Middle school age youth are dealt the difficult task of balancing increasingly complex interactions with parents, caregivers, teachers, and peers within exponentially complicated environmental factors. This population is referred to our offices for difficulties regarding self-regulatory abilities (e.g., problems with impulsivity and aggression, difficulties with social reciprocity, and academic problems). 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, which includes family and culture. As such, the evaluation will rely on collateral information from other sources familiar with the child and his or her family. This information is essential to a complete CDI, as likely the problems originated at an earlier age and are now interfering with their psychosocial development (see developmental milestones Appendix A).

During this age, the child’s cognitive abilities expand, and he or she is better able to problem solve and hold two opposing viewpoints in mind. This allows for the vitality needed to remain engaged in peer group activities, and difficulties in this area frequently reflect cognitive and relational complications. Many times difficulties in peer group activities are viewed from a traditional one-person model as a result of neurotic or immature ego defenses against the angst experienced. We propose that from a two-person relational model, the angst of children at this stage is generally due to difficulties with temperamental, cognitive, or relational abilities, influenced by innate internal working models and not from unconscious intrapsychic pressures from the id and superego or object relation problems.

When seen from a traditional one-person model, the case conceptualization may take several paths, depending on whether it is viewed from a drive theory; ego psychology; object relations, or self-psychology perspective; or a combination of these theories, which is known as being pluralistic. To this, we provide the reader a broad view from a traditional one-person perspective and hope that it can serve to contrast the differences of case conceptualization and therapeutic interventions with the two-person relational model used in this case.

In the traditional psychoanalytic literature, the death of a parent is considered to have a significant impact on a child’s intrapsychic processes, which leads a child to use defensive mechanisms to deny the reality of the death. Menes (1971) captures this masterfully: “There is also wide agreement that a particular set of responses tends to occur in children who experience the death of one of their parents. These reactions include unconscious and sometimes conscious denial of the reality of the parent’s death; rigid screening out of all affective responses connected with the parent’s death; marked increase in identification with and idealization of the dead parent; decrease in self-esteem; feelings of guilt; and persistent unconscious fantasies of an ongoing relationship or reunion with the dead parent.” Further, Menes believes that the child’s responses serve to avoid the acceptance of their parent’s death and there is a need for a reorganization of the object attachments that such an acceptance would require. For Furman (1964), mourning in children occurs only when a psychoanalytic treatment is initiated in order to facilitate the mourning process to develop through the transference to the analyst.

Further, it is suggested that the death of a parent reawakens oedipal conflicts. This is best captured by Gill (1987): “Death of the oedipal rival results in a confusion of the unconscious wish with an external happening. The child, unable to cope with the consequent guilt, resorts to repression. Thus, the critical aspects of the oedipal triumph remain potentially operative in the unconscious, hindering the patient’s functioning in all closely associated areas.”

Therefore, in the traditional one-person model, Charlie may have been thought as defending himself from the painful mourning process with a decrease in self-esteem and unconscious feelings of guilt for his anger at his mother and at God. To this, the psychotherapist’s interest in the verbal narrative of the events with some attention to neutrality allows for transference manifestations to develop and be best understood. The psychotherapist will likely be initially experienced as the good—father object—which Charlie unconsciously and in the transference will use to deny the reality of his own father’s imminent death. This will also be noted by an increase in ego-ideal identifications and idealizations of the ill parent, likely to increase after his death. The traditional one-person psychotherapist will be attentive to the patient’s use of ego defenses and be alert to pressures from his superego, typical during this phase of development; his fear about the death of his father; and his guilt for his age-appropriate anger and possible unconscious feelings of oedipal triumph.

Regarding Charlie’s mother, in the traditional one-person model, the psychotherapist may have provided regular educational sessions during the psychotherapeutic process to help her understand her son psychologically and to support the process. She may have initially been seen as also struggling in not wanting to be reminded of the loss of her loved object (her husband) by her son’s need for psychotherapy. In the Kleinian model there may have been little contact with her during the psychotherapeutic process.

The two-person relational psychotherapy is a rich and complex process that has evolved from the traditional one-person model. For an in-depth definition of contemporary two-person relational psychotherapy, we refer the reader to Chap.​ 3. In short, it is an interaction between patient and psychotherapist that promotes the cocreation of more adaptive experiences for the patient in the form of a new emotional experience, from the psychotherapist’s personal healthy attributes, which is then stored in nondeclarative memory. The relational psychotherapist makes careful use of timed self-disclosures and occasional enactments. We note that at times self-disclosures and enactments occur unknowingly to the psychotherapist and its presence is revealed by the patient.