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.     

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.     

Lines of advance in psychoanalytic psychotherapy

Freud's 1919 paper is taken as a starting-point to review how far we have advanced towards fulfilment of his prophetic remarks about the need to develop psychoanalytic psychotherapy for the masses. A glance is taken back to some of the circumstances and characters involved in Budapest where the paper was given at the 1918 congress, where there was much talk about the need to do something about the war neuroses. Similar pressures led to the founding of the Tavistock Clinic and Cassel Hospital in the UK, long before the start of the NHS. The pressures of both world wars advanced the applications of psychoanalysis; the next wave of pressures may come from NHS changes and entry into Europe. The history of psychoanalytic psychotherapy in the UK is also considered via looking briefly at the history and development of psychoanalytic publications, of the Tavistock Clinic, of psychoanalytic training, of child psychotherapy and the emergence of adult (non-medical) psychotherapy. There have always been tensions between exponents of the pure gold of analysis and the needs of its wider applications. More flexible arrangements and boundaries are necessary if we are to spread psychoanalysis beyond London and to fulfil Freud's own hopes about the large-scale application of psychoanalytic therapy.     

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.     

Revisiting ‘What works for whom?’: A qualitative framework for evaluating clinical effectiveness in child psychotherapy

This paper describes a framework for evaluating the effectiveness of child psychotherapy used by child psychotherapists in an inner city Child and Adolescent Mental Health Service (CAMHS). The Hopes and Expectations for Treatment Approach (HETA) involves using the assessment for psychotherapy that normally precedes treatment to derive a baseline from which to generate a set of hopes/expectations as regards the effects of the treatment on the part of parents and the psychotherapist, to be revisited one year after the start of the psychotherapy and/or at its completion. The Strength and Difficulties Questionnaire, for parents and schools, was also administered before and after the treatment. The characteristics of the first 30 children referred for psychotherapy over a particular time period are described. Of the first 15 children in this group to complete one year of individual psychotherapy, all showed change or significant change in the areas concerning parents' and therapists' hopes at the end-of-year review, as rated by parents and psychotherapists. A case of a child with conduct disorder is used to describe how the assessment generated a psychoanalytic formulation, how the therapist's understanding was fed back to the parents, and how the parents' and therapist's hopes and expectations were derived and recorded. This case illustrates powerfully the impact of trauma in the parents' backgrounds on the internal world of the child, and how the method provides a useful bridge between parent and child work. Feedback from the psychotherapists, the parents and the referrers using the framework is reviewed, and in conclusion the paper argues for the framework's value in promoting good practice in the treatment and management of complex cases and in enhancing awareness of the nature and scope of the psychotherapy process.     

Adolescent Patients’ Responses to Interpretations Focused on Endings in Short-Term Psychoanalytic Psychotherapy

Discussing endings is a crucial part of the work of short-term psychoanalytic psychotherapy with adolescents, but there are different views on how best this should be done and whether it is helpful or appropriate to link endings to interpretations of the transference. This study looks at how adolescent patients suffering from moderate to severe depression respond to interpretations around endings in a 28-session long, manualized psychoanalytic psychotherapy. Data come from a randomized clinical trial in which all sessions were audio-recorded. Purposive sampling was used to identify four sessions with four different adolescents in which therapists raised the issue of upcoming endings, explored the patients’ emotional responses, and linked these to the transference. The four extracts were transcribed and analysed using conversation analysis. Findings show that patients either emphasized or diminished the importance of their relationship to the therapists and the consequences of the separation from them in response to transference interpretations. They managed the conversational exchange by either “trouble-telling” or “story-telling.” The authors reflect on the implication of patients’ responses for treatment technique and consider whether transference work with adolescents should be paced and adapted more flexibly in short term psychoanalytic psychotherapy.     

Psychoanalysis in Psychiatric Institutions - Theoretical and Clinical Approaches

The paper presents historical remarks about psychoanalysis in institutions with a special focus on the contributions of nurses working in psychoanalytic settings. A case report of the forensic psychotherapy ward in Reichenau Mental Hospital, which is organised as a therapeutic community, shows how individual psychotherapy, group psychotherapy and special nursing care contribute to significant progress in the treatment of a severely narcissistic arsonist.     

Like a phoenix: the journey toward core-self restoration following paediatric skin-burn injury: a psychoanalytic perspective

Severe and sudden injury to the skin during childhood may damage both the child’s outer appearance and mental state. Such a trauma can provoke a complete and utter breakdown of the core-self and regression to an ‘unintegrated’ state. We present the case of 11-year-old Michael, who played with matches, set a fire and sustained severe burn trauma. Michael was treated in our rehabilitation ward over several months and received skin treatment, physical therapy and psychotherapy. Paediatric burn injury is not only a physical struggle but is often accompanied by intense emotional distress of the child and his family. In describing Michael’s therapeutic process, we show how the restoration of the core-self, alongside the healing of the outer skin, provoke issues concerning early infantile skin formation, normative age-related conflicts and vulnerabilities specific to the child. By integrating psychoanalytic thinking into the clinical work of skin rehabilitation, following burn injury, we demonstrate how the significant relationship between the skin and the self manifest in different practice.     

'Talk to me baby, tell me what's the matter now': Semiotic and developmental perspectives on communication in psychoanalytic infant treatment

Infants suffer to a considerable degree from disturbances in nursing, sleep, mood, and attachment. Psychotherapeutic methods are increasingly used to help them. According to case reports, psychoanalytic work with infants and mothers has shown deep‐reaching and often surprisingly rapid results, both in symptom reduction and in improved relations between mother and child. The clinical urgency of the method makes it important to study its results and theoretical underpinnings. Among the theoretical issues often raised in discussions on this modifi ed form of psychoanalysis, those addressing the nature of communication between analyst, baby, and the mother are the most frequent. For example, how and what does an infant understand when the analyst interprets to her? What does the analyst understand of the infant's communication? These issues are addressed by investigating the infant's tools for understanding linguistic and emotional communication, and by providing a semiotic framework for describing the communication between the three participants in the analytic setting. The paper also investigates problems with the traditional ways of using the concept of symbolization within psychoanalytic theory. The theoretical investigation is illustrated by two brief vignettes from psychoanalytic work with an 8 month‐old girl and her mother. demand for the breast. Like the two lovers in the blues, they seemed to be slaves to     

A MOLE LEAVES HIS HOLE

This paper uses the example of setting up a community-based adolescent psychotherapy and counselling service to explore the difficulties and anxieties that can arise when psychoanalytic practitioners venture out of the consulting room to become involved in planning and organizing services. Emphasis is placed on the complications of such a task in a climate of rapid change, when levels of anxiety, fuelled in many different ways, can threaten the viability of the task one is engaged in. The author argues that in a political climate that is generally not very supportive of psychoanalysis, it is possible none the less for psychoanalytic ideas to have an important impact on how psychological services can develop, and this in itself can challenge many of the preconceptions about psychoanalytic practitioners that one can be confronted with when one leaves the comfort of the consulting room.     

Audit in psychoanalytic psychotherapy with children and adolescents

The importance of multidisciplinary audit in child and adolescent psychiatry, including the work of child psychotherapists, is discussed. Research is highlighted which shows that certain groups of children in particular benefit from psychoanalytic psychotherapy. The problems related to auditing psychoanalytic psychotherapy are discussed, and a possible method of audit based on peer review of notes, which takes into account both inner and outer change, is presented.

A patient is discussed whose notes have been audited using the audit form. It is suggested that this form of audit has good educational potential as well as ensuring a high standard of patient care.     

Growth in emotional intelligence. Psychotherapy with a learning disabled girl

This paper describes the once-weekly psychoanalytic psychotherapy of a girl, called Ellie, aged eight at the start of her treatment. Ellie had a learning disability and displayed difficult behaviour at school and at home. In her therapy, Ellie grew in emotional intelligence, more in touch with and able to express her feelings. Her behaviour improved and so did her capacity to learn. In the therapy there were certain limitations to progress and this is discussed in terms of how Ellie's disability affected the basic achievements of emotional development, including a mind with a solid ‘reality ego’, able to contain anxiety, and able to maintain depressive functioning. The importance of parallel parent work, to share observations and understanding of the child's functioning is discussed. Difficulties for both child and parents in dealing with the pain of difference and how this limits emotional intelligence are discussed. The author hopes that this paper will encourage the offering of psychoanalytic psychotherapy to children and young people with learning disabilities, who are significantly more likely to suffer from mental health problems than their peers.     

Puerperal psychosis: Vulnerability and aftermath

The puerperium is a particularly vulnerable time for a depressive psychotic breakdown, with important consequences for both mother and child. While general psychiatric experience helps in the overall management, psychoanalytic insights help towards understanding the central psychopathology. Illustrative case-studies are presented.

Based on hospital admission rates, puerperal psychosis is regarded as a rare condition (one in 500 deliveries). In this paper, evidence is given to suggest that puerperal psychosis is a far commoner condition (three in 100 deliveries), and that many less-severe cases remain undetected and untreated in the community. It is argued that understanding interventions in these cases can be therapeutic for the mother, as well as having major implications for the baby's development.     

Effectiveness of child psychoanalytic psychotherapy in a clinical outpatient setting

The objective of this study was to evaluate the outcome of child psychoanalytic psychotherapy in a clinical outpatient setting in a city in southern Brazil. Three psychological tests (Rorschach, Bender and WISC III) were administered to 23 children, aged 6–11 years old, and the Child Behaviour Check List (CBCL) was completed by the parents. All testing was completed before the beginning of the individual psychoanalytic psychotherapy. The same measures were repeated after 12 months of intervention. The 23 children who received individual psychoanalytic psychotherapy were compared with a control group who did not receive any kind of intervention. In the clinical group, the results indicated a statistically significant reduction of anxiety symptoms (0.002) and school problems (0.031), improvement in interpersonal relationships (0.022), and positive change in the following CBCL scales: withdrawn (0.010), thought problems (0.022), anxiety and depression (0.017), internalising (0.008) and total (0.003). An effect size of 0.696 was calculated based on the CBCL total scale before and after the intervention. The results revealed that child psychoanalytical psychotherapy is mostly effective in the treatment of female children who present internalising disorders.     

Psychoonkologische Therapie und Psychoanalyse: ein Widerspruch?

Psycho-oncological psychotherapy and therapeutic work with severely somatically ill patients seems to be an area of limited interest in psychoanalysis. For example, case reports of psychoanalytic treatment with terminally ill patients are rare. This stands in contradiction to the importance of the fear of dying and death (wish) in psychoanalytic theory construction (e.g. narcissism theory). In addition to the obvious differences between psycho-oncological therapy and psychoanalysis, such as limited time perspective, the need for a flexible setting and dealing with the depth of regression, there are also important similarities and in particular the therapeutic work on early unconscious defence processes and coping with the fear of death. The theoretical and clinical work of the French psychoanalyst Michel de M’Uzan on experiences in psychoanalytic treatment of dying patients are an important example but are not well known in the German psychoanalytic community. The way psychotherapists deal with their own separation anxiety and fear of death is still a major issue and a barely appropriately reflected phenomenon, which possible represents a mutual confrontation (or an impossibility?) of psychotherapeutic work with dying patients.     

Gender/ed identities: an overview of our current work as child psychotherapists in the Gender Identity Development Service

Abstract

This paper is adapted from a presentation first given at the 2017 Association of Child Psychotherapists (ACP) Conference. We hope to give a feel of our work as psychoanalytic child psychotherapists working in a Tier 4 national assessment service for gender variant children and connect with our colleagues working therapeutically with these families in Child and Adolescent Mental Health Services (CAMHS) and other settings. Gender variance does not have a single cause, or straightforward developmental pathway; rather it is a complex interplay of multiple factors, akin to sexuality in the diverse manifestations and ‘tributaries’ taken. This paper is given as a plea for complexity, to counter the current intense focus on gender identity and the consequent reductionism this can lead to. To this end, three case studies from the clinic, taken from Under Five, Latency and Adolescent phases of development, are explored. The complexity of the cases is then discussed, followed by parallel issues of development, divergence and difference. These three ‘average’ cases from the Gender Identity Development Services (GIDS) serve to demonstrate the need for child psychotherapy as part of multi-disciplinary thinking about gender variance and how attention must be maintained to each unique story and process of identity development; as well as our clinical task to establish and encourage depressive functioning and secondary processes where possible.     

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.     

The day the earth stood still: The presence of trauma in time experience

The experience of time is commonly perceived as developing within the context of the early relationship between mother and infant. The beginning of life occurs in an adapted environment, aimed to protect the child from internal and external disruptions. Through healthy development, the mind acquires a feeling of continuity that gradually becomes a cohesive sense of personal identity. However, in cases of traumatic interruptions to the primary environment, the defensive shield of the self is penetrated and the individual becomes prematurely aware and adapted to the external reality. This forced acknowledgement of time and reality could be manifested in various types of time disturbances, such as disorientation about time or difficulties in following a schedule. In therapeutic relationships, this drama would be enacted in a struggle against the psychoanalytic setting, which disrupts the continuity of being with the therapist. Importantly, these patients express a deep conscious or unconscious fantasy to live in a timeless world, in which they would not be forced to adapt themselves to others’ expectations or needs. Clinical examples are used to illustrate how traumatic history is evident in the patient’s time experience and in the psychoanalytic dialogue.