Chapter 24 – Working Psychotherapeutically with Children




Abstract




The essential goals of the child and adolescent psychotherapist are not dissimilar to those of the adult therapist: to understand and render meaningful troubled aspects of the personality. The process brings insight to bear on the nature of the internal world and its mixed population of figures, benign and persecutory. Mental development occurs not so much through ‘ironing out’ the difficulties, but rather through ‘an increase in the capacity to bear reality and a decrease in the obstructive force of illusions’ [1, p. 51]. Bearing reality lies in being able to reintegrate aspects of the personality that have been disowned, or disavowed as too threatening to psychic equilibrium. The process of integration involves taking back projections and bearing the discomfort of being brought into relation with the less manageable aspects of the self. The method is based on the observation and interpretation of the transference and countertransference relationship, the elucidation of dreams and, in the case of children and adolescents, the underlying meaning of play and enactments of whatever kind that take place both in and outside the consulting room.





Chapter 24 Working Psychotherapeutically with Children



Margot Waddell



Introduction


The essential goals of the child and adolescent psychotherapist are not dissimilar to those of the adult therapist: to understand and render meaningful troubled aspects of the personality. The process brings insight to bear on the nature of the internal world and its mixed population of figures, benign and persecutory. Mental development occurs not so much through ‘ironing out’ the difficulties, but rather through ‘an increase in the capacity to bear reality and a decrease in the obstructive force of illusions’ [1, p. 51]. Bearing reality lies in being able to reintegrate aspects of the personality that have been disowned, or disavowed as too threatening to psychic equilibrium. The process of integration involves taking back projections and bearing the discomfort of being brought into relation with the less manageable aspects of the self. The method is based on the observation and interpretation of the transference and countertransference relationship, the elucidation of dreams and, in the case of children and adolescents, the underlying meaning of play and enactments of whatever kind that take place both in and outside the consulting room.


Some years ago, I listened to a child psychoanalyst vividly recollecting her first training case, seen in the early fifties. The little boy in question, I’ll call him Simon, was two-and-a-half when he was referred to the Clinic. His father had died soon after the birth of Simon’s younger sibling. For most of the session, we were told, Simon stood anxious and uncommunicative. Then, towards the end of the time, he turned to his toy box, hitherto unopened. He set out a street scene with cars and buses and people crossing the road. Finally he spoke, ‘There was an accident and a man was killed, and then a policeman came.’ Simon looked very anxious. With few words, he was managing to communicate a great deal about the state of his inner world: there had, in reality, been an accident there, a mortal accident – his father had died. Perhaps he also regarded the birth of his younger sibling as a terrible accident. But of particular interest is his reaction to the presence of the policeman. His stated upset may have been a way of registering relief at an authority figure being at hand who might help out – as with a child’s tears when the testing time is over. But the policeman’s approach seemed to bring not so much reassurance as further anxiety – a possible indication, one might infer, of some kind of guilt. Since this was a first session and Simon did not yet know his therapist, his response might also have indicated his worry as to what kind of policeman/person he was about to encounter; fear too, perhaps, about punishment for what, in his mind, he may have felt that he had somehow done. Maybe he had an unconscious fear that he was implicated in the accident – had he, quite naturally, hated his father as well as loved him? Beyond the everyday feelings of ambivalence towards a parent, he may have felt a special antipathy towards his father at this particular time – for somehow giving his mother another baby, for example, and then for having abandoned them by dying. Had his ordinarily angry impulses been experienced, now, to be death-dealing?


This little episode is full of possible meanings and it also seems a very hopeful beginning to therapy. For Simon, young as he is, and despite inevitable anxiety about being with a strange lady in such an unusual situation, was able to find symbolic expression for his internal predicament – one which his therapist could, in turn, emotionally register, explore over time and find ways to talk to him about.


This description stayed in my mind because it contrasted so starkly with the first session of another boy whose case I was supervising at the time. ‘Peter’ came into therapy when he was 11. He, too, had experienced an ‘accident’ – his parents had separated when he was four and his mother had moved away with Peter to another country, with the result that son and father seldom saw one another. As a little boy, living alone with his mother, Peter had, according to her, seemed to manage this total and sudden upheaval ‘surprisingly well’. In particular, as she recounted, he had excelled at school and, in reading and writing, was well ahead of his peers. By 11, however, a different picture presented itself and he was referred for treatment by a child psychiatrist who was alarmed by the intensity of his withdrawn and depressed state: friendless, earnest and obsessional, by turn clinging to and icily rejecting of his mother, Peter would, not infrequently, talk about suicide. His first session was in stark contrast to little Simon’s. He, too, remained silent and withdrawn for most of the time, but towards the very end of the session he commented, rather sourly, that he didn’t feel there was any point talking, and anyway, he was too clever for any professional, or anyone come to that, to understand him. With his insistently negativistic responses to whatever his therapist ventured, he effectively ‘killed off’ any possible link with her, leaving her feeling guilty, inadequate and anxious about ever being able to reach this rather cold and seemingly arrogant youngster who was so clearly in terrible pain. It might be assumed that ‘guilty, inadequate and anxious’ was a fair description of Peter’s own feelings, if he could have allowed himself any contact with them.


At the very end of the session Peter precociously asserted that it was pointless talking about his feelings because he didn’t have any. Or, he added, with a touch of uncertainty, if he did, he ‘strangled’ them as soon as possible. Asked what he meant, he said: ‘It’s like crying. When I want to cry in a film or watching TV, I tell myself it’s just a mass of pixel points. Then I feel better. It’s the same with books – if they’re upsetting I tell myself that they are only a lexical arrangement.’ This strangling of emotions by cognition was very chilling. And it was a long time before Peter even opened his toy box or showed any capacity for creative or symbolic thought.


The impact of this first session was enormous. His therapist felt quite overwhelmed by the intensity of the feelings that Peter was seeking to deny by the impenetrability of his defensive, precociously intellectual carapace. It would seem that, early on, Peter had adopted ‘cleverness’ as a defence against feeling and against fears about the risks attached to establishing any meaningful emotional link with somebody else who might then betray him, and/or disappear. Was he the reason his parents had separated? Was it his wish to have his mother all to himself that had brought about that very situation – so dreaded and so desired? Child therapists are particularly aware of how cognitive abilities, quite as much as apparent cognitive deficits, can act as defensive procedures, as bastions against the turbulence of emotional experience, especially when that experience involves unmanageable degrees of anxiety and guilt. Had Peter also been in therapy when the ‘accident’ first occurred, perhaps he could have been spared the isolating, obsessional, aloof, frozen self that he had developed in order to protect himself from the pain within.



Historical Development of the Theory and Practice of Child Psychotherapy


It was interest in these kinds of anxieties and guilts in young children and the way in which they affected later emotional growth and development – in particular their natural curiosity and ability to learn – that first stirred the compassion and involvement of the pioneers of child therapy and characterised their earliest cases.


An early quote about work with children can, perhaps surprisingly, be found in the writing of Elizabeth Craig in her 1948 encyclopaedia of housekeeping tips, among entries about baking and laundry (1948 edition of Elizabeth Craig’s Compendium of Lively and Up-to-Date Information on Every Household Subject):



Nervous Children: If in spite of all your care and patience, a child continues to show signs of nervousness, never neglect them. The happiness of his whole life may depend on your seeking expert advice now. Psychoanalysis, which uncovers the core of the fears, examines it in the light of day and so minimises it and removes it, is a form of treatment that is becoming more and more widely used and successful. Your doctor may be able to help you set about obtaining this treatment or you can get into touch with the Institute of Child Psychology, 26 Warwick Avenue, London W9.


Awareness of the plight of children was particularly acute during and after the two World Wars. Trauma, bereavement and massive displacement of children characterised both periods. The early child practitioners were all too aware of the relationship between external experiences of separation and loss and that between these events and internal, not consciously known, impulses. They also recognised how these experiences might be engaged with and mitigated through their symbolic representation in play. It was during and after the First World War that work directly with children first began and the end of the Second World War saw the founding of three training schools for the psychoanalytic treatment of children, funded both privately and by the NHS, now under the umbrella of a joint registering body – the Association of Child Psychotherapists.


Turning first to an historical overview: strictly Freud’s ‘Analysis of a Phobia in a Five-Year-Old Boy’ [2] (Little Hans, 1909) was the first recorded case of intensive psychotherapy with children. But this ‘treatment’ was a sort of analysis by proxy – that is, it was based on Freud’s comments on a series of detailed observations of Hans as noted by his psychoanalytically well-informed father. Freud himself met Little Hans only once. The outcome of the father’s discussions about this delightful, intelligent and articulate little boy who, in anticipation of his next sibling’s birth had developed a fear of horses, did much to reassure Freud about the nature of his early theoretical reconstructions of the Oedipal period and the idea that the so-called ‘infantile neurosis’ was a precursor of later adult neuroses. Although the treatment was largely successful, Freud was, apparently, perturbed by the response to the paper’s publication [2]: ‘ … a most evil future had been foretold for the poor little boy because he had been robbed of his innocence at such a tender age and had been made the victim of psychoanalysis’ [2, p. 148]. Although implicitly repudiating such a response, there was, nonetheless, a sense that the psychoanalysis of children might be dangerous lest the ‘soul is disturbed instead of freed’, as one of the first to work directly with children, Hermine von Hug-Hellmuth [3, p. 289], put it.


Freud himself was sceptical about whether the deeper strata of a child’s unconscious was therapeutically penetrable and was also concerned about the limited range of expression (by which he meant words and thoughts) available to the child [4]. It was three redoubtable women who, though working in rather different ways, effectively pioneered the treatment of children in person: Hermine von Hug-Hellmuth, Anna Freud and Melanie Klein. I shall briefly sketch these early approaches before concentrating, primarily, on the Kleinian development, which is the one most rooted in the child’s earliest and later development.


In these early days Anna Freud thought of the child therapist’s role as that of a kind of educator – a view largely shared by von Hug-Hellmuth – and advised that attempts to address the transference relationship with the therapist should focus on the positive aspects rather than on the negative. ‘It is in their positive relationship to the therapist that truly valuable work will be done’ [5, p. 41]. It was considered important to gain the child’s affection and cooperation the better to support his or her weak ego functioning.


In general, Anna Freud tended to resist, even disapprove of, embarking on intensive (three or more sessions a week) work with a child until he or she was at least seven or eight years old. She also tended to favour one aspect of her father’s thinking – his scientific concern with the organic energy that propelled the individual from within. She formulated an impressive model detailing the emotional growth of children and meticulously worked out the various stages of normal and pathological development with their specific anxieties and defences. In her emphasis on the ego’s complex tasks in its moves towards an adaptation to reality, her focus tended to be more on the id-ego model of internal drives and impulses than on that of internal object relations [6].


While Anna Freud’s position remained close to her father’s, Klein’s ideas, by contrast, resulted in what amounted to a fundamental reframing of psychoanalytic thought. Certain pivotal concepts (example penis envy or castration anxiety) lost their centrality, to be replaced by an extraordinarily rich and complex picture of the inner life of the young child, and even of the baby. In this account it was the nature and quality of emotional relationships that took precedence rather than a picture based on the quantitative intensity of impulses and drives. The language of instinct and impulse remained but its significance was much altered.


Klein and others, notably Fairbairn and Winnicott, traced a crucial developmental shift from anxiety about self-survival to concern for others, emotional responsibility and a desire to repair. With the linking of development to ethical concerns and matters of value, psychodynamic work with young children and adolescents gradually became less instinct-bound and more interested in emotional life and in meaning. This interest in the formative effect of early relationships became known as an ‘object relations’ approach, a term which, albeit clumsy, stresses the primary significance of the nature and quality of relationships between self and other, from the very first, as being central to a person’s continuing psychological development.


It was with these ideas about the role of infantile anxiety and the impact of environmental failure on young people’s lives, later detectable in the symbolic arena of speech and play, that the ground was laid for the psychoanalytic understanding and treatment of psychotic processes (on the whole regarded by Freud as not amenable to psychoanalytic treatment) and, more recently and extensively, of autistic and borderline states. Clinical experience, especially with children, continued to yield new insights. The origins of severe learning and developmental difficulties began to be located in disturbances of thought, of which the emotional determinants were sought in the earliest unconscious exchanges, and in the quality of care in the infant’s primary relationship with mother or caretaker.


Wilfred Bion’s work in the 1950s, 1960s and 1970s concentrated attention on the relationship between the way in which a person uses his or her mind and that person’s capacity for emotional development. Bion did not, himself, work with children, but some of his theories had a fundamental, indeed, transformative effect on how child analytic thinking has developed. Despite their radical and innovative ideas, both Bion and Klein always considered their work as adhering to Freud’s earlier psychoanalytic principles:



I was also guided throughout by two other tenets of psychoanalysis established by Freud, which I have, from the beginning, regarded as fundamental; that the exploration of the unconscious is the main task of the psychoanalytic procedure and that the analysis of the transference is the means of achieving that aim.


[7, p. 5]

Kleins own first paper, ‘The Development of a Child’ [8] was, like Little Hans, based on the analysis, at home, of a boy of five-and-a-quarter, Fritz – later revealed to be her own son, Erich. Her observations from this work led her to conclude that in-depth analysis of very young children was possible but incompatible with the therapist taking up an educative role [8].


It was Klein’s view that it was precisely those areas of the child’s emotional experience that were not consonant with what he had been taught that gave access to the internal world of psychic reality – thus to the nature and character of the various figures (primarily, at first, parental) who populated that world. These were figures who, as she soon noted, usually bore little resemblance to the external people whom they appeared to represent and seemed more based upon strongly held intuitions. Her own analysis in Budapest with Sandor Ferenczi, allowing intense examination of her own past relationships and also her passionate interest in the inner lives of her own children, further confirmed these ideas to Klein and many of Ferenczi’s own ways of thinking about children’s development were reflected in her later theories.

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Jun 6, 2021 | Posted by in PSYCHOLOGY | Comments Off on Chapter 24 – Working Psychotherapeutically with Children
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