Two-Person Relational Psychotherapy: Elementary School Age Youth

, Jeffrey R. Strawn² and Ernest V. Pedapati³

(1)

Division of Psychiatry and Child Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

(2)

Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, USA

(3)

Division of Psychiatry and Child Psychiatry Division of Child Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

It’s crucial that we start our children off on the right foot in school. The stakes are high in these first years and what we do really matters.

—Margaret Spellings, Secretary of Education

Children typically begin elementary school—primary education—at 5 years old, after kindergarten. Elementary school generally goes through the sixth grade, typically to 11 years old. In elementary school, children learn the basics of reading, math, science, and other subjects on which later learning will build. Socialization skills are an important aspect of this period. Granic and Patterson (2006) eloquently stated, “Parents and children are confronted with a variety of daily tasks (e.g., clean-up time, playing games, problem solving when conflict arises, eating dinner together). From our perspective, the extent to which parents and children can flexibly and appropriately respond, emotionally, cognitively, and behaviorally, to shifts in contexts may tap a repertoire of alternative strategies that correspond to how children will adapt to future challenges at school and with peers.” Thus, during this age, the child’s most skilled way in communicating his or her affective states is initially through playing and making drawings, and later, in preadolescent years, verbal communication takes hold.

In two-person relational psychology , importance is given to the innate variability within the context of norms of development for a child and throughout his or her life span, with attention to the influence by family systems and cultural factors. Developmental research has provided evidence regarding the complex processes in the scaffolding of physical and psychological competencies over time derived from biogenetic developmental influences. More likely, children have a genetic developmental blueprint that is strongly influenced by family and environmental factors, which are interwoven and can act synergistically to promote further development (Delgado et al. 2012). During elementary school age, the developmental milestones that children need to achieve are complex (see developmental milestones Appendix A). Among the most salient developmental tasks are competition in games, enjoyment of conversation in groups, increased interest in the opposite gender, and respect of parents.

In traditional one-person psychologies, this period is viewed within the context of psychosexual stages and is described as a latency period, “a biologically based phase characterized by decreased sexual drive intensity (compared to the preceding oedipal phase and the succeeding adolescent phase)…. During latency, a greater equilibrium is established between defenses and drives” (Auchincloss and Samberg 2012). In traditional psychoanalytic theory, latency is defined as a period that begins with the dissolution of the Oedipus complex and extends to the onset of puberty , typically between the ages of 6 and 12 years old. It is believed that during this period, there is intensification of repression, which brings in amnesia of the early conflicts, development of sublimation, moral values including shame, and aspirations for future activities. This phase was thought to be of relative psychological stability.

11.1 Psychodynamic Psychotherapy in Elementary School Age Youth

The reasons for which school age children come to our offices are many, from inhibitions—social and academic—to disinhibitions—verbal or behavioral. The child and adolescent psychiatrist or clinician will benefit from a careful use of the contemporary diagnostic interview (CDI, Chap. 8) in order to understand the child’s unique attributes—temperament, cognition, cognitive flexibilities, and internal working models of attachment—within the context of the environment in which they live in, which includes family and culture.

During this age, play becomes central in children’s development. Virginia Axline (1969) believed that children used play to communicate in a frank and honest manner. Anna Freud and Melanie Klein were pioneers in viewing a child’s play as equivalent to free associations of the adult. They believed that through the interpretations of the conflicts caused by the pressures of the different developmental psychosexual stages represented in their play, psychoanalytic treatment helped children overcome their unconscious inner conflicts.

Consequently, the psychotherapist of young children will need to understand the role play has in the child’s life, which allows using this form of communication in the psychotherapeutic process. The authors agree with Krimendahl ’s (2000) view: “I do not view my role as finding ways to ‘get’ school age children to talk, for talking is not the most developmentally natural medium for children.” For children that arrive to the psychotherapist’s office with play inhibitions, the task will be to implicitly help the child to be able to enjoy playing, as Krimendahl (2000) states, “getting children to ‘play’ at playing games.”

The Association for Play Therapy (2014) defines play therapy as “the systematic use of a theoretical model to establish an interpersonal process wherein a trained play therapist uses the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development.” Additionally, Schaefer (2011) states, “Children use play to communicate when they do not have the words to share their needs and look to adults to understand their language.” From a two-person relational perspective, the use of play is a form of communication that will always be influenced by the ever-present implicit contribution of the psychotherapist’s personal characteristics to the child’s choice of play. In children who often bend the rules in their play, Krimendahl further states, “rather than focusing on the child’s reasons for cheating, it is more important to assess why we let a child win or not, for we are more swayed to do this with some patients than with others.”

11.2 Heather

History of Present Illness

Heather, a 9-year-old girl, was referred by her pediatrician who noticed that she was an anxious girl that worried constantly: “She just can’t stop worrying. I think this child needs therapy.” Heather’s parents described her as a bright girl that worried about completing her schoolwork, “even though learning comes easy to her. She really doesn’t need to study that much.”

Heather was brought to the consultation appointment by her mother and father. They said: “We know she needs help. She is a good kid but we can’t figure her out. She suffers so much.” They added that she avoided going out with friends after school or on weekends because she would spend hours completing schoolwork, which at times was weeks in advance, or spend most of her time reading. They had reassured her that she was doing well at school and wanted her to go out and have fun with other children. They had attempted to arrange play dates with other children for her although she would refuse to go. They noticed she was unhappy and sought help from her pediatrician.

Heather would worry every morning before going to school, fearing she had forgotten an assignment or a book and would anxiously say that she was not happy. Her mother would feel guilt ridden after leaving her at school, although somewhat comforted to know Heather was excelling academically and well liked by her teachers. At school, the teachers noted she was overly self-critical. She would become worried when a peer was corrected, fearing the child would feel bad.

Her parents and extended family described Heather as an easy, jovial, and intelligent child. At the time of the evaluation, her teachers described her as a very bright and active fourth-grade student with excellent grades.

Past and Family History

Heather was the product of an uncomplicated full-term pregnancy who achieved most of her developmental milestones on time. She was precocious in spelling, reading, and math (reading and math were at a second-grade level when she was 5 years old). She was a healthy child in a close-knit family. Heather lived with her stay-home mother, 32 years old, and her father, a 35-year-old engineer. Heather’s parents had a good relationship and were well respected in their community. She had a 6-year-old brother and a 4-year-old sister, who ostensibly were doing well. The family was close to both paternal and maternal grandparents, who lived in the same community. All family members were in good health.

Contemporary Case Formulation Following Use of the CDI: Heather

Summary: A 9-year-old female who presents with new functional impairment timed with the beginning of fourth grade

Internal working models of attachment (IWMA): Secure and ambivalent/anxious

Temperament: Mixed—slow to warm-up and easy/flexible

Cognition: Above average/gifted (see developmental milestones Appendix A)

Cognitive flexibility: Adequate

Formal psychiatric disorder: Symptoms of anxiety but did not meet DSM-5 criteria

Treatment recommendation: Twice a week two-person relational play psychotherapy to address her anxiety and social inhibitions, and consider use of formal cognitive behavior psychotherapy (CBT) or medication after 6 months, if needed.

Contemporary Case Formulation Following Use of the CDI: Heather’s Parents

Summary: Parents were very caring and supportive of their daughter, and were easy to engage by the psychotherapist. One possibility is that they may have implicitly had contributed to her inhibitions during her early years by implicitly rewarding her precocious abilities in reading and math at the expense of playfulness.

Internal working models of attachment (IWMA): Secure and ambivalent/anxious

Temperament: Easy/flexible

Cognition: Above average/gifted

Cognitive flexibility: High/adequate

Formal psychiatric disorder: Did not meet DSM-5 criteria

Treatment recommendation: Work with Heather’s parents as part of her two-person relational play psychotherapy.

11.3 Case Conceptualization from a Traditional One-Person Model

From a traditional one-person model, Heather’s case conceptualization may take several paths depending on whether it is viewed from a drive theory, ego psychology, object relations, self-psychology perspective, or a combination of these theories, which is known as being pluralistic. What is common to pluralistic traditional one-person approaches is that they rely on a wait-and-see approach by the psychotherapist in order to organize the information obtained through the play and verbal narrative of the child. After which, the psychotherapist conceptualizes the case as representing unconscious intrapsychic conflicts (those the patient is unaware of), maladaptive ego defenses, and object relations conflicts. It would be beyond the scope of this book to review all the possible case conceptualizations that may be considered by a traditional one-person child psychotherapist. Thus, we limit our review to a broad overview of the conceptualizations likely to be considered and contrast them to the two-person relational model used in Heather’s treatment.

In traditional one-person psychoanalytic literature, Heather may have been thought of as having an obsessional neurosis . That is, she unconsciously used ego defense mechanisms to defend against the painful feelings from her unconscious conflicts: isolation from peers, displacement onto schoolwork, reaction formation in being an overly compliant child, and negation of her anger. With this in mind as a diagnostic conceptualization, the psychotherapist would let the play develop and wait for the correct time to point out the use of maladaptive ego defense mechanisms used by Heather during the play, if they were thought to be interfering with her ability to resume her healthy psychosexual developmental track.

In the school of self-psychology, Heather’s obsessional neurosis may have been considered to be due to an empathic failure on the part of her parents and not because of regressive and angry feelings directed at them. Soavi (1993) states, “The symptoms should be seen in connection with the attempt to defend oneself from various forms of anxiety and with the failure to create within the self the capability of orienting oneself in the world of affects.”

From a Kleinian view, Heather’s problems may have been conceptualized as due to her angry feelings toward her objects—parents—who she unconsciously experienced as rejecting. Her intense desire for knowledge and avoidance of play were defenses against the destructive fantasies. Reading and knowledge represented her anger at the internal representations of her parents as bad objects, an obsessional neurosis (Klein 1932). The psychotherapist would help Heather work through these conflicts by promoting strong transference feelings toward the psychotherapist, who would later make comments regarding the unconscious ambivalence, guilt, and fear of her angry and destructive fantasies toward her parents.

Regarding Heather’s parents, in the traditional one-person model, the psychotherapist may have provided regular educational sessions during the psychotherapeutic process to help them understand their daughter psychologically and to support the process. In the Kleinian model, there may have been little contact with Heather’s parents during the psychotherapeutic process.

11.4 Two-Person Relational Psychodynamic Psychotherapy in Elementary School Age Youth

Two-person relational child psychotherapy has evolved from the traditional one-person model. Two-person relational child psychotherapy has incorporated the contributions of developmental research, attachment theory, and neuroscience to mental health and behavioral issues. In a two-person relational model, the psychotherapist takes an active role to first become “like them”: to be immersed in the patient’s and parent’s subjectivities and implicit relational knowing during the sessions. It is through this bidirectional process that occurs in the intersubjective field that allows the patient to implicitly become, over time, an ally to the psychotherapist’s healthier and more adaptive form of interaction with others. In essence, the two-person relational psychotherapist provides new emotional experiences for the patient and parents, which will be stored in nondeclarative memory at an implicit level.

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