 50 minutes over a three-week period. I explain that I like these sessions to be weekly, as this affords me an opportunity to notice what use the child or adolescent makes of his or her sessions with me. I say that I would expect the child to be nervous at the first session, and I am trying to see if he or she can relax over the three-week period. I go on to say that, after I have seen the child three times, I will then meet back with them, the parents, without the child. At this meeting I will give them my thoughts about the sessions with the child, and we will decide what is the best way to help the child. (Location 2083)
Purpose of the assessment I tell the parents I am here to help them understand their child’s behaviour a little better, so they are in a better position to manage in a more effective and sensitive way. I add that they could read a book about how to help their child’s behaviour, but this would not take into account the individuality of their child. Thinking about the behaviour in this individual way conveys to the child a sense that his or her behaviour has meaning and can be understood. In explaining my way of working in considerable detail, I am trying to help the parents feel that this is a working parnership, that I want to include and inform them as much as possible. I am also trying to define my role, and to give them some idea of what to expect when I meet back with them after I have seen the child. (Location 2089)
What to tell the child After describing my philosophy and the assessment process, I then direct attention to practical issues. I raise the issue of preparing the child for the assessment. What do you tell the child? I begin by asking if the child knows that the parents are coming to see me, and if so, what has he or she been told? If the child has not been told anything, I generally suggest to the parents that it is helpful to tell their child that he or she is going to see a man who helps children with their feelings, with things that might be worrying or upsetting them. I tell the parents I prefer to explain it in this general way—because it is the truth, and also it is best to avoid naming specific behaviour, such as fighting with your sister or wetting the bed. This conveys to the child that the assessment is about feelings and trying to understand things rather than just changing behaviour. If the child asks, ‘What will happen?’, I advise the parents to say that there will be some toys to play with, so the man can get to know you. For an adolescent I suggest the parents say that I am a psychologist, and I am being asked to see him or her because the parents are worried that he or she gets upset about things, and they think it would be helpful to see me. (Location 2095)
Confdentiality The last practical issue is confidentiality. I explain that the child must have a sense that what he or she talks about is not going to be told to the teacher or doctor or anyone else. But I do not promise a child complete confidentiality. I say to the parents that I will not be disclosing everything that the child says or does, but I will discuss the themes of the sessions. Also, if anything did come up that I felt they needed to know, then I would tell them. I inform them that I will be letting the child know that I am telling his or her parents about this. Obviously, if the child discloses some abuse or states an intention of serious harm to him- or herself or someone else, this needs to be discussed with the parents. (Location 2121)
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Being mindful of the child’s anxiety, I begin by asking questions about an area that I hope will not stir up too much anxiety. Both in the assessment period and for ongoing therapy, the determining factor in how much to ask about an area of concern is the level of anxiety it generates for the child. A child psychotherapist must be acutely aware of this anxiety. It needs to be sensitively monitored to enable the child to feel safe enough to explore the issues of concern. (Location 2206)
If the presenting problem concerns home and the family, I would start by asking about school. If there were school difficulties I would begin by talking about home. I am trying to start on an area that is less anxiety provoking for the child. In these questions I use a ‘funnelling’ technique. I start with a very general question and then work down to more specific issues. This is in line with the psychoanalytic principle of trying to follow the child and giving enough space to see (Location 2212)
what will evolve. (Location 2216)
After I have asked a general question I become more specific. With the school question I would usually follow up with a question like, ‘Tell me the things you like about school and the things you don’t like’. I would then ask the child to tell me about his or her teachers: ‘What do you like or not like about them?’ Then I ask about other children at school. I try to look for particular themes or worries. I would also be looking for particular themes in relation to their family. I would ask the child to tell me about home by asking, ‘What is the best thing about your family?’, then ‘What things are not so good about your family?’ I ask the child to tell me about his or her Mum; again I would ask, ‘What is the thing you like most about her?’, ‘What things don’t you like so much about her?’, and ‘What do you do that makes her cross?’ I would ask these sorts of questions about each family member, starting generally and becoming more specific. (Location 2230)
After this I ask the child to tell me about his or her best or happiest dream, and then follow this with a question about the scariest dream. (Location 2249)
To this day I can see some children where my milking ability is painfully low. After he or she gives me a one-word response I find my mind is blank and I have nothing else to say. This situation highlights the need to not only listen to the answers but also to feel the atmosphere in the room. Some responses are accompanied by an atmosphere of, ‘Don’t think any more about that’, and certainly one can be infected by this. (Location 2252)
My next set of questions involves ‘feelings’. I ask, ‘Can you tell me about the things that you feel would make you most happy?, most unhappy?, most angry?, most sad?, and most frightened?’ Again it is likely I would be asking for elaborations on these responses. Sometimes I turn this into a storytelling exercise, asking the child to make up a happy story, a sad story, and so on. If I feel the child needs more engagement I make up stories myself. I sometimes surprise myself with my stories. I may relate a story that highlights a theme of which I was not consciously aware. While this may sound rather ‘wild’, I think it gives my unconscious permission to be freer and to engage truly in the intersubjective experience. (Location 2256)
The questioning would then stop, and I would ask the child to do some drawings. Again I would attempt to give maximum space by asking the child to do a drawing without any specific direction. Following this I become more detailed—asking for a happy, sad, angry, and frightened drawing. Then I request that the child draws him- or herself, and after this a drawing of the family. I may also ask for a drawing of a dream, by drawing a small figure on a bed with a large bubble coming out of its head, and requesting the child to draw a dream in the bubble. (Location 2262)
If the child is starting to enjoy this, I may then add the further task of making up a story about the completed squiggle. Again I would go first to lessen the child’s anxiety. (Location 2272)
The unstructured approach to assessing a child is difficult, and nearly impossible, if you are not experienced or having supervision. In this approach you simply see what happens between you and the child. Because there is so little structure, the space for something to emerge is maximised. It is potentially the richest way to understand a child. It is uncluttered by diagnostic labels or preconceived ideas. But this makes it anxiety provoking. You must have some sense of being held, either by your experience or by your supervisor. (Location 2321)
Klein believed the child’s relationship to play comes from his or her relationship to earliest caregivers. The infant’s world is his or her mother’s body. Good and bad experiences are transmitted through her. Hunger is cured by the magic of her milk. Her binding arms, voice, and eyes alleviate terrifying unintegration. The infant’s world is shaped by these intimate and personal exchanges. They form the blueprint for later development. As the infant’s psychic structures begin to form, one achievement is the capacity to symbolise. An infant who has had many good experiences begins to develop a belief that the sources of goodness may go away, but they will return. These repeated experiences enable him or her to wait. In analytic terms, he or she begins to develop the concept of a good absent object. In contrast to this, the infant who cannot wait, or feels that the waiting has been too long, is not able to form an idea of a good absent object. The pain of waiting is too painful, and it is experienced as a bad present object. There is no idea of absence. This idea of an absent object is crucial for the development of symbolism and play. Symbolism means that one thing stands for another. B stands for A. But this presupposes that the object being symbolised is not there. In Kleinian language, symbolism can only develop if the individual can tolerate depressive anxiety; that is, is able (Location 2407)
to recognise that the original object is not there (see chapter 12). (Location 2417)
play with toys and other objects is not some independent cognitive activity, but is intimately related to the infant’s or child’s feelings about their current interpersonal relationships. (Location 2425)
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When I observe play, one of the things I am attempting to do is to put the relationships in the play into human form. I look at how the child is shaping the play, and how the relationships in the play may be acting out phantasies about human relationships. (Location 2433)
For example, when observing a child drawing I try to observe the activity by imagining what it would be like to be the paper. Would I feel I was quickly brushed over, or would I feel poked into, or so lightly touched as to feel I must be fragile and easily injured? How would I feel if I were the pencil? Would I feel frantic or very tentative, hoping not to (Location 2435)
make the wrong move? Would I feel strangled by such a tight grip, or constantly anxious of being dropped by being held so loosely? If one believes all behaviour has meaning, then this way of thinking, this anthropomorphising of the play activity, allows one to play with the play. It is a diagnostic form of entering the play. This is something I shall discuss in chapter 11 in relation to ongoing therapy. (Location 2437)
Play that is ‘emotionally alive’ has a very different feel to play that is closed and stale. One of the first things the assessor needs to observe is his or her reaction to the play. While this is very subjective, nevertheless (Location 2455)
it can be one of the most significant signs of whether the play has an aliveness that links the inner and outer world of the child. This aliveness is evidence of the child using the play to work through their emotional issues. Play that bridges the subjective inner world and outer objective reality is interesting, and at times fascinating to watch. It has a flow and spontaneity that holds one’s attention. In the presence of such play, time seems to fly. Alternatively, play that is emotionally disconnected feels boring and tedious. Fifty minutes of such activity feels like hours. (Location 2456)
The link between his inner subjective experiences and the outer reality had been weakened by the overemphasis on the objective, external reality of the school buildings. This is very common with latency age children. Their acquisition of objective knowledge, so encouraged at school, can be used to control and manage feelings of uncertainty about their inner world of feelings. While this drawing of the buildings may contain some symbolic significance, the atmosphere surrounding it made it feel dead. I felt that Ian not only gave me the drawings but also an unspoken message of, ‘Don’t go there; don’t even think about it’. Having a good or bad session may not have to do with your clinical ability, but rather with what you are being allowed to do by the child. (Location 2470)
Play that is emotionally connected engenders a sense of enjoyment. It is fun. Part of this enjoyment comes from the relief that anxieties can be symbolically expressed. They can be controlled and managed by displacing them onto the play. Also, the sense of open exploration enables the child to be more in touch with his or her joy in the aliveness of creativity. Closely related to this enjoyment is a feeling of lightness. The play doesn’t feel heavy and serious. As Vygotsky (1933) notes, real play has no consequence. In Kleinian terminology, real play conquers depressive anxieties because it is pretend; nothing will really happen. Things will not be destroyed or damaged within the safety of the play. This is a source of celebration. It is not manic denial but a release from the anxieties of everyday interactions. This is linked to Freud’s idea of the importance and power of humour (Freud 1927). In humour and in play the superego takes a holiday! (Location 2494)
One of the technical difficulties of assessment of a child of this age is determining whether the child is able to separate from the parent. With small children, especially if they are not going to school, I would not attempt to separate them. As noted earlier, (see p. 104), I invite the mother or father to accompany them into the room. I would have discussed this with the parent beforehand, explaining that I do not wish to make the child so anxious that he or she cannot function. I would also explain my need to follow the child’s play, and for this reason would ask the parent not to initiate any play. I ask them to allow the child to determine what activities are undertaken. (Location 2638)
Small children’s emotions are powerful. They are extreme. Love and hate, bliss and disaster still populate the young child’s mind. This is not a time of sustained ambivalence. Events are experienced in black or white, all good or all bad. The force of their emotions also come from the speed and uninte-grated quality of their feelings. They are still at the very early stages of knowing how to process their emotions; they are still dependent on their parents for this. (Location 2647)
as the preschool child’s ego capacities are still forming, and because their anxieties are very powerful, their communication lacks this clarity and coherence. I would not expect a preschool child’s stories to have a clear beginning, middle, and end. (Location 2656)
This fluidity of subject and object can leave an assessor totally confused. A preschooler’s material cannot be observed in a logical way. In this sense the material can feel more like observing a dream. The activity has a primary process feel. Symbols do not remain stable and consistent. Contradiction and lack of logic predominate. (Location 2669)
Without the support of the parents or those responsible for the child, there is little point in offering therapy. It won’t work. This question is the most important to consider. Therapy can only be effective if those looking after the child can work with the therapist to create an atmosphere of security and thoughtfulness. (Location 3207)
Parents need to understand that therapy is about the child’s feelings. It is not about controlling behaviour, but rather coming to understand and manage the feelings that produce the behaviour. This understanding has nothing to do with intellect. Highly educated parents can struggle with this idea, while parents with less education can understand immediately. understanding that therapy is a process allows the parents to recognise that this is something that cannot be given a definite time frame. They need to appreciate that this is something that evolves and is nonlinear. They need to be able to bear not knowing. Child therapy does not produce miracle cures, so parents need to be able to endure flat periods in the therapy, timse when it feels as if nothing is happening. New insights and strategies will not be emerging each week. While they may not be able to articulate it, parents need to have the ability to recognise that their child’s therapy is about the development of meaning. What was worrying them about their child now begins to make sense, to have a meaning, both for themselves and for their child. (Location 3228)
Some parents, after some time, begin to think about their own dynamic and how this may contribute to the difficulty. In the early stages I don’t delve into the parents’ background. The parents must feel safe enough before such issues can be explored. However, if in the assessment meetings I gain the impression that the parents see all the problems in the child, and are unable to even consider their part in the problem, I would be cautious about offering therapy. Such a move runs the risk of colluding with the parents and putting all the issues onto the child. In this case a family approach may be more appropriate. (Location 3242)
After a child or adolescent has been seen individually for three assessment sessions, I meet back with the parents to discuss my thoughts about the assessment. I talk about what I perceive to be their child’s anxieties, how he or she is trying to manage these feelings, and how these emotions are influencing behaviour. The parents will also be expecting some discussion as to what is the best way to help the child and themselves with their presenting concerns. Although discussing the assessment, this meeting is also a therapeutic consultation. (Location 3403)
‘Before I start and give you my thoughts, I wonder if you could give me some feedback on how Joseph has been going since I saw you last. Also, could you give me some idea of how he has reacted to the sessions with me?’ (Location 3412)
The question implies I need to hear from them, as well as valuing their observations and comments. (Location 3420)
I remind parents of this by stating that, while I am going to talk about the difficulties or struggles the child is experiencing, I don’t want them to go away thinking that this is all there is to the child. All children have difficulties; it is the nature of being a child. I further comment: ‘What we need to think about is whether these difficulties are so powerful or widespread that they are interfering with your child’s development. Are we looking at a hiccup or a more serious blockage of development?’ (Location 3440)
The therapeutic process is private. Exploring one’s innermost fears and desires, and looking at areas of your life in which things are not going well, can be excruciating, especially for children. The child doesn’t have the adult’s capacity to observe from a distance. Talking about feelings, even in the displaced form, can make a child feel uncomfortable. Certainly this is the case if such an activity is not part of their family’s functioning. But even with families in which talking about how you feel is commonplace, children can still feel embarrassed and ashamed to reveal their jealousy, fear, sadness, or rage. Having their inner world exposed to outside scrutiny can leave them feeling as if they are emotionally naked. Their sensitivity needs to be respected, and part of this respect is demonstrated by the therapist engendering an atmosphere of trust and confidentiality. (Location 3838)
If a child or adolescent asks me about this, I say that I won’t be telling anyone about our meetings. But I qualify this by noting that, if there are things they tell me that I feel Mum and Dad need to know, then I will tell them. But I would always let them know that I was telling the parents. (Location 3851)
To the parents I say that I will not go into great detail of exactly what the child says or does. I will tell them about general themes, and try to give them some understanding of how their child is seeing the world. I add that, if the child says or does anything that I feel they need to know about, then I will tell them. They also know that I will be letting the child know that I am telling them. I would only disclose specific material if I felt the child were in danger, if he or she told me about plans of suicide, dangerous drug taking, or being involved in some criminal activity. (Location 3853)
unlike other forms of intervention, analytic child psychotherapy is not determined by particular strategies or exercises. It does not have predetermined goals or objectives. To paraphrase Winnicott, therapy is two people playing. This, in a nutshell, describes therapy. While it may sound oversimplified, it captures the essence of the therapeutic process. As a therapist I try to play; I try to put myself into a position to be able to play. I am also attempting to create the right conditions for the child to join me in this play. If I can do this I believe I am being therapeutic. By creating the right space for play, I mean establishing a feeling of safety and openness with the other so new things can be experienced and known. Winnicott talks about the spontaneous gesture, and being spontaneous is part of this discovery. Spontaneity means enabling your ‘being’ to be. In real play you discover who you are. In playing with another, you get to know who the other really is, and who you are in relation to this other. This true authentic engagement with self and other is the essence of life, and it is my aim in therapy. (Location 3864)
This is the dilemma of psychoanalysis. Much of its potency comes from this aimless philosophy. This allows for the richest and deepest discoveries in a human being—not to be shackled by a (Location 3876)
therapeutic direction. The boundaries can be open, so the fullness of the self can be known. But it is this very aimlessness that prevents its acceptance in a world driven by cause and effect, a world devoted to the gods of science and economics. (Location 3877)
My own partial resolution to this dilemma is to think about the personal meaning behind the worrying behaviour. I do have an aim. The aim is to help the child and family with the presenting problem. But my thinking is broader then this. While I am aware of the problem, my focus is more directed to trying to understand what meaning this problem has for the child. I am more interested in getting to know the child, how he or she sees the world and his or her relationship to it. In doing this, as well as trying to convey this understanding to the child and parents, I believe I am helping with the problem. If the child and parents can understand the feelings driving this behaviour, they are in a better position to manage it. I hope that this improves the behaviour, but more importantly that the child feels emotionally known. My aim-lessness manifests in trying to not have any preconceived ideas of what the child’s behaviour may mean. I try to follow the child, in play, stories, and in their relating to me. I aim to create a play space so I can get to know the child authentically. Putting this in a more functional way, my aim is to help the child to think about his or her feelings. This parallels my work with the parents, to help them have an OTT experience; that is, to observe, think, and talk about their feelings. (Location 3884)
The setting is the physical and mental space within which psychoanalytic work occurs. It provides the backdrop to the clinical work, and helps to define it. (Location 3956)
Once I begin with a set of toys I do not add to the box, even if a child persistently asks for a new toy or piece of equipment. Such requests would be thought about rather than met. (Location 4081)
With slightly older children, approximately 12 to 16 years, I do not use a box, but would have some pencils and paper at hand as well as some modelling material, such as a ball of plasticine. If the young person is finding it difficult to talk, I would suggest that he or she might like to draw or make something. (Location 4091)
The setting needs to engender a sense of reliability and continuity. In analytic work, both child and therapist are entering and attempting to explore this frightening place called the mind. In entering this inner world, they are confronted with terrifying objects or states of mind that can threaten their very existence. Now the child, with the aid of the therapist, is encouraged to face the uncertainties about his or her feelings. By living in this shaky internal world, the child needs the support of a stable external world more than ever. This is why it is so important to have the same room, on the same day, at the same time, with the same toys. (Location 4094)
The child must feel some sense of containment in the reception of his or her projection. Powerful and frightening projections will only continue to flow if the child feels they can be accommodated in a firm, safe, and confidential abode. Part of this safety lies in the predictability and continuity of the therapist’s mind. It is fundamental for the child to feel that the therapist’s mind, like the room and the toys, will continue to survive. This ability to survive, in itself, helps to contain many of the child’s most frightening anxieties. (Location 4112)
Mentally ‘being there’ means not only surviving and being predictable, but it must include a receptive attitude that goes beyond mere attention, an attitude that is demonstrated by the therapist’s careful observations as well as his or her curious and thoughtful approach to the child’s play or words. In this way, the child begins to feel that all her communications are important and have meaning. The child soon discovers that she is not there to be taught but rather to lead the therapist, to feel the therapist is there to help her explore her feelings. The child begins to realise that analytic work is not about receiving answers, but exploring questions. It is a process of opening up and expanding the mind, to regain lost aspects of oneself, and not to kill (Location 4121)
questions with answers (Blake 1987). (Location 4126)
The therapist is trying to discover the unconscious elements in the child’s behaviour. In this listening and in his or her reactions to the child, the therapist should convey a feeling that even the most cruel, embarrassing, shameful, or bizarre thoughts can be accepted and explored without a judgmental response. I am talking about thoughts and not actions. Stopping the child from acting out violently is part of the therapeutic process. I shall elaborate this point in the section on limit setting. (Location 4130)
With more experience I have become friendlier, more supportive, and more personally open to both children and parents. I think, or hope, that this gives the child and parents an experience of a more authentic me. This is more important than remaining analytically pure. (Location 4156)
Nevertheless it is important to have these Freudian principles in mind. They remind us that we are not there to befriend or to educate a child, but to help him or her experience and think about his or her feelings. Freud’s recommendations can help to maximise our understanding of the person’s inner world, but this must not be achieved at the cost of adhering to principles that threaten the opportunity to have a mutual and authentic relationship. (Location 4158)
It is crucial to understand why the child wants to leave. If this is based on absolute terror, then continuing the session, after trying to talk about the terror hasn’t worked, is pointless. The session should be stopped or the parent brought in to the room to calm the terrified child. If the child’s demands to leave the room are based on a rage of not being allowed to do what he or she wants to do, then standing up to this omnipotence may be necessary. As Anne Alvarez once said to me, if you are in the room with a Hitler, don’t be a Chamberlain. (Location 4173)
I set the limit that the room is to be left as it was found. This is in line with maintaining a sense of reliability and predictability, not only for a particular child but also for all others who use the room. It also relates to the issue of sharing. If there were a common blackboard, this would be cleaned before we leave the room. Similarly, chairs and such would be put back into their correct position. If the child doesn’t do this, I do it while the child is present. (Location 4190)
if a child wanted to touch my genitals, kiss me, or undertake other sexual activities with me, I would stop this. A firm distinction needs to be made between sexual phantasies or wishes and the acting out of such desires. As the child’s therapist, one needs to acknowledge and talk about these phantasies and what they mean, but let the child know that the acting out of these phantasies is not acceptable. (Location 4232)
Generally I would allow a child to masturbate, as long as it was not done in an exposing or violent manner. Again my emphasis would be on trying to understand and talk to the child about why he or she felt the need to do this. (Location 4238)
To maintain my capacity to think, I would not engage in any activity such as playing football, where I would find myself so physically active that I could not think. In this situation I say to the child, ‘I don’t want to play anymore. Moving around so much makes it hard for me to think.’ (Location 4250)
Karl Menninger (Menninger & Holzman 1958) similarly cautioned about the dangers of overvaluing the interpretative process. He warns young analysts that they are not oracles, wizards, linguists, detectives, or great wise men, but quiet observers, listeners, and occasionally commentators. (Location 4312)
This research highlights the importance of attunement and mutuality in the earliest mother–infant interactions, and that this sense of attunement is vital for emotional well-being and development. Holmes (1998) emphasises this aspect of psychotherapy. He argues that findings from attachment research led to a rethinking of the aims of psychoanalytic psychotherapy. Holmes notes the importance of the person feeling understood rather than receiving understanding (Steiner 1993). From this safer and more secure position, the person him- or herself is in a better position to allow for emotional growth. (Location 4335)
Neurological studies, having recently been integrated into psychoanalytic literature, suggest the earliest preverbal interactions of the infant with the caregiver leave a neurological blueprint, so that ‘states’ become ‘traits’ (Perry et al. 1995; Pally 2007). This indicates that early disturbances in the infant– caregiver relationship are not known at a conscious level but reside ‘in the bones’. (Location 4346)
Winston’s presentation of findings from trauma medicine that it is important not to intervene when the body has experienced trauma may provide a medical parallel to not intervening with psychic trauma—that the mind needs holding, like the cool wrapping that is so effective in physical trauma (Winston et al. 2001). (Location 4363)
Klein reawakened my doubts when I began reading The Narrative of a Child Analysis (1961), her account of her analysis of a 10-year-old boy. Much of her thinking made clear clinical sense to me. It was exciting and clinically useable. The problem of The Narrative was not so much the thinking behind the interpretations, but how they were delivered and the amount of interpreting. I could not find a ‘perhaps’, ‘maybe’, or ‘might’ in any of the sessions. Interpretations felt like they were delivered as indisputable pronouncements, with the child’s play and verbalisations used as raw data that was fed into the impressive interpretative machine that was Klein’s mind. While I was aware that what was presented in the narrative was a condensation of interpretations, the length, number, and complexity of the interpretations were difficult to grasp, even when I reread them slowly. I tried to imagine what a 10-year-old boy would make of them. (Location 4370)
But what did ‘making him aware of’ mean? Did it mean he had an intellectual understanding of his troubled dynamics, and that he could articulate them? Klein seems to suggest this when she states that it is important for the child to be able to speak about his or her difficulties, and would not consider an analysis to be complete until the child could do this (Klein 1926). This issue of insight, and the child’s capacity to verbalise understanding, raises important questions about the nature of therapeutic change in child work. (Location 4379)
In distinguishing between insight and insightfulness, Sugarman is promoting the idea of the child’s need to develop a theory of mind, or what Fonagy (1991a) calls ‘mentalisation’, which has a self-reflective function. I think of this in more simple terms as the child being able to think about feelings. While the child may not be able to think about or articulate his or her own feelings, I believe the process of thinking about someone’s feelings (even if this is about how Bart Simpson feels) is an important development towards the attainment of a self-reflective functioning. (Location 4432)
Spiegel (1989) believes that direct interpretation may not only be inappropriate or ineffective, but also be damaging, by too forcefully challenging the child’s defences. Like Alvarez, he notes the importance and value of defence mechanisms. He refers to Sullivan’s comment that ‘Repression does not block development, it enables it’ (Spiegel 2004). (Location 4443)
One way of respecting the child’s defensive structure, while addressing his or her anxieties, is to allow the child’s thoughts and feelings to stay in the play, to allow the magic of the metaphor to create a place for playful thought. Staying in the metaphor of the play respects the developmental needs of the young person’s functioning. Spiegel suggests that child therapists should stay in the metaphor as much as possible. He particularly notes that, ‘Interpretation to adolescents is almost never to be recommended’ (Spiegel 1989, p. 155). He also quotes Sullivan, ‘The supply of interpretations, like that of advice, greatly exceeds the need for it’ (Spiegel 2004). (Location 4452)
Play is the safe ‘in between’ area that Winnicott calls the transitional space. Play is like ‘a transitional interpretation’. It is in between reflective functioning and self-reflective functioning. From play, thoughts and feelings can be explored without the threat of the child feeling overwhelmed. As Joyce and Stoker (2000) note, play does not threaten the child’s internal equilibrium, because it is not a direct reference to his or her internal experience. (Location 4464)
In play the child can control his or her environment, so that the child has the power to destroy, but also to create and make right. But as Vygotsky (1933) notes, play paradocially is defined as an activity that has no consequences. The magic of play is in this paradox: it is of fundamental importance and of no importance at all. (Location 4472)
Play, in and of itself, promotes integration through the freedom of mental space. Frankel (1998) notes that in play the child is free from any external goals and pressure, and this allows for greater exploration and spontaneity. He emphasises the integrative quality of play when he states that pretending is straddling two self-states. He links this idea to Bromberg’s (1996) thoughts of the self initially consisting of a multitude of separate selves, and it is only by integrating these discontinuous experiences that a core sense of self develops. As he states, ‘This is playing isn’t it, bringing dissociated states into communication with each other in an interpersonal relationship?’ (Frankel 1998, p. 154) (Location 4475)
It is important to stay with the play and not rush into linking it to how the child might be feeling. Mayes and Cohen (1993) suggest this, especially for children under eight years old. As they explain, for these children play is thought in action, and is not experienced as a reflection of mental activity. (Location 4486)
notes how articles that demonstrates clever and effective interpretations surround novice therapists. They cannot avoid being influenced by this. Slade states that even for experienced therapists there can be pressure to interpret. She proposes that therapists can feel guilty by simply playing. She adds that interpretation is hard to surrender when there can be countertransference pressures to cure magically by words. Birch echoes these sentiments, noting the complaints she has received from adults for ‘just playing’ with her child patients. She notes (1997, p. 58): The high value our culture places on rational, logical, scientifc thought often leaves me, like many other child therapists, feeling vaguely guilty when our time with children is spent ‘just playing’. And yet case after case, although the so-called real issues that led the child’s family to bring her to therapy are rarely addressed directly, and although we spend our working hours unprofession-ally crawling around on all fours, growling, or hiding under tables, the child gets better. She concludes that it is an error to violate the play by translating it into propositions about the child and his or her family. This Procrustean pressure ‘is experienced by the child as breaking the rules and thus the spell of make believe, destroying rather than illuminating its meaning’ (Birch 1997, pp. 70-1). (Location 4498)
It is useful to look for times when entering the play may be the most hearable form of engagement for the child. This is most readily accepted in preschoolers, but I have been surprised that even with latency children and younger adolescents this technique is accepted and enjoyed. Even if one does not enter the play overtly, it can be helpful to think about it. By pretending what it would be like to be the piece of paper that is being scribbled upon, or the pen doing the scribbling, the child therapist can stay closer to the child and his or her play. This Gestalt technique, articulated by Oaklander (1978), can be helpful, both diagnostically and therapeutically. (Location 4530)
Entering the child’s play allows for greater attunement and mutuality in the clinical setting: it is not delivered from the distance of an observer, as is the case with an interpretation. To use Sullivan’s language, one becomes a participant and an observer. (Location 4598)
This reminded me of a little autistic girl who would only listen to me if I framed my comment in a fairy tale form of ‘Once upon a time’. If I didn’t say these words she would not listen. I think my tone of voice, plus the proclaimed ‘pretendness’, enabled her to listen and be interested. (Location 4606)
Trevarthen (2001) believes the main organising emotional states in the earliest stages of life are shame and pride. If the mother is unable to fully respond to her infant in the early interactions, a sense of shame related to the self begins to form, while positive engagement results in a sense of pride and joy. So often children presented for psychotherapy feel they are a source of either disappointment or at least concern and worry for their parents. It is not surprising that they may experience our engagement, or rather our disengagement through observation, as highlighting this shame, and this is unbearable. (Location 4620)
Being more playful than interpretative is obviously not restricted to the play technique. For the latency child, a therapist must play with the factual information that is often presented. Talking about how the breaks and gears on a bike work is one way of playing and discovering the feelings of being out of control and needing regulation. Does it really matter if we don’t directly relate this back to the child? I believe it is more important to let the child do this in his or her own time. (Location 4625)
I know one adolescent therapist who watches and discusses videos with a young man who brings them to his sessions. Some may complain that this is not psychoanalytic. Where are the transference and the interpretations? I would argue they are still there but are being used in a different way, so that thinking and talking about feelings is promoted rather than the gaining of insight. (Location 4630)
There is a danger that child therapists may interpret too much, and need to be more playful with the child. This is not a matter of having an individual style of working. This is based on the belief that a verbal direct interpretation to the child about how he or she is feeling is generally too powerful for the fragile and still developing psyche of the child. Remaining in the play or entering the play is more developmentally attuned to the child. Such a technique is less likely to threaten the child, and is more likely to produce therapeutic gains. (Location 4634)
As Slade (1994) states, ‘The ability to tolerate the separation between a feeling and its acknowledgement is a development accomplishment’ (p. 91). She echoes my thoughts when she notes, ‘It has been my experience over the years that even older healthier children sometimes find traditional uncovering approaches to play disruptive’ (p. 98). Like Killingmo she makes an important distinction between making and uncovering meaning. She emphasises facilitating the discovery of meaning rather than uncovering meaning. She argues that therapists are no longer ‘purveyors of knowledge or omniscient translators of psychic experience; rather we are curious co-explorers who have a little more experience at how best to dig’ (p. 103). (Location 4666)
Another modification proposed by Alvarez is to couch comments in terms of needs rather than anxieties. This is a significant and major shift in Kleinian technique. Perhaps more than anything else it has influenced my way of talking to children. Virtually any anxiety can be flipped over into a need: the anxiety of being alone—the need to have someone there; the anxiety of being sad—the need to feel happy; the anxiety of panicking—the need to stay calm; the anxiety of feeling frightened—the need to feel safe. Looking at anxiety from this different perspective does not confront or challenge the child’s sense of self. Yet at the same time it addresses and stays with the problem. The child can be so anxious about these disturbing states that all he or she hears is the word ‘alone’. This can start the alarm bells ringing, so that nothing else is really heard, let alone thought about. But, by turning this anxiety around, and focusing on the need, the child is no longer confronted with the dreaded word; rather he or she hears ‘someone there’. This is a positive. It implies one has a right to this. It is a human need, a state of being we all need. It doesn’t feel pathological. Saying to the child, ‘I know it’s important for someone to be there’, is very different from, ‘I know you are worried about being alone’. Anxiety for children and adolescents can so easily mean fragility, vulnerability, a sense of failure, a lack of strength, and a source of worry and shame. (Location 4709)
While one cannot plan spontaneity, it is important for child therapists to give themselves permission to be themselves with the child, to laugh, cry, and be frustrated. I am not talking about spilling out and losing all sense of boundaries, but it can be helpful to become freer and not always be the thoughtful observer. (Location 4727)
He suggests that interpretations need to be given ‘in the context of support’, rather than the classically abstinent position. By support he means framing the interpretation in such a way that it makes it possible for the person to bear. The person must be left with defences that protect him- or herself from overwhelming feelings—so the interpretation is hearable. (Location 4733)
It is not uncommon for humour to break a therapeutic impasse. This certainly was the case for the boy with the dust and myself. Our mutual enjoyment was crucial to the therapeutic change. (Location 4804)
Real play is emotionally alive. A critical factor in play, from an emotional point of view, is whether it is spontaneous. Winnicott always stressed this feature. Real play is about discovery, of not knowing what is going to happen next. When it is present, the play flows, and as Winnicott states, if it is flowing then the most therapeutic thing you can do is to leave it alone (Winnicott 1971). (Location 4820)
Real play is a process of the player exploring and discovering who he or she is. This is why it is so important, and why it is especially important in therapy. (Location 4830)
symbols. The player finds some part of the outside world to represent or symbolise his or her subjective experiences. Play becomes dead and emotionally useless when this process of symbolising is disturbed, when the symbols no longer have a personal meaning. That is when they no longer carry the mix of inner and outer, or what Winnicott (1971) calls me and not me. (Location 4832)
a symbol is something that stands for something else. (Location 4836)
there must be a coming to terms with the loss of the original object. Being able to bear the pain of such loss (as in depressive pain) is implied in the formation of a symbol. If this depressive pain cannot be maintained, then symbol formation is severely impaired. The individual will not be able to tolerate substitution. There is a risk that the symbol will be equated with the original object and, as such, there is no ability to differentiate the two. Segal calls this a symbolic equation rather than a symbol, (Location 4838)
Winnicott (1971) emphasises this point when he discusses play as a transitional phenomenon. It is a safe area, which can help children retain their own sense of self while making the transition from its infantile omnipotence (‘I am the world’) to an acknowledgment of the external world. Play is neither in nor out of self, but somewhere in between. It is between me and not me. (Location 4846)
This tension between me and not me, although primitive, is something that continues throughout life. If you are too outer world orientated (too much not me), life can feel personally meaningless. But if you are too inner world orientated, there is no relating to others. In this sense we all need to play to manage this tension. Play continues throughout life, as seen in creativity in the arts, in sport, in the sciences, and generally in our culture. In these pursuits we are discovering who we are by exposing ourselves to the unknown—to place ourselves in the unknown position so we can be spontaneous. (Location 4853)
it is not surprising that clinically the link between psychosis and obsessionality is so strong. However, while the obsessional, unlike the psychotic, is able to acknowledge a differentiation of self from object, he or she is nevertheless still anxious over the loss of control implied in the separation. The child attempts to control this by denying all feelings associated with it. In the psychotic there is a retreat into the inner world. In the obsessional there is a ‘retreat’ into the outer world. In the psychotic it is all ‘me’, in the obsessional it is all ‘not me’. This ‘retreat’ into the real world is reflected in the play of the obsessional child: it is especially real and, in that sense, it is dangerously safe, as it does not allow for a personal, emotional link to objective reality. It is all ‘not me’. From the therapist’s point of view, this is why it is so dead, so boring. In such play, symbols are used or displayed, but they are not meant to be shared. They are not used to explore the ‘me’ bits in the ‘not me’ reality. They remain as ‘things’ rather than symbols, and any attempt to draw them back into the original object relationship that they signify is strongly resisted. The child’s play is not seeking understanding but is used rather like a shield. The reason such play is not seeking understanding is that such a move would mean the child has to acknowledge that there is another upon whom he or she is dependent for such understanding: a ‘me’ and ‘not me’ relationship would have to be acknowledged. Such acknowledgment can only happen if the child has a firm sense of ‘me-ness’. (Location 4871)
The first step in being able to play is to have a sense of ‘me’ in relation to a ‘not me’, and this can only feel safe enough, in the earliest stages, if there is a sense of possessing the other, of being the puppeteer on the end of the strings. Clinically, for these children, it means enabling them to feel they possess the therapy, including the therapist. Shared experiences come later. (Location 4889)
This quality of continuity relates to Bick’s thoughts about the infant who does not feel held by his or her own skin, and needs to develop a second skin function to defend against primitive fears of spilling away or falling apart (Bick 1968). Such infants desperately seek some object or activity that can bind them together. She speaks of a muscular type of self-containment, in which the muscles, by their constant movement, hold the infant’s attention and thereby can be experienced as holding parts of the personality together. This was reflected in Sam’s constant activity: continuity must be maintained. For Sam to stop was to end forever. Stopping threatened to make him aware of the gaps in time, and for him this did not feel like a space to explore, but rather a horrible hole in which he could spill out or fall apart. (Location 4976)
In more recent times I have seen many adolescents who have been obsessed with computer games. One game, World of Warcraft, invariably takes over their world. This two-dimensional world seems to represent an attempt to live in a world in which they are completely in command. Through the flick of a finger, engagements with others are omnipotently controlled. Violent actions, revenge, explosions, grotesque figures, spell-casting characters surround them, and yet they seem to be emotionally detached from any attempt to relate such feelings to themselves. To do so would be too dangerous. It would overwhelm their emotional system. At a primitive, infantile level, experiencing and acknowledging such emotional relationships would lead to being flooded by too many separate, or not-me experiences. (Location 5039)
Waiting is especially difficult when working with children publicly. Waiting lists and monthly statistics exert enormous pressure to keep intakes moving. Public funding does not allow ‘just being’. It demands ‘doing’. But with children lost in dead play it is this very ‘doing’ that is the problem. The child keeps busy to avoid having space to experience. (Location 5108)
The therapist’s capacity to bear the pain of no contact, of being kept waiting, is like the mother who has to contain her infant’s primitive anxieties. The child needs to know that the pain behind the dead play is bearable. (Location 5112)
It is difficult to know if Sam’s and David’s feelings were cut off for purely defensive purposes, when they were just too painful to acknowledge, or whether their lack of affect may have started out this way but now had become more a way of life, when there was no feeling of anxiety behind these non-feeling states. If this anxiety is lacking, you can be confronted not only with mindlessness but also with perversity. This appears to be at a level of symbolic functioning that is even beyond symbolic equation (Alvarez 2007). In this case, the significance of the object is recognised, but such recognition is used for the purpose of attacking and denigrating it; that is, the infant acknowledges the dummy is not the mother, but is in a state of mind that rejoices in his or her triumph over no longer needing the object. The substitute not only replaces the original object; it is infinitely better. (Location 5130)