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.     

Mindful Parenting: a group approach to enhancing reflective capacity in parents and infants

In this paper, the process of ending therapy is likened to the ordinary developmental task of ‘letting go’ that parents have to undertake, to help their child to grow up. ‘Letting go’ is contrasted with the process of ‘holding’ the child in mind that is so central to the therapeutic and parental task Following thoughts about some of the external issues that play a part in the decision to end a child's treatment, this developmental perspective of psychoanalytic psychotherapy is discussed through a clinical illustration of the ending of a 5-year-old boy's treatment. Different strands of the therapeutic relationship as highlighted during the ending phase of therapy are distinguished and attention is drawn to the role of the ‘new relationship’ between therapist and child and how this differs from the transference relationship. Countertransference issues in their broadest form are also considered.     

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.     

Countertransference in group psychotherapy

This paper attempts to up-date our understanding of countertransference in the therapy group setting. After a brief review of some of the psychoanalytic and the group psychotherapy literature dealing with countertransference, the paper points out the vulnerability of the group therapist and presents examples of possible countertransferential situations, such as stereotyped roles, reactions to external aspects of patients, and therapists' insecurities. It concludes by suggesting ways in which group therapists can become more sensitive to their countertransferences.     

Clinical commentary by David Trevatt,Clinical Manager of ‘Hear and Now’ Adolescent Counselling Service,Redbridge and Manager of Open Door's Parenting Teenagers Project,Haringey

Leading the charge to link intervention research with clinical practice is the development of process research, which involves a detailed analysis of specific therapeutic processes over the course of treatment. The delineation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – can inform therapists of what may be expected from patients with particular patterns of symptoms or behaviours in their clinical practice and how interactions change over time. Using the Child Psychotherapy Q-Set, this study aims to compare the different interaction structures that emerged in the two-year psychotherapy of a six-year-old child conducted, for one year each, by two doctoral-student therapists in a university-based community mental health clinic. The study allows for exploration of the independent role of the therapist in the psychodynamic therapy of a child diagnosed with Asperger's disorder. The results suggest that four distinct interaction structures between child and therapist could be identified in this psychotherapy and that the interaction structures differed between the two therapists and also differed over time within each treatment. The implications of these findings for training and clinical practice are discussed.     

Countertransference,enactment and sexual abuse

This paper examines the development of a therapeutic relationship with a sexually abused latency girl who, in the course of her two years of four times weekly psychotherapy, was placed in two different foster-homes. It is argued that the child's re-enactment of the abuse in the consulting room allowed her to move from a seductive relationship with the therapist to one characterized by basic trust. This was paralleled by her development of a capacity to think and to tolerate affect states. The use of an imaginary twin by the child and the use of powerful countertransference feelings in the therapist are seen as the main therapeutic tools in the treatment. The premature termination of the treatment – due to the therapist's departure – enabled the child to articulate for the first time her feelings, in the transference, about the trauma and the traumatizing agent. The child's progressing moves in the therapy are also presented.     

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.     

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.     

Therapist memory and reverie: implications for the clinical setting

In this work, the author considers reveries to be ‘dream-like-memories’. In the course of a session they appear as proto-memory – the therapist’s early traumatic object relations that are recorded in the unconscious at an almost bodily level (a type of unthought known) and which are resurrected between therapist and patient when a similar traumatic subject arises between them. The therapist’s reveries are recollections in the form of dream-like allusions to his past experience. A clinical vignette from the psychotherapy of a child whose father suffered from PTSD (following a wartime experience in Afghanistan and Iraq) is discussed. Dissociative dynamics were repeated in the therapeutic relationship, in the form of an obsessive game intending to preserve the state in which there was no need to remember what had been unconsciously transmitted to the child: his father’s wartime experience. The projection of the primary elements which had been silenced evoked in the therapist allusions to his unconscious identification with his ancestor’s post-traumatic experiences. These allusions helped in overcoming the dissociated state. The role of memory in child psychotherapists’ receptivity of trauma is revisited.     

Thoughts about the internalised speaking object: psychoanalytic psychotherapy with children of delayed verbal development

This paper discusses the meaningful effects of intensive psychoanalytic psychotherapy on language development in children with verbal delay or disorder. Three clinical cases of children aged five to seven are presented; two of these display significant verbal delay and one exhibits unusually high verbal abilities. Following Meltzer, the author explores the concept of the ‘internalised speaking object’ – a good object speaking to the child, which has been internalised. This internal model is essential for the child’s development of language and speech. At times, these children experience this internal object as a persecutory object which must be warded off and avoided. Even more so, when the external object addresses the children verbally, language itself becomes a persecutor and they experience a fear of disintegration. During such times, the therapist must find new and creative ways for communication. The author describes his therapeutic efforts in dealing with these difficulties which stem both from the lack of a reciprocal verbal communication and from the therapist becoming a persecutory object to the child, and demonstrates the manner in which he facilitated gradual shifts in the patient, from an anxious and defensive position into a more relaxed one. These efforts set in motion a process of internalisation of a speaking object by the child and the development of internal language, that is, thinking along with expressive verbal language. The article furnishes some evidence to support the idea that verbal development relies significantly on establishing good, strong and healthy early object relations.     

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.     

A Patient Who Does Not Look: A Collaborative Treatment with Video Feedback

We describe a collaborative treatment of a woman in face-to-face psychoanalytic psychotherapy (with Larry Sandberg), whose persistent gaze aversion was a symptom immune to interpretive efforts. After many years of treatment, the patient agreed to engage in video feedback sessions (with Beatrice Beebe), which have occurred for the past decade. The face of Dr. Beebe, but not the face of the patient, was videotaped during psychotherapy sessions. Dr. Beebe and the patient then reviewed segments of the videotaped session, collaboratively observing and thinking together, translating between the verbal dialogue and the therapist’s implicit action dialogue. We examine the impact of this intervention on the psychotherapy process.     

Beyond silence: working with Phoebe

This paper gives an account of a three-year period of silence that took place during the course of the intensive psychotherapy of a pre-adolescent girl with a diagnosis of ‘major depression’. The meaning and significance of silence in the therapeutic context is explored, as well as the importance of the ‘safety’ (Quinodoz, ‘The psychoanalytic setting as the instrument of the container function’, International Journal of Psycho-Analysis, 73: 627–35, 1992) and containing function of the setting that allows patients with a similar pathology a much needed regression, eventually enabling the birth and development of mature ‘verbal’ object relationships. Challenges and changes in the countertransference during a silent period in the course of psychotherapy are also discussed.     

Doing things differently: an appreciation of Meltzer’s contribution

In this paper I wish to draw attention to aspects of Donald Meltzer’s ways of working which characterised his practice as a psychoanalyst and which I consider important in appreciating his originality. Several central themes are described and elaborated including: the central relevance of child analysis and the unity of child and adult analysis; the value of working in a clinical group with colleagues; the revision of psychoanalytic theory; joint research and writing projects; Meltzer’s recognition of the power of infant observation as a tool for learning; the commitment to a wider psychoanalytic culture; the particular contribution to the Tavistock child psychotherapy training. Examples from Meltzer’s written archive, both his books and papers, are used to demonstrate and illuminate these themes, alongside clinical material from child psychotherapy work brought to the author’s attention in supervision.     

Client self-image,therapist acting,and the establishment of the therapeutic alliance in a training context

This study examined how clients’ self-image and perception of therapist’s behavior are related to the therapeutic alliance, as well as how these variables change in the psychotherapy process in trainee-led psychotherapy. A total of 164 participants (M = 28.9 years) who attended two semesters of treatment at the Psychology Clinic of Umeå University completed the Working Alliance Inventory (WAI) to evaluate their perception of their alliance with the therapist. They also completed two questionnaires based on the Structural Analysis of Social Behavior (SASB) model to give insight into their self-image patterns and to analyze their perceptions of the therapist’s behavior. The results show that a positive self-image and positive perceptions of the therapist’s actions increased significantly over the course of the therapy, with a corresponding decrease in negative patterns. The alliance scores show that the therapeutic alliance gains significance over time and that it is influenced more by the perception of the therapist’s behavior than by the self-image. The self-image becomes relevant after the mid part of therapy, underlining the role of the therapist in co-creating the treatment relationship. The implications of these results are discussed, and so are directions for future research in other trainee-led settings and samples.     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.     

Clinical experiences during the COVID-19 pandemic

Most of the clinical experiences discussed in this article arose from monthly Zoom meetings at Rome’s Italian Centre of Analytical Psychology (CIPA). We set up a discussion group in April 2020, one month after lockdown began in Italy, and these monthly online meetings continue to this day. All senior analysts and analysts-in-training at Rome’s CIPA, whose backgrounds range from child and adolescent psychotherapy to adult psychotherapy and analysis, to sandplay therapy and medicine and psychiatry, have been participating in these meetings. The group discussions focus on the present time and its impact on us, as well as on our relationships with patients. By further developing these reflections during the lockdown in Italy (9 March - 3 May 2020), it is fair to ask whether a sense of unreality, depersonalization, or derealization has occurred, either in the therapist or patient, and if so, whether it is possible that therapists miss the human contact more than clients. We will mainly refer to clinical and personal experiences as our most precious guidelines.