Psychoanalytic aspects of inpatient treatment

This paper looks at the experience of inpatient hospital treatment at the Cassel Hospital and how formal psychoanalytic psychotherapy, with its emphasis on the transference and the inner world, fits into that context and orientates itself to some of the realities of the setting. It outlines how psychotherapy and nursing can work to inform and enrich each other, and what is psychoanalytic about the overall work. A bridge of understanding is built using the patients' perceptions of, adjustment to and conflict about the inpatient setting, and the affective impact of the processes on patients and staff alike. Two clinical examples of severe child abuse family cases are given, the first of Munchhausen syndrome by proxy, the second in which a baby sibling had been killed. They show how in-depth psychoanalytic work with mother and child and individual psychotherapy of the child can be combined with psychotherapy of the parents and intensive work in the therapeutic community. Such a combination can contribute, even in cases of severe pathology, to the development of the relationship between mother and child and promote successful rehabilitation in the outside community.     

‘It’s silly these doors don’t open’: a six-year-old girl emerges from a chronic state of emotional withdrawal

This clinical paper explores the way in which the first two years of a long-term psychotherapy helped six-year-old Anna to lessen her retreat into a chronic withdrawn emotional state. Over the course of the first year she would occasionally pick up the fridge from the doll’s house and try to open the doors, but because the fridge was actually a block of wood the doors could not open. In treatment, this inquiry came to represent the difficulties of engaging and making contact with a baby who found it very hard to feed. The author describes how, as Anna entered into a therapeutic relationship, it slowly became clear that there was an inner world jam-packed with persecutory anxieties and a family history of unmourned loss and trauma. Through fear Anna slammed the doors to her mind – to knowing herself – and by not feeding, Anna starved herself of opportunities for mental growth. It took some time for her to state, “it’s silly these doors don’t open, they should”. In the discussion of this clinical material the author draws on the work of Francis Tustin, Alessandra Piontelli and Marguerite Reid to consider the link between intergenerational and prenatal trauma and subsequent emotional disturbance in the child.     

Establishing emotional mutuality not formed in infancy with Japanese families

Young mothers in Japan today are faced with a conflict between the traditional image of motherhood and a sometimes lonely life without physical and emotional support from their husbands, family, and community. As a consequence of this, more and more children are becoming emotionally disturbed as a result of poor mother-child interactions that arise as early as infancy. With several cases of poor interaction, hospital treatment was undertaken to establish emotional mutuality between mother and child through therapeutically induced regression into infancy. Each mother-child pair was hospitalized in the baby unit of the pediatric ward, and the mother provided consistent emotional availability to her child. The child then regressed into infantile states that involved the following four phases: (1) The child began to interact with her mother more actively; (2) she became demanding, like a toddler in the rapproachment crisis; (3) the mother's sustained acceptance won the trust of her child, who began to show a strong attachment to her; (4) the child began to progress to a stage appropriate to her age and used the mother as a secure home base. Each child lost previous symptoms and acquired a stable character. This approach, which utilized the Japanese affinity for intimacy and regression, proved effective in the management of psychopathologies rooted in infancy.     

PARENTS AND THEIR CHILD AND THE ANALYST IN THE MIDDLE

The first part of this paper explains how the transgenerational mandate influences the mental activity of the child. When a child acts the denied suffering of the parental couple, the analyst risks being imprisoned by the transgenerational mandate. Frequently the analyst is unconsciously asked by the parents to cure without curing because the child's psychological birth, still in the making, threatens the defensive equilibrium of the parents. The analyst is thus caught between the parents and the child and must find his/her own way forward in order to free the child from the burden of the mandate. In the second part of the paper, an analysis of a 5-year-old child is presented. The author shows how a transgenerational mandate may hold a traumatic potential because it can impair heavily the child's capacity to think. The author also describes the way in which she works with the parents and how she manages the setting and the style of the interpretation. She insists in particular on the need to sustain the child's perceptions in order to gradually allow the child to take roots in his/her experiences and therefore develop his/her own identity.     

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.     

A Single Intervention: A Visit to the Family

The following letter is reported unchanged except for disguised names. Concern with repairing disrupted relationships of adult members of a family with their own parents has been a matter of growing interest to a number of family therapists; Bowen (1), Boszormenyi-Nagy (2), and Framo (3), among others have stressed the importance of sending family members back to their families of origin. This report makes no effort to formulate the process in any particular theoretical framework (i.e., as reestablishing connectedness after an “emotional cut-off” or rebalancing a ledger of fairness, or whatever) but is intended only to illustrate the kind of outcome one may hope for in prescribing such a maneuver. It is offered simply as a clinical note. The letter needs little prefatory explication. Mr. Jack Newburgher had been a patient in psychoanalytic treatment for four years, with a quite successful outcome. On two occasions in the course of his therapy a joint session had been held with Mr. Newburgher and his wife, Muriel, when changes in his behavior had precipitated crises in the marital relationship. His therapy had terminated about two years before the visit referred to in the letter. Mr. Newburgher had called and asked for a joint consultation with Muriel about an acute family problem they were experiencing. Some — not all — of the background material was described, not nearly as coherently as it is reported in Muriel's letter, but in sufficient detail to make it plain that she was in distress about having to withdraw completely from her parents and that their family was in disarray as a consequence of her distress. The acuteness of the emotional disturbance, against a background of a lifelong adversary relationship between Muriel and her father and a history of ten years of illness on her fathers' part, suggested that the distress was the product of Muriel's anxiety and guilt over a decision to cut herself off completely from her parents. As a consequence, Muriel was urged to visit her family of origin, with the caveat that she might indeed discover them to be malignantly self-centered people indifferent to their effect on her and her family, but that she would at least have the gratification of having tried. The reference to “speaking French” was to the therapist having suggested that, on the other hand, she might find that her parents expressed their feelings in a different modality from her definitions of how feelings should be expressed, much as though their native tongue were French and she were insisting that they must speak to her in English.     

False‐self sensitivity to countertransference: Anatomy of a single session

This paper describes how a patient's sensitivity to the counter‐transference sparked a transference regression that generated insight about her core conflict: False‐Self compliance at the expense of her needs for love, emotional support, and nurturance.

My patient's regression was important, first, because it produced symptoms that dramatically illustrated to her how much self‐denial she was willing to exercise to feel needed by others. Previously, such insight had not been effective because of the extraordinary secondary gains of her behavior. This time was more successful because of the ego‐dystonic symptoms that developed, with intense shame and embarrassment. Second, the regression resulted in a transference dream that provided her with new insights into the anxiety she was warding off through False‐Self compliance to the narcissistic requirements of her parents.     

When a Non-resident Worker is a Non-resident Parent: Investigating the Family Impact of Fly-In,Fly-Out Work Practices in Australia

Non-resident work practices, which involve prolonged separations from family, long-distance commuting between home and remote work sites and long work hours across compressed rosters, are now commonplace in Australia. This study examined the impact of these work arrangements, often termed Fly-In/Fly-Out (FIFO), on children and families, and to identify family-related and employment-related factors that influence child and family outcomes. Anonymous online surveys containing measures of family and couple relationship quality, child behavioral and emotional adjustment, parenting and personal adjustment were completed by 232 partners of FIFO workers, 46 FIFO workers, and a comparison group of community parents (N = 294 mothers, N = 36 fathers). There were no differences between FIFO partners and community parents on family or couple relationship quality, parenting competence and child behavioral or emotional difficulties. FIFO partners reported higher levels of personal emotional problems and greater usage of harsh discipline practices than community mothers, while FIFO workers reported greater work to family conflict and alcohol use than community fathers. Regression analyses on the FIFO partners sample indicated that child and family functioning were best predicted by family factors, including harsh parenting and parental emotional adjustment. Implications of the findings for the design and provision of family-based support for FIFO families are discussed.     

“Why Didn't They Keep Me?”: The Search For Belonging in the Analysis of a Four Year Old Adopted Child

The purpose of this clinical article is to discuss aspects of the analysis of a child whose adoption functioned as organizer of her personality. Her fantasy life, defensive organization, sense of self and other, and object relations were all organized around a personal mythology surrounding her adoption. These organizing myths took various forms that emerged in the course of the analysis. Her adoptive parents also created a mythology that had a critical impact on the child's development and on their development as parents. The analytic work demonstrates how these organizing mythologies governed the parent–child relationship and how the collision of their mythologies led to a breakdown in the child's development and in parental functioning. In the course of the analysis, the child developed the capacity to grieve and to react to loss in an organized way as progressive development was restored and she was able to feel valued and loved. Her parents began to grieve the dual loss of not having biological children or a perfect adoption, and to develop more motherly and fatherly feelings for their child.     

On mirroring in group psychotherapy

“A woman has two images. There is a magical person seen or remembered by those who love her, her finest qualities are flesh and spirit illuminated. She herself knows this ideal self; she projects it, if she is confident; or she daydreams her ideal self; or she recognizes it with gratitude in the admiring eye of others. There is at the same time a second image; the woman as seen by those who dislike or fear her. This cruel picture has an all too powerful mirror in her own negative idea of herself. She sees with fear her own ravaging impulses and most painful of all, a graceless, freakish, and unlovable physical self, this was the mirror her parents held before Edith. Her brothers saw her with love. She herself knew both images. Her life, and her poetry, constituted a flight from the second one.”     

Parents' Involvement in ASD Treatment: What Is Their Role?

The rising prevalence of autism spectrum disorders (ASD) warrants a greater level of clinical attention to best treat those with ASD. The characteristics of ASD lead to impairment for both the child with the disorder and his/her family. To effectively treat children with ASD, parents need to be included in intervention efforts. Research suggests that parental involvement in treatment improves the generalizability of skills and increases the amount of intervention the child receives. Numerous benefits have been found in child and parent outcomes when parents are included in treatment. The purpose of this paper is to discuss the impact ASD can have on the parent-child relationship, the factors that influence treatment outcome, and the advantages of including parents in treatment. The different roles parents can have in treatment will also be discussed along with providing clinicians guidance on practical ways to involve parents in the treatment of children with ASD.     

The fear of love: the denial of self in relationship

This paper explores the fear of love and relationship which develops when a child has experienced parents who cannot tolerate emotional separation and so attempt to retain perfect contingency with their infant, long after the infant needs to begin to separate and individuate. The child is a 'self-object' for the parents, who depend on the responses of others, including their own child, to maintain a sense of their own identity. The impact of this demand for 'reverse parenting' on the child's development is explored and clinical work with an adult patient whose history reflects this process is described.     

Family‐level coparenting processes and child gender as moderators of family stress and toddler adjustment

The goal of this multi‐method study was to examine how child gender and coparenting processes influence associations between family stress and toddlers' social adjustment. The participants, 104 dual‐earner couples and their 2‐year‐old children, were videotaped in their home during a freeplay activity. Mothers and fathers completed questionnaires about stress in their roles as partners, workers, and parents and their child's social–emotional adjustment. Consistent with previous research, higher levels of family stress were associated with poorer adjustment for children. Family harmony, represented by warmth and cooperation, was significantly associated with fewer internalizing problems for children even when family stress was considered. Conversely, coparental banter or ‘playful humour’ between parents moderated the nature of the association between family stress and children's adjustment. Banter between parents was especially protective for girls suggesting that, even in families with toddler‐aged children, gender plays an important role in family‐level coparenting processes. Future research needs to consider more fully the impact that child characteristics, such as gender, have on the interplay between the family context and children's development. Copyright © 2008 John Wiley & Sons, Ltd.     

Determinants and Consequences of Child Culture Brokering in Families from the Former Soviet Union

Child culture brokering occurs when immigrant children help their families navigate the new culture and language. The present study develops a model of the child culture broker role that situates it within the family and community economic and acculturative contexts of 328 families from the former Soviet Union. Path analysis was utilized to explore the relationships of community and family economic and cultural contexts with child culture brokering, child emotional distress, and family disagreements. All children reported some culture brokering for their parents. Less English proficient parents with lower status jobs, and living in areas with more Russian speaking families tended to utilize their children as brokers more often. Further, community economic conditions also predicted brokering indirectly, mediated by parent job social status. Brokering was related to child emotional distress and family disagreements. Further, culture brokering was a mediator of the impact of parent job social status on both child emotional distress and family disagreements. These results add to our understanding of the culture broker role and emphasize the utility of approaching research on it from an ecological perspective.     

Parenting,Protecting, Preserving:Mission of the Adolescent Female Runaway

This paper presents a systemic framework for therapy with families of adolescent female runaways. The runaway adolescent is viewed as serving three functions within her family. First, she often parents her parents and siblings. Second, she protects her parents' marriage and regulates marital distance. Third, she preserves her family unit at the preadolescent developmental stage. Interventions are described that remove the adolescent from those roles by empowering the parents to take charge of the adolescent, by changing the communication process such that the couple deal with their marital issues without the help of the teenager, and by facilitating the family's movement toward a new stage of separation and individuation.     

The transactional model of early home intervention

This article describes a developmental model for early home intervention and treatment of environmentally and biologically at-risk infants and their parents: The Transactional Model of Home Intervention. The model identifies the development of both infants and parents as targets of intervention and considers their ongoing interactions or transactions within the family context as the vehicle of intervention. The child and his physical/social environment are conceptualized as actively influencing one another in their reciprocal transactions. An early intervention program based on this transactional model is described. The intervention is tailored to suit the needs of both child and parents and, more generally, the needs of the family. The intervention process involves a problem-solving model of education by which parents acquire cognitive strategies that will enable them to assess the needs of their child and to design a program to fulfill these needs.     

Psychodynamic perspectives on teacher stress

Melanie Klein's concept of projective identification is now in common use by counsellors and psychotherapists. Julia Segal describes her own hypothesis about the way it works as well as her use of it in her practice, working as a counsellor for people with multiple sclerosis, members of their families and professionals working with them. When a person cannot bear to feel an emotional state they can evoke the feeling in someone else, not only a therapist or counsellor but also others within the family. Segal describes the way powerful emotions can be evoked in the counsellor; in particular the feeling that a certain idea cannot be shared with a client. She also describes working with clients who are on the receiving end of such projected feelings, sometimes evoked by illness within the family. She also points out that unresolved emotional states suffered in childhood can leave adults unable to bear certain feelings. If the feelings threaten to re-emerge in adulthood, perhaps triggered by their own children reaching a certain age, parents sometimes attempt to rid themselves of the emotional state by projective identification and in the process, evoke a version of the feelings in their own children. This may, for example, exert pressure on parents to divorce just as their own children reach the age they were when they themselves lost a parent.     

Münchhausen by proxy syndrome in clinical child neuropsychology: a case presenting with neuropsychological symptoms.

Münchhausen by proxy syndrome (MBPS) is a rare but dramatic variant of child abuse. In MBPS adults, mostly the mother, invent, manipulate, or produce the child's illness, and as a consequence the child has to undergo numerous diagnostic or treatment procedures. Typically, valid information about the etiology of the child's illness is withheld by the parents, and reversible symptoms vanish, when the child and the responsible adults are separated. Although valid statistical data about the epidemiology of MBPS are not available, MBPS should be considered more often than normally recognized. Neurological and neuropsychological presentations including developmental delays and learning problems appear to be common among MBPS cases so that clinical child neuropsychologists should be aware of this problem and consider MBPS at least in some of the mysterious cases that come to their attention. The present study describes a case of MBPS in which neurological and neuropsychological symptoms predominate. It presents a MBPS variant that is characterized by developmental delays and learning problems induced by unnecessary isolation at home, hospitalization, and treatment procedures. In the present case MBPS was at first suspected following neuropsychological assessment, since some of the main features of non-authenticity of symptom presentation gave cause for suspecting deceptive behavior on the mother's (and possibly also on the maternal grandmother's) side.