Playing Together: DIR and Child Psychodynamic Therapy

ABSTRACT

This article describes the integration of the developmental, individual difference, relationship model (DIR) and relational child psychodynamic therapy. DIR is an effective treatment for many children with uneven development, not only for those on the autistic spectrum. The importance for child psychodynamic therapists to understand individual differences, as delineated by occupational and speech/language therapists, and to include parents within the treatment will be discussed throughout this article and in a particular case. An understanding of individual differences makes psychoanalytic formulations, especially about the body, more accessible and actionable. Overlooking the contribution of individual differences to a child’s play and development has consequences for progress in treatment. Together, DIR and child psychodynamic therapy can most effectively integrate “psyche” and “soma” (Winnicott, 1949). The child psychodynamic therapist’s particular expertise, in such areas as countertransference enactments and unconscious meaning, crucially contributes to this integration.     

Therapeutic action in psychoanalytic therapy with toddlers and parents

Psychotherapy with toddlers and parents can focus on promoting attachment, facilitating development and improving interactions. Some techniques provide guidance to the parents, whereas others interpret to them their unconscious fantasies or ‘ghosts’ contributing to the child’s disorder. A recent paper introduced a psychoanalytically oriented technique, which emphasised the therapist’s interaction with the child in the presence of the parent(s). The child was addressed about his/her unconscious motivations in the session and the feelings towards the therapist. Also, the parent’s transference onto the therapist was seen as a vehicle that might further the therapeutic process and was accordingly addressed. The present paper analyses the therapeutic action in such treatments. Whereas work with the parents resembles that of ordinary psychodynamic therapy, therapeutic action is more difficult to conceptualise regarding the toddler, whose understanding of verbal interpretations and the therapist’s dialogues with the parent is more limited than that of an adult. However, a clinical vignette demonstrates a toddler’s precise and swift reactions to communications from mother or therapist. The paper investigates evidence from neuroscience and psychological research as to which communicative channels – beyond words – toddlers might perceive and comprehend. In addition, it is claimed that the countertransference is key to explaining how the therapist understands such communication.     

Restoring Dyadic Connection in the Face of Multiple Disruptions: Accounting for Vicissitudes in the Therapist’s Capacity for Reflective Functioning

This article describes the working method of our study group comprised of former Chestnut Lodge Hospital therapists and focusing on understanding therapeutic work with severely disturbed adolescents. Using process material from one therapy session, the therapist’s commentary on her feelings and reactions in the session, and the group’s discussion of the work, we explore factors disrupting the therapist’s moment-to-moment capacity to maintain a theory of her own and the patient’s minds. We then discuss what allows her to refind her theory of mind in the face of the patient’s aggressive nihilism and her own sense of loss. Salutary factors included the therapist’s empathy for the patient’s shared sense of grief, the patient’s offering the therapist cues to his inner state, and the dyad’s capacity to tolerate the therapist’s vulnerability in the patient’s presence.     

Teaching and learning the esoteric: an insight into how reflection may be internalised with reference to the occupational therapy profession

This paper is concerned with the ways in which reflective practice is learnt, taught and assessed within the profession of occupational therapy. It utilises individual experiences of reflection of both students and staff members in university and practice placement settings. The discussion places reflection within learning a profession’s way of being and individual learner’s relation to this ‘sense of being’. It concludes that the ‘rote’ way in which reflection is currently used to demonstrate evidence of reflective practice is detrimental to the development of a reflective professional, in this instance, an occupational therapist.     

Behind the Mirror: Reflective Listening and its Tain in the Work of Carl Rogers

Although Rogerian reflective listening is considered a fundamental therapeutic practice, it is widely misunderstood. This article endeavors to dispel myths about Rogers’ reflective approach through detailed readings of his work, while also opening up a central problematic in Rogers’ thinking. Rogers struggled repeatedly with the dilemma of how the therapist can faithfully reflect the client's experience while avoiding insincerity. The metaphor of a mirror and its tain, or back surface, is used to guide a close analysis of how Rogers grappled with the tension between the therapist's reflective listening process and his or her inner experience while reflecting. It is shown that each of Rogers’ revisions of his conceptualization of reflective listening constitutes a dialectical shift that opens a different approach to the problem of the tain, eventually concluding in an interactional formulation of reflection as the provision of tentative therapist understandings designed to be amended in response to client feedback.     

One and One and One is Minus Three: Therapeutic Consultations in Child and Adolescent Mental Health Services with Separated and Conflicted Parents

Many children and young people attend mental health services where the conflict and dynamics between their separated parents contribute to their mental health difficulties. Without intervention in the conflicted co-parenting relationship, the child’s mental health may not improve. This article discusses the issues from the position of both children and their parents and describes some psychoanalytic thinking that can be applied in this work. This includes the development of triangular space and a third position in which the relationship itself is seen as a separate third and the understanding of grievance as a state of mind and a psychic retreat. The therapist’s countertransference offers insight into the experience of the child.     

Discussing the therapeutic setting in child and adolescent psychoanalytic psychotherapy

The aim of this paper is to contribute to a debate on the particular characteristics of the therapeutic setting in child and adolescent psychoanalytic psychotherapy and its differences from the setting in adult therapy. In our opinion, there is a fundamental difference between these two, as in child and adolescent psychotherapy two distinct aspects co-exist and in some areas, overlap. In this paper, we attempt to delineate these two aspects, following Green’s division of the analytical setting into the active matrix and the casing. We propose that in child and adolescent psychotherapy the therapeutic contract, the active matrix, concerning the necessary conditions for making a therapy psychoanalytic – namely, the therapist’s free-floating attention and the patient’s free associations – is agreed between the therapist and the child/adolescent. We argue that in contrast, the contract regarding the casing – the timings of sessions, the fees and so on – is agreed primarily with the parents or carers of the child/adolescent. Ruptures and possible modifications in both the matrix and the casing of the setting are discussed through the presentation of clinical material.     

King Tiger and the roaring tummies: a novel way of helping young children and their families change*

Therapy with young children and their families poses special challenges for the therapist. In particular, it is important for the therapist to meet the child at his or her ‘view’ of the world. King Tiger is a special helper who can assist the therapist in this task. Once the idea or existence of King Tiger has been introduced to the child and family in therapy, the therapist can commence writing letters and stories to the child on King Tiger's behalf. These written interventions can affect the entire family. The paper will examine some of the useful and creative techniques that can be incorporated into King Tiger therapy. A case example will illustrate how King Tiger can work as a co-therapist.     

The mirroring function of the child analyst

This paper follows the progress of four years of twice-weekly psychoanalytic psychotherapy with a borderline girl aged 4 at the start of treatment. It describes how her early experience with her mother, who was ill, and her subsequent removal from her mother and placement with a foster-family led to her having severe difficulties in relating to others. Using the work of Ekstein as a framework, it follows the changes in the child’s behaviour in the therapy from acting out to playing with toys to role playing to the apparent development of her capacity to phantasize. It focuses on what the dolls’ house represented for her and how it came to be a transitional space where the inner world of the child could be represented. The play in and around the dolls’ house is described to show how she moved from playing on the outside of the dolls’ house to playing in part of the inside to using the whole house and how this seemed to parallel the development of her relationship with her therapist. Furthermore, it presents the views of a number of commentators on the use of the dolls’ house and what it represents for children in therapy and in our culture in general.     

The role of personal practice in therapist skill development: a model to guide therapists,educators, supervisors and researchers

Prior to 2000, personal practice (PP) for therapists mostly meant personal therapy. Recently a new landscape of PPs has emerged, with meditation-based programs and therapy self-practice/self-reflection (SP/SR) programs playing an increasing role in training and personal/professional development. The challenge now for practitioners and researchers is to refocus on the role of PPs in training and professional development. Are PPs of value - or not? Do they have a role in therapist development? How might PPs enhance therapist skilfulness? Do different PPs act in similar or different ways? Currently, the PP literature lacks a theoretical framework to guide practitioners in their choice of PPs or researchers in their choice of research questions and measures. The purpose of this article is to provide such a framework, the Personal Practice (PP) model. The PP model proposes primary impacts of PPs in four domains: personal development/wellbeing, self-awareness, interpersonal beliefs/attitudes/skills and reflective skills. The model also suggests a secondary impact on therapists’ conceptual/technical skills when therapists use reflection to consider the implications of their PP for their “therapist self”. We offer some suggestions to enhance the quality of future research, and conclude that PPs may play an important and perhaps unique role in therapist training.     

What Are We Doing There? A Therapeutic Tale

In this paper I try to portray our interpsychic work as reflective of an infinite conversation: an intersubjective dreaming of one’s life, moving between multiple positions/self-states, those of the patient and our own; becoming involved while pondering the movement we are part of, sometimes in our hearts and minds, many times aloud and openly with our patient; recognizing her experience and enabling her to see us, and sometimes not reflecting at all—“the “moving talk.” The dilemma of the therapist’s positioning, internally and interpersonally, is further postulated, especially in regard to the posttraumatic patient who suffered severe childhood abuse.     

Intersubjectively oriented,time-limited psychotherapy with children: how does the therapist evaluate the therapeutic process and what are the therapist’s tasks?

Based on the therapist’s evaluations of three therapies, this research aims to study the therapeutic process in intersubjectively oriented, time-limited psychotherapy with children. A primary objective is to further develop the therapy method. The study comprises therapies with children 6–11 years of age, who had experienced difficult family situations. Each child received 12 therapy sessions. The number of therapy sessions with children and parents was agreed upon beforehand, and the therapeutic objectives were approved by the parents. Each of the therapy processes were evaluated by the therapist by answering three questions and filling in three forms after each therapy session. The forms were: The Feeling Word Checklist; an alliance form for the child; and a process form. The therapeutic alliance and the behaviour of the therapist during the therapy sessions are discussed on the basis of the total material. The following main tasks for the child therapist emerged: structuring the therapy sessions; following the child’s initiatives; participating and cooperating with the child; exploring the child’s expressions; and understanding and regulating emotions.     

Early reflections on becoming a therapist: Development of reflective practice in clinical training programmes in an Australian context

The development of competent counsellors, psychotherapists and psychologists depends upon not only the clinical competencies, but also the development of the person as the psychotherapist. This qualitative study investigated the experiences of twenty provisional psychologists enrolled in a university‐based clinical psychology training programme. Participants were requested to write reflective essays describing their experiences in relation to their first year of training. Utilising an interpretative phenomenological approach methodology, three superordinate themes were identified: beginning awareness and internalisation of the role of the therapist, therapy as an inter‐subjective experience, and personal transformation. Themes encompassed a range of key areas identified by trainee therapists as central to their development as reflective practitioners. Findings from this study may contribute to the small but growing literature base explicating the early lived experience of being a therapist working from an integrative framework. The findings contribute to our knowledge of the critical elements involved in fostering the theoretical, practical and reflective processes involved in becoming a competent therapist.     

A Child Therapist at Work: Playing,Talking, and the Therapist’s Inner Dialogue

The author reflects on his work with a child patient struggling with affect regulation, loss, and his adoption through a detailed process account of the treatment with a focus on the therapist’s inner dialogue in relation to the child’s play and words—how each affects the other. Drawing from his personal use of clinical theory stemming from multiple theoretical influences, the author shows how his associations, identifications, and tentative formulations inform his work and how the various transference/countertransference matrices influence his inner dialogue. Attention is paid to the movement from the therapist as an object within the patient’s closed system to a system that gradually becomes more open, in which the patient is able to take in the therapist’s own person as they come upon various ways to communicate and build a narrative together.     

Sliding doors: some reflections on the parent–child–therapist triangle in parent work–child psychotherapy

The parental presence as therapy agents, namely as a medium and support for the therapeutic process, is one of the paradoxical parameters of working with children. Parental presence serves as a reminder of the need to find a balance between inner and outer reality. The door that is closed in the therapy room leaves a parent on the other side but at the same time provides the child’s inner world with more latitude to reveal itself. This paper examines the fabric of relations created in the therapeutic parent–child–therapist triangle (analogous to Britton’s conceptualisation of the parent–parent–child link). How does this triangular connection affect the ability to be with the silent self (Winnicott) when the parent remains (tangibly and symbolically) on the other side of the therapy door? This paper presents two clinical examples to illustrate the complex fabric of relations created in the therapeutic parent–child–therapist triangle and the interactions between the internal and external reality of the parent–child relationship.     

Narrative Child Family Therapy

In this article, child family therapy is presented as a hermeneutic activity shaped by an interest in the evolving narrative. Over brief, analytic play interviews, the therapist documents a child's narrative understanding of the presenting family problem. This allows psychological meaning to be jointly constructed in therapeutic conversation with the child and family. The idea of play as narrative integrates child psychotherapy into recent social constructionist thinking in family therapy. The article also discusses how narrative therapists can use prior theory and training.     

Developing the Working Alliance in Marital Therapy; A Psychodynamic Perspective

A good working alliance in marital therapy is one in which the partners are actively collaborating with their therapist to work through conflicts. The therapist begins to develop the alliance by setting the frame of therapy and helping the couple understand the guidelines of treatment. The partners gradually identify with and emulate the therapist's working style and use of self as a reflective instrument. The working alliance can be weakened by empathic failures and strengthened by increased feelings of trust in the therapist and the process of treatment This paper looks at the development of the working alliance in marital therapy from a psychodynamic perspective. A clinical illustration is included.