Case history of Farida: A year of psychotherapy with a girl who said she was sexually abused

This paper discusses how thinking about a playroom involves our thinking about the setting in psychoanalytical work with children in general - the physical as well as the human aspects - and how this encourages us to rethink some of the basic aims in psychoanalytic work. The paper describes the importance of the setting being such as to help the therapist to have the freedom to think and to feel what is going on in the child and himself. Links are then made with aspects of transference and counter-transference, and brief examples given.     

Child psychotherapy: Converging traditions

In this paper I outline some of the ways in which I believe the psychoanalytic traditions in North America and in Great Britain are influencing each other. I identify points of convergence and divergence at this moment in the evolution of psychoanalytic theory and technique. I then point out some of the implications of relational perspectives in child psychotherapy as this perspective is developing in the United States.     

Infantile defences in parent‐infant psychotherapy: The example of gaze avoidance

Findings from parent‐infant observational research have stimulated the development of intersubjective models of psychotherapeutic action. These models have brought out the infant as an interactive partner with the parent. Conversely, interest in describing the individual psyche of the baby has decreased, especially the unconscious levels of his/her experiences and representations. In parallel, clinicians and researchers have been less prone to apply classical psychoanalytic concepts when describing the internal world of the infant. The author argues that this is inconsistent with the fact that psychoanalytic theory, from its inception, was founded on speculations of the infant's mind. He investigates one such concept from classical theory; the defence. Specifically, he investigates if selective gaze avoidance in young babies may be described as a defence or even a defence mechanism. The investigation links with Selma Fraiberg's discussion of the phenomenon and also with Freud's conception of defence. The author also compares his views on the baby as a subject with those suggested by infant researchers, for example, Stern and Beebe. The discussion is illustrated by vignettes from a psychoanalytic therapy with a 3 month‐old girl and her mother.     

Young infants' vocalizations towards mother versus stranger: associations with the infant–mother relationship

Infants' differential vocal response (DVR) towards their mother and a female stranger at 3 months of age has been predominantly investigated as an index of early cognitive functioning. The present study explored the relationship between DVR and different infant and mother indicators of the developing relationship quality in a sample of 23 mother–infant dyads. Mother–infant interactions and stranger–infant interactions were videotaped during home visits when the infants were 3 months old. At the age of 12 months, infants' behaviour was assessed in the Ainsworth's strange situation. In both assessments, mothers noted the infants' behavioural states on 3 successive days. Results revealed a specific relation between DVR and the emotional atmosphere of the early mother–infant interaction. Particularly, DVR was less pronounced in favour of the mother when the mother displayed emotional expressions defined as rejection. DVR is discussed as an index that may indicate both infant emotional engagement and infant cognitive competencies. Copyright © 2005 John Wiley & Sons, Ltd.     

Pete the diesel: Psychotherapy with a severely disturbed five-year-old boy

The psychic significance of the figure of the grandmother in psychodynamic psychotherapy has received scant attention. This paper develops the concept of the ‘grandmaternal transference’ in parent–infant psychotherapy and explores its identification, its possible functions and its therapeutic significance. The grandmaternal transference has special relevance to parent–infant psychotherapy since the grandmother often represents both the mother’s mother and the child’s grandmother and offers a unique third position between mother and child. Three clinical vignettes illustrate how the grandmaternal transference may operate in this third position. In the first vignette, the therapist becomes in the transference a containing grandmother thereby facilitating maternal containment. In the second case, the therapist may be experienced as a differentiating grandmother able to help mother and infant with separation and individuation. In the third one, the therapist is transferentially experienced as a paternal grandmother who acts as a pseudo-father able to embody the paternal function. In each of these positions, the transference and countertransference – whether positive or negative – require that the therapist responds to rather than enacts the grandmaternal role. The three configurations of the grandmaternal transference have different clinical manifestations and offer different therapeutic ports of entry.     

Levels of change in parent–infant psychotherapy

This paper offers a way of thinking about the process of parent–infant psychotherapy. I start by outlining some ideas as to what can go awry in troubled parent–infant relationships, and then a way of working with parents with pre-verbal babies. I suggest a model for understanding three interlaced levels at which change might occur if a psychodynamic, systemically sensitive, therapeutic intervention is offered. I describe a particularly challenging clinical case in which a mother and I also worked with video material of her and her son.     

Light and movement: making contact with a traumatised and embattled latency girl

This paper shows a child psychotherapist learning and developing her technique as she attempts to make contact with a child who is extremely hard to reach. It is based on the first two years of three-times-weekly intensive psychotherapy of a latency girl who had little faith in a helpful therapeutic relationship. Her defences against such a relationship were entrenched and hard to shift. In this clinical work, the psychotherapist relies on close observation and her countertransference to develop a relationship with the child, in order to begin to make sense of her non-verbal emotional experience and communication.     

Psychoanalytic witnessing as a prerequisite to psychotherapy with a severely sexually abused young adolescent male ex-inner city gang member

This paper discusses psychoanalytic witnessing as the prerequisite for psychoanalytic psychotherapy with a severely sexually traumatised young adolescent boy, Dean. This form of witnessing acted as a prior stage for treatment through the psychotherapist acknowledging Dean’s trauma, without seeking to symbolise its registration in the psychotherapeutic relationship. As sexual abuse is about something done to the person, this acknowledging crucially conveys belief in the truth of what has happened to the patient at the hands of the external world. My work with Dean taught me that such acknowledgment allows for such traumatised patients to then feel more able to accept interpretations based upon what they are doing to the external world, encapsulated in the transference to their psychotherapist. Because trauma is often so deeply felt, and leaves patients dissociated or fragmented, seeking evidence of its presence needs keen observation. Here the paper discusses an experience of bodily countertransference that alerted me to the location of Dean’s trauma’s registration in our relationship. Overall, the paper seeks to demonstrate the importance of psychoanalytic witnessing as a form of containment in itself, and the essential basis for psychotherapeutic work using symbolisation and the transference.     

The psychotherapy of parenthood: towards a formulation and valuation of concurrent work with parents

This paper explores the process and value of concurrent work with parents when their child is being treated in individual psychotherapy. The position taken is that psychoanalytic understanding generally and the specific formulations presented in this paper have a broader applicability in other aspects and approaches in child and adolescent mental health practice. The central issues are the interweaving of knowledge of family processes, child development and psychopathology, and the uses that can be made of an understanding of transference and countertransference. A particular formulation is presented in relation to aspects of the work that constitute ‘child guidance’ and those that may be considered as ‘psychotherapeutic’ in relation to parental psychopathology. We have coined the term ‘the psychotherapy of parenthood’ to give this work the status it deserves and to define a boundary within which to explore the areas and levels of this complex work. Some practice and training implications are considered.     

Agreement of adolescent ratings with mother ratings and teacher ratings of ADHD symptom groups: A correlated trait-correlated method minus one analysis

This study examined the level of agreement of adolescent ratings with mother ratings, and adolescent ratings with teacher ratings of the inattention (IA) and hyperactivity/impulsivity (HI) symptom groups of ADHD. A total of 214 adolescents provided self-ratings of IA and HI, and their IA and HI were also rated by their mothers and teachers. The correlated trait-correlated method minus one model was applied, with adolescent ratings as the reference method, and the other two ratings as the non-reference methods. The findings indicated no additional variance in adolescent ratings for IA and HI that could not be accounted by mother ratings of IA and HI, respectively. In contrast, there was additional variance in adolescent ratings for IA and HI that could was not accounted by teacher ratings of IA and HI, respectively. The findings suggest that when diagnosing ADHD in adolescents, their reports of their own ADHD behaviors are not needed when mother reports of such behaviors are used.     

Predictors and moderators of improved social-emotional functioning in mothers with substance use disorders and their young children enrolled in a relationship-based case management program

Mothers with substance use disorders (SUDs) typically have trauma histories and psychosocial difficulties that lead to poor social-emotional functioning and disrupted mother–child relationships. This 12-month study explored associations of family adverse circumstances and services (case management, therapeutic, and community-based) received by 57-mothers with SUDs and their infants (less than 24-months-old) with changes in social-emotional functioning. All mothers were enrolled in a relationship-based case management program (Parent–Child Assistance Program [PCAP]) that emphasized connecting mothers to appropriate community services. A subset of mothers was additionally provided a trauma-focused psychotherapeutic intervention (infant–parent psychotherapy [IPP]). Dyads in both treatment groups improved in overall social-emotional functioning as assessed by the Functional Emotional Assessment Scale (FEAS). A combined-sample regression analysis revealed that improved FEAS scores were significantly predicted by the number of community services received but not by PCAP case management hours (IPP was not included in this analysis). More adverse circumstances were associated with less improvement in social-emotional functioning in the children; but among the mothers trauma level did not predict FEAS scores. We also found a moderating effect of trauma: Dyads with relatively more adversity showed a significantly greater association of community services received with improvement in FEAS scores than did those with relatively less adversity.     

Parenthood and parental functions as a result of the experience of parallel psychotherapy with children and parents

The concept of parenthood as defined in classical theory and later theorizations is discussed. Parenthood is defined as a transformative process, activated by the idea of having a child and by interaction with the child, through which a constellation of affective and psychic capacities is developed, promoting growth and psychic change and evolving over time. Parental functions, rather than being learnable skills, are considered as mind functions linked to character traits that cannot be split from the personality as a whole and are, as such, susceptible to improvement through psychotherapeutic work. The author illustrates this with a model of psychotherapies and parallel analyses of parents and children tested and elaborated in public and private practice, showing its therapeutic and cognitive advantages. The central thesis of the paper is that whatever the approach and working method with the parents, the therapeutic space offered encourages certain processes that are vital for the structuring of the self and the psychic growth of the child: creation of a space for the representation and emotional investment of the child; improvement in the parental functions; and identification with the therapist as a new or reactivated developmental object. Two clinical cases illustrate the parallel evolution of therapeutic relationships and of the parent‐child relationship.     

States of identity: a perspective drawing upon Fordham's model and infant studies

This paper examines the Jungian concept of identity and distinguishes it from projective identification and participation mystique which also refer to non-differentiation between self and object but involve projective mechanisms. Clinical work by Fordham and a psychoanalytic infant observation are used to illustrate early perceptual operations defined by experimental researches. These operations are understood to be expressions of the primary self which manifest themselves before the structuring necessary for normal projective identification. This paper attempts to describe an intersubjective experience between mother and baby that allows for their separate ways of relating, but does not depend on projective mechanisms that can exist only after there has been adequate development.     

Child psychotherapy with looked after and adopted children: a UK national survey of the profession

Relatively little empirical data is available about the range of work undertaken by child psychotherapists in the UK; however, previous surveys have shown high levels of complexity amongst children referred to child psychotherapists and an increasing proportion of work with children in foster or adoptive placements. Aims: We sought to examine child psychotherapists’ working practices with looked after and adopted children (LAAC), including the types of activities undertaken and their views on this work. Method: An online survey was designed to elicit this information from the members of the Association of Child Psychotherapists (ACP), the regulatory body for child psychotherapists in the UK. The survey included a number of categorical and open-ended questions, which were analysed quantitatively and qualitatively. Findings: 215 responses were received (24.5% of the eligible ACP membership). The vast majority of the sample were working with LAAC in some context (87.9%). Respondents were conducting a range of work: the most frequently conducted activities were assessment (83.7%), direct psychotherapy (82.3%), work with foster carers and adoptive parents (80.9%) and consultation with the professional network (76.7%). Thematic analysis of qualitative data suggested the complexity of problems amongst the children attending psychotherapy, as well as the perceived need for long-term work with these children. Many respondents placed emphasis on the importance of working with the professional network around the child, including foster carers and adoptive parents, despite feeling that this was often an under-resourced area of child and adolescent mental health services. The implications of the survey for practice and future research are discussed.     

A place within the heart: finding a home with parental objects

For adopted and Looked After children with compromised early experiences, there can be troubling phantasies and anxieties associated with parental objects. These internal object relations can seriously restrict the development of secure intimate relationships with new parental figures. Adoptive parents and foster carers bear the brunt of the associated difficulties. Clinical work with the child, parents/carers, family, or network, may help processes of containment, differentiation, working through, mourning, and integration. This paper is based on thinking derived from clinical work with children who are adopted or Looked After, and with adoptive parental couples, carers, and networks. The primary focus is on how the child needs to find a ‘psychic home’ in the minds of others for their damaged internal parental objects, and the emotional capacities required in adoptive parents to provide this. I describe some of the complexities for adoptive parents and others in providing what is needed to enable the child to experience their internal parental objects in a fuller way. This process can allow the child to introject, identify with, and re-imagine their internal parental objects, and through this develop a more realistic relationship to their adoptive parents and to their birth parents. It promotes trust, freedom, and emotional depth in the relationship with parental figures.     

The elephant tied up with string: a clinical case study showing the importance of NHS provision of intensive,time-limited psychoanalytic psychotherapy treatments

Prof. Richard Layard's influential advocacy for greater provision of ‘evidence-based’ psychological therapies, based in part on an economic rationale, has lead to greatly increased provision of cognitive behavioural therapy (CBT) and short-term therapies for depression, through the Increasing Access to Psychological Therapies (IAPT) initiative, whilst longer-term psychodynamic treatments are under threat, criticised as lacking an evidence base. This paper argues for the continuing provision of intensive thrice-weekly psychoanalytic psychotherapy treatments, time-limited to two years. It does so by describing such a treatment within an NHS psychotherapy department with a patient with a long history of severe personality pathology, including significant levels of perversity. The paper describes the patient's difficulties and his movement through the treatment, focussing on his difficulties making genuine emotional contact, his destructiveness of such contact, his acting out in the treatment, his perversity and the vital working through of the ending. The shifts the patient made are described, and follow-up information on the patient is given. The paper discusses the unique benefits of time-limited treatment and intensive psychoanalytic treatments for this ‘hard-to-help’ group of patients, and the economic rationale that can be made for such treatments.     

Application of focusing‐oriented psychotherapy in dealing with issues of Asian immigrants: A single‐case study of a Korean immigrant in Japan

A single case study is presented of the successful application of focusing‐oriented therapy in the case of a Korean woman who migrated to Japan. The client had a host of problems related to the discrimination she faced from her own family and from Korean society for being female, as well as relationship and cultural difficulties in trying to adjust to married life in Japan. Through 10 sessions of focusing‐oriented therapy, the client was able to re‐examine her situation from a positive perspective and began to accept herself as a person, not necessarily as a woman or a Korean in Japan. Issues related to Korean women immigrants in Japan are explored and the related effectiveness of focusing‐oriented therapy for the particular population is discussed.     

Moved to tears: Technical considerations and dilemmas encountered in working with a 13-year-old boy with acquired quadriplegia 1

This paper is about therapeutic work with David, a 13-year-old boy who, at the age of 5, was the victim of a hit-and-run road traffic accident resulting in quadriplegia. The circumstances leading to the accident and its sequelae reveal a particularly complex picture, which combines early emotional deprivation and trauma. Although cognitively intact and able to speak, David could not move. Yet he created movement in others through a desperate necessity, by communicating via the employment of extreme projective forces. The highly complex presentation of emotional, psychic and bodily damage in the child, and in particular, David's physical paralysis, has had a profound impact upon what I have come to think of as the ‘mindbody’ of the therapist. Winnicott has talked of the infant's ‘psyche/soma’. Here I want to extend the notion and consider the bodily impact of projections in particular and how these have a powerful emotional and physical resonance on the ‘mindbody’ of the therapist, especially in therapy with a young person whose body is damaged. In this paper, I consider technical challenges and dilemmas encountered in the work, including the complex interplay of transference/countertransference phenomena. This unusual presentation of a boy in extraordinary circumstances led to considerations of psychoanalytic method and interpretative activity, which may be viewed as being inspired by ‘emotional truthfulness’.2 2 Alex Dubinskey (Chair ACP conference 2004) commenting on aspects of this work used the term ‘emotional truthfulness’.

Dans cet article, l'auteur raconte son travail thérapeutique auprès de David, âgé de 13 ans, qui à l'âge de 5 ans fut victime d'un accident de la circulation avec délit de fuite, accident qui le laissa tétraplégique. Les circonstances qui aboutirent à l'accident et à ses séquelles forment un tableau particulièrement complexe mettant en jeu des carences affectives précoces et des traumatismes. Bien que ses capacités cognitives ne fussent nullement atteintes et qu'il fut capable de parler, David ne pouvait pas bouger. Par l'urgence désespérée de son discours, transmise grâce à des projections extrêmement puissantes, il réussissait à susciter du mouvement chez ses interlocuteurs. La présence conjointe et extrêmement complexe de dommages affectifs, psychiques et corporels chez cet enfant – et notamment sa paralysie physique – eut un impact profond sur ce que l'auteur en vient à appeler l'“ esprit-corps ” du psychothérapeute. D. W. Winnicott a parlé du “ psyché-soma ” du jeune enfant. Dans son texte, l'auteur élargit cette notion, notamment pour prendre en considération l'impact corporel des projections, ainsi que leur résonance émotionnelle et physique massive sur l'“ esprit-corps ” du thérapeute, surtout lorsque son patient est une personne jeune dont le corps est endommagé. L'auteur explore les défis et dilemmes techniques rencontrés au cours de son travail, y compris le jeu complexe de phénomènes transférentiels et contre-transférentiels. Ce traitement, inhabituel, avec un garçon dans des circonstances sortant de l'extraordinaire soulève des questions concernant la méthodologie psychanalytique et l'activité interprétative, questions qui peuvent être considérées comme étant inspirées par la “ véracité émotionnelle ”.

Dieser Artikel ist über die therapeutische Arbeit mit David, einem 13-jährigen Jungen, der im Alter von 5 Jahren das Opfer eines Unfalls mit Fahrerflucht war, der zu einer Querschnittslähmung führte. Die Umstände, die zu dem Unfall führten und seine Folgen legen ein besonders komplexes Bild dar, das frühe Vernachlässigung und Trauma kombiniert. Obwohl David kognitiv intakt war und sprechen konnte, konnte er sich nicht bewegen. Doch schaffte er Bewegung aus verzweifelter Notwendigkeit in anderen, indem er mit mithilfe der Benutzung von extremen projektiven Kräften kommunizierte. Die höchst komplexe Präsentation von emotionalem, psychischem und körpelichem Schaden in dem Kind und insbesondere Davids körperliche Lähmung, hatte eine tiefe Auswirkung auf das, was ich nun den ‘mindbody’ (Gemütskörper) des Therapeuten nenne. Winnicott sprach vom Psyche/Soma des Babies. Hier möchte ich diesen Begriff ausweiten und besonders die köperliche Auswirkung der Projektionen betrachten und wie diese eine starke emotionale und physische Resonanz auf den ‘mindbody’ des Therapeutens haben, insbesondere in der Therapie mit einer jungen Person, deren Körper beschädigt ist. In diesem Artikel betrachte ich technische Herausforderungen und Dilemmas, denen man in dieser Arbeit begegnet, einschliesslich der komplexen Wechselwirkung von Übertragungs/ Gegenübertragungsphänomenen. Diese ungewöhnliche Behandlung mit einem Jungen in aussergewöhnlichen Umständen führten zu Überlegungen zur psychoanalytischen Methode undzur Deutungsaktivität, die von ‘emotionaler Wahrheit’ inspiriert wird

Riassunto: In questo articolo si parla del lavoro terapeutico con David, un bambino di 13 anni che, all'età di 5 anni, fu vittima di un incidente stradale che portò alla quadriplegia. Le circostanze che portarono all'incidente e la sua sequela rivelano un quadro particolarmente complesso, nel quale emerge un misto di deprivazione emotiva precoce e trauma. Sebbene David fosse abile cognitivamente e potesse parlare, egli non poteva muoversi. Eppure il bambino generava movimento negli altri attraverso una disperata necessità, comunicando con l'uso di estreme forze proiettive. Il presentarsi di un danno nel bambino altamente complesso nella sua dimensione emotiva, psichica e corporea, ed in particolare, la paralisi fisica di David, hanno avuto un profondo impatto su ciò che ho iniziato a pensare come il ‘corpomente’ del terapeuta. Winnicott ha parlato dello ‘psiche/soma’ del neonato. L'autrice vuole nell'articolo estendere la nozione e considerare l'impatto corporeo delle proiezioni e come queste abbiano una risonanza emotiva e fisica molto forte sul ‘corpomente’ del terapeuta, soprattutto nella terapia con un ragazzo giovane il cui corpo è stato danneggiato. Nell'articolo considero le sfide tecniche e i dilemmi incontrati nel lavoro, compreso il gioco complesso dei fenomeni transferali e controtransferali. Il trattamento insolito con questo bambino in circostanze molto particolari ha portato a considerazioni riguardo al metodo psicoanalitico e all'attività interpretativa, che si possono considerare come ispirati da ‘verità emotiva'¹