Technique in Child and Adolescent Analysis

TECHNIQUE IN CHILD AND ADOLESCENT ANALYSIS

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TECHNIQUE IN CHILD AND ADOLESCENT ANALYSIS

Edited by

Michael Günter Translated by Harriett Hasenclever

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First published in 2011 by Karnac Books Ltd 118 Finchley Road London NW3 5HT Copyright © 2011 by Michael Günter

The right of Michael Günter to be identified as the author of this work has been asserted in accordance with §§ 77 and 78 of the Copyright Design and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. British Library Cataloguing in Publication Data A C.I.P. for this book is available from the British Library ISBN-13: 978-1-85575-715-8 Typeset by Vikatan Publishing Solutions (P) Ltd., Chennai, India Printed in Great Britain www.karnacbooks.com

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CONTENTS

FOREWORD

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BIOGRAPHICAL NOTES

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INTRODUCTION

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CHAPTER ONE Problems of technique in analysis of children and adolescents: transference—interpretation—play Michael Günter CHAPTER TWO “Lillifee thinks she’s an arsehole.” Three levels of technique in child analysis: containment, transformation, interpretation Angelika Staehle

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CONTENTS

CHAPTER THREE Clinical and technical problems in child and adolescent analysis (following in Bion’s footsteps) Antonino Ferro CHAPTER FOUR What about the transference? Technical issues in the treatment of children who cannot symbolize Maria Rhode CHAPTER FIVE Identity and bisexuality: thoughts on technique from the analysis of an adolescent girl Helga Kremp-Ottenheym CHAPTER SIX Some thoughts on psychoanalytical technique in the treatment of adolescents: on the development of body image, body ego, and ego structures Elisabeth Brainin CHAPTER SEVEN Rivals or partners? The role of parents in psychoanalytical work with children Kai von Klitzing

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REFERENCES

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INDEX

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FOREWORD

The importance of child analysis

Introduction This book is a strong, powerful voice for the importance of child analysis. Psychoanalytic work with children and adolescents is currently under threat. In a time of financial pressures, there is a demand for brief ‘quick fixes’ that can be provided for large numbers of troubled young people. We recognize that the need for help is far more widespread than was previously thought. However, what often goes unrecognized is the emotional turmoil of development that underlies ‘the problem’. If emotional, intellectual, and social development are to be fostered, this turmoil must be addressed. Psychoanalytic work is with the underlying emotional turmoil, this is not addressed by ‘quick fixes’ which modify only the presenting problem. Psychoanalytic work with children and young people can promote emotional growth and assist the individual, both to use their potential and to accept their limitations Child analysis has to, therefore, prove its value to funders, politicians, government. But it must also convince adult psychoanalysts that it is truly psychoanalytic, not an application, but as vii

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much psychoanalysis as adult analysis. The theoretical core of adult psychoanalysis—the work of Freud, Bion, Klein, and Winnicott—is shared by child analysis, as the contributions to this book illustrate. Child analysis building on Freud has continued to grow and develop theoretically and technically. Bion and Winnicott extended our understanding of early mother–child experiences and of working with psychotic and antisocial states. The chapters of this book offer ideas formulated in a lively and creative way, accompanied by clinical examples. We can follow the individual authors’ use of the transference and countertransference, of the concepts of projection, projective identification, and container–contained. Michael Günter’s excellent theoretical overview leads on to Angelika Staehle and Maria Rhode on work with very disturbed and damaged children. Their psychoanalytic work based on Bion’s idea leads them to apply the concepts of Frances Tustin’s distinction, in relation to the transference, between, children who are ‘shutters up’ and those who are ‘drawers in’. These formulations help them to work with autistic spectrum and borderline children in a creative way enabling contact and some progress. The children begin to symbolize and thence to play and speak so that an emotional connection can be established. Such work requires of the professionals a huge degree of mental containment and transformation. These chapters speak to the skill and commitment required and should encourage others who try to help these children. Antonino Ferro also focuses on work with very worrying children, illustrating his own understanding of mind, externalization, and the emotions. Helga Kremp-Ottenheim and Elizabeth Brainin describe work with very ill adolescents where the developing body, the body ego, and gender identity cause immense problems. All of these authors are working on the edge with children and young people that might be thought beyond psychoanalysis. They use their intense, demanding clinical work as a psychoanalytic ‘research laboratory’ to expand technique and theory. The ideas in this book will be so useful to others working with such disturbed children and young people. The final contribution from Kai von Klitzing is a cry from the heart. While clinicians working with children or adolescents do acknowledge the importance of work with the parents or carers, they tend to think of the work with their patient as the crucial

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FOREWORD

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task. But, in reality, working with parents as at least as difficult and demanding as individual work with young people. The parents cannot be approached as patients, though their own difficulties may have become more entrenched than the child’s, they will understandably withdraw, if they are treated in a way they have not authorized. They must be worked with as parents, respecting the portal of entry ‘via the child’. They need help and understanding for themselves, of the child, and of everyone’s reactions to therapy. The professional involved may have to mediate with the extended family, with external agencies, and the school. The parents must be helped gradually to become aware of their part in the family problem, of what they can contribute to its resolution, and of the possible impact on them and the family dynamics. The growth of their capacity to disclose family secrets, to acknowledge their own fear, aggression or despair, pain, and longing needs sensitive support. This is a daunting task which requires skill, patience, courage, and a sense of humour and this chapter conveys it. This book—the fruit of a conference—will become a helpful inspiration to anyone working with seriously troubled children, adolescents, and their families. It also demonstrates convincingly that child analysis is truly psychoanalysis. Judith Trowell Psychoanalyst, Child Analyst, Consultant Psychiatrist, Tavistock Clinic Professor of Child Mental Health Past Chair—Child Analytic Training Committee British Society

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BIOGRAPHICAL NOTES

Elisabeth Brainin, Dr., MD, Training analyst and child analyst in the WPV/IPA. Specialist for Psychiatry and Neurology. Former Medical Director of the “Child Guidance Clinic” Vienna. Numerous publications on the history of the Vienna Psychoanalytical Association, on trauma, on anti-semitism, on aftermaths of persecution, on child analysis and on neuropsychoanalysis. Dr. Elisabeth Brainin, Halbgasse 6/30, 1070 Wien, Austria, email: [email protected] Antonino Ferro, Dr., Past Professor of Child Psychoanalysis and Psychotherapy at University of Milano. Psychoanalyst for Children, Adolescents and Adults, Training and Supervising Analyst for the SPI/IPA. Specialised in Psychiatry at University of Pavia. Directed a Centre for Rehabilitation of Movement and Language Disorders. Subsequently he has been Lecturer at the University of Pavia Psychiatric Centre. Supervisions, lectures and seminars at the Psychoanalytic Societies of various countries (Europe, North America and South America). National Scientific Secretary for the SPI for two years and subsequently President of the Milan Centre for Psychoanalysis for four years. For several years Antonino Ferro has been xi

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mainly in private practice as analyst and supervisor. He has written several books translated into various languages and many articles. Editor-in-Chief of the Italian Year Book of IJP, Editor of the’Quaderni di Psicoterapia Infantile’, member of the editorial board of numerous international journals. Since 2003 until September 2008 Editor for Europe of the International Journal of Psychoanalysis. Memberships in several committees, Chair (2007) of the Sponsoring Committee for the Turkish Provisional Society of Psychoanalysis. In 2007 Antonino Ferro was selected to be a recipient of the Mary S. Sigourney Award. Antonino Ferro, MD, Via Cardano 77, 27100 Pavia, Italy, email: [email protected] Michael Günter, Dr., MD, Professor of Child and Adolescent Psychiatry and Psychotherapy, Director of the Department of Child and Adolescent Psychiatry and Psychotherapy of the University of Tübingen, Germany. Psychoanalyst for children, adolescents and adults, Training analyst (DPV/IPA), Specialist for Psychosomatic Medicine. Studies in medicine, art history, and empirical cultural science. Co-editor of the Journal Kinderanalyse (Child analysis). Numerous publications on child psychotherapy, forensic child psychiatry, emotional adaptation of children with severe somatic disorders, early onset psychosis. Most recent English monographs: “Playing the Unconscious. Psychoanalytic interviews with children using Winnicott’s Squiggle technique.” London: Karnac 2007. Franieck & Günter: On Latency: Individual Development, Narcissistic Impulse Reminiscence, and Cultural Ideal. Karnac 2010. Editor of several books. Director of the professional training curriculum in Psychodynamic Psychotherapy at the University of Tübingen and of the South-West-German professional training curriculum in Forensic Child and Adolescent Psychiatry. President of the International Association of Forensic Psychotherapy 2007–2009. Professor Dr. med. Michael Günter, Dept. Psychiatry and Psychotherapy in Childhood and Adolescence, University of Tübingen, Osianderstr. 14, 72076 Tübingen, Germany, email: michael.guenter@ med.uni-tuebingen.de Kai von Klitzing, Dr., MD, Professor of Child and Adolescent Psychiatry, Director of the Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics of

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the University of Leipzig, Germany, Psychoanalyst, Member of the Swiss Psychoanalytical Society and German Psychoanalytical Association/IPA, Training Analyst, Co-editor of the Journal Kinderanalyse (Child Analysis), Board Member of WAIMH. Scientific interests: Developmental psychopathology, early triadic relationships (mother–father–infant), children’s narratives, psychotherapy (individual and family), neurobiology. Books on children of immigrant families, Psychotherapy in Early Childhood, Psychoanalysis in Childhood and Adolescence. Professor Dr. med. Kai von Klitzing, Clinic for Psychiatry, Psychotherapy and Psychosomatics in Childhood and Adolescence, University Hospital Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany, email: [email protected] Helga Kremp-Ottenheym, Dipl. Psych. (Psychologist), Psychoanalyst for children, adolescents and adults, Training analyst (DPV/ IPA) in her own practice. She is also working as a supervisor. Helga Kremp-Ottenheym, Wallstr. 20, 79098 Freiburg, Germany, email: [email protected] Maria Rhode, formerly Professor of Child Psychotherapy at the Tavistock Clinic/University of East London, is a member of the Association of Child Psychotherapists and the Tavistock Society of Psychotherapists, and an Associate of the British Psychoanalytical Society. She works as Honorary Consultant Child Psychotherapist at the Tavistock Clinic, where she formerly co-convened the Austism Workshop, and in private practice. She is the author of numerous publications and co-editor of Psychotic States in Children (1997), of The Many Faces of Asperger’s Syndrome (2004) (Karnac Books: Tavistock series), and of Invisible Boundaries: Psychosis and Autism in Children and Adolescents (2006) (Karnac Books: EFPP series). Maria Rhode, Department of Children & Families, Tavistock Clinic, 120 Belsize Lane, London NW3 5BA, GB, email: mrhode@ tavi-port.nhs.uk Angelika Staehle, Training and Supervising Analyst, Training Group Analyst (DAGG, GAS). For several years director of the psychoanalytic training and member of the board of the DPV. Director of the training in child analysis of the DPV/IPA. She is working in

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her own practice with children, adolescents, and adults, single and in groups. Scientific interests: Psychoanalytic technique, especially disturbances of symbolization in children, adolescents, and adults. Numerous publications. Dipl. Psych. Angelika Staehle, Annastr. 28, 64285 Darmstadt, Germany, email: [email protected]

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INTRODUCTION

The Freud/Klein controversies in the early 40s of the last century were sparked above all by the differing views of the two opponents on the techniques of child analysis. Anna Freud doubted, at least in her early years as an analyst, whether the child was capable of a transference neurosis and this moved her to make far-reaching modifications in technique. She concluded that the analyst possessed significant value as a real object and that therefore educative elements were important in child analysis. In her “Introduction to child analysis” she wrote in 1927: “But the child analyst must be anything but a shadow. We have already heard that for the child he is an interesting person, endowed with all sorts of impressive and attractive qualities ... And such a well-defined and in many respects novel person is unfortunately a poor transference object, that is, of little use when it comes to interpreting the transference.” (Anna Freud, The Writings of Anna Freud Vol. 1 Introduction to psychoanalysis. Four lectures on child analysis (1927) pp. 46–47.)

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Melanie Klein, by contrast, did not see detachment from the parent figures as the precondition for the patient to develop a transference and maintained her conviction that one ought to interpret transference explicitly and straightaway in order to reach the deeper, aggressive–destructive fantasies and negative transference associated with them. “If we wish to understand the child's play correctly in relation to its whole behaviour during the analytical session we must not be content to pick out the meaning of the separate symbols in the play, striking as they often are, but must take into consideration all the mechanisms and methods of representation employed by the dream-work, never losing sight of the relation of each factor to the situation as a whole. Early analysis of children has shown again and again how many different meanings a single toy or a single bit of play can have and that we can only infer and intepret their meaning when we consider their wider connections and the whole analytical situation in which they are set.”

(Melanie Klein (1932) in The Writings of Melanie Klein. Vol. 2 The Psychoanalysis of Children, Part 1:The technique of Child Analysis pp. 7–8. London, Hogarth Press 1975)

Beyond these classic controversies and despite fundamental changes in the theory and technique of psychoanalysis there has been too little discussion of specific problems of technique in the psychoanalysis of children. How is transference to be handled in the different age groups? What kind of interpretation do we use and how do we communicate our interpretations to the child? What place does the child's play have, how do play and therapeutic work interlock? What kind of work with parents produces what kind of problem? How do we deal meaningfully with transferences and cross-identifications in this part of our work? What are we to do about the tendency of adolescents to deal with inner conflicts by acting out in reality? How does their urge to seek independence fit with therapeutic work involving regression and transference? How does the child perceive us? As what?

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Some of these questions on the technique of child analysis are discussed in this volume. Male and female analysts from a wide variety of theoretical traditions offer their reflections and present material for further discussions of great interest. For technique in our profession is not a dry, theoretical thing. In the analysis of children and adolescents it is inseparably connected with the question: How I can develop a relationship with the child and its inner world that is alive? The life blood of therapeutic technique is in the spontaneous encounter between analyst and child and one cannot hope to tame or control such a technique beyond a certain point.

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CHAPTER ONE

Problems of technique in analysis of children and adolescents: transference—interpretation—play Michael Günter

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n the psychoanalysis of children it is children’s play that offers us the easiest access to the inner world of the child. At the same time, children’s play and playing with children has caused the most headaches over the question of what is correct therapeutic technique. We often experience play as getting out of hand, as breaking the bounds of norms and rules. The forces at the heart of play opposing and attacking “proper behaviour” emanate from libido. Children’s play can, admittedly, also get lost in narcissistic over-inflation of self-importance which blanks out the disturbing reality of others and of triangulating thought, or which in obsessive repetition acts as defence against all forms of threatening inner objects. Nevertheless it is play that allows us to come into contact with children and their unconscious inner world. Melanie Klein explored and brought out the equivalence of children’s play with dream in The Psychoanalysis of Children (1932) pointing out that associations can be obtained as well from a child as from an adult, if we use children’s play as a medium in the analysis. Winnicott built his entire theory of creativity and with it his fundamental access to psychoanalysis on play. It was not without reason that he described his now famous technique for first interviews as the squiggle game (1971a). 1

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It is therefore presumably no accident that Freud referred to his rules for technique as the rules of the game in his work On Beginning the Treatment: In what follows I shall endeavour to collect together for the use of practising analysts some of the rules for the beginning of the treatment. Among them are some which may seem to be petty details, as, indeed, they are. Their justification is that they are simply rules of the game which acquire their importance from their relation to the general plan of the game. I think I am well advised, however, to call these rules “recommendations” and not to claim any unconditional acceptance for them. The extraordinary diversity of the psychical constellations concerned, the plasticity of all mental processes and the wealth of determining factors oppose any mechanization of the technique; and they bring it about that a course of action that is as a rule justified may at times prove ineffective, whilst one that is usually mistaken may once in a while lead to the desired end. These circumstances however do not prevent us from laying down a procedure for the physician which is effective on the average (1913c, p. 123).

We can therefore regard children’s play as the central medium of psychoanalytic therapy in childhood and may legitimately assume that the fundamental “rules of the game” for psychoanalytic technique of treatment, the free association of the patient, the analyst’s evenly suspended attention and abstinence are just as realizable in child analysis as in the analysis of adults. This is also true even though the real-life sessions go beyond speech: in containing play they allow action, i.e., acting out. Admittedly if we accept this, the question then arises as to whether we need to talk about a specific technique for child analysis at all. The contentious character of this question is connected to the fact that we have, on the one hand, equated overlengthy (treatment) techniques with specific options for interpretation and setting variations and have, on the other hand, confused questions of technique with fundamental theoretical tenets—and in doing so were too fixated on the problem of how to get metapsychological constructs across to the patient, in this case, to the child. I am aware that I have formulated this in a provocative form.

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When I review the papers on the technique of child analysis that we have put together in this volume and take the current developments in modern psychoanalysis into consideration, it may seem that we are beginning to take decisive steps forward. We are beginning, more and more, to differentiate between three different aspects of technique. When we, however, take a closer look at the literature on technique we see that, in fact, such questions have been posed ever since the beginnings of psychoanalysis. It was one of the most fruitful discoveries I made when reading these older texts, that the tension between the ideal of a correct application of psychoanalysis and the necessity of handling it flexibly in terms of technique had throughout triggered intense reflection. In the following I shall outline the central points of view from which the term technique of treatment can be seen and discuss some implications of these ways of seeing it for child analysis. Interestingly, we shall find that certain problems of technique which are contentious today and lead to controversy have long been seen and discussed in psychoanalysis. I am, however, convinced that today, since conditions of work have changed, we are forced to answer the questions associated—at least in some provisional form. 1 Technique can be taken to cover the question of setting, frequency of treatment, adaptation of psychoanalytical procedure to illness-related necessities and to general conditions of analytical work This simple, so to speak, technical understanding of the term technique has always played a role in discussion and in some cases has led to very wise and differentiated reflections. There is, however, in my view a danger here that we are leaning too heavily on this outward and thus very technical concept of technique. This is particularly true of times—such as ours—in which we are under pressure from outside to defend the legitimacy of our work and are inwardly shaken in our confidence as to what particular steps we take, what has genuine beneficial effect, and on what theoretical foundation we need to base it. The essential argument for holding onto defined conditions and the suspicion aroused by any outward deviation from them is of course justified in principle and familiar to everyone working in the field of science; it is only with the greatest possible constancy of outer conditions that the real task can be carried out in the proper

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manner and excluding uncontrollable influencing factors. Moreover we know—and this is fundamentally a reasonable argument—that in our area of work a higher dose produces better results as a rule, even if the marginal utility may grow progressively smaller. Yet Freud had already pointed out in Lines of Advance in Psychoanalytic Therapy that “the various forms of disease treated by us cannot all be dealt with by the same technique” (1919a, p. 165). The way his thinking and theory of technique were developed at that time, Freud formulated thus: if the technique were applied to patients on a large scale one would be compelled to “alloy the pure gold of analysis with the copper of direct suggestion” (ibid, p. 168) but he also established, as regards a further development of the technique of treatment, that “its most effective and important ingredients will assuredly remain those borrowed from strict and untendentious psycho-analysis” (ibid, p. 168). Ella Freeman Sharp formulated a position of this kind in very decided form in the memorandum on technique that she gave on 24 November 1943 at the British Psychoanalytical Society in the context of the so-called Freud/Klein controversies. Referring to Freud’s statements, quoted above, on the necessity of adapting technique to the form of illness she emphasized: A different technique can be a correct psychoanalytic technique, if it was developed to treat different illnesses. Every person is different and has his own history. A technique which was based from the outset on the assumption that every person suffered from the same illness is static and therefore dead. Such a technique has rules and standard expressions which can be learnt and used mechanically. A correct technique is not a rigid yardstick but adapts itself to the particular needs of the individual. It is not fixed from the start, it develops in the course of the “process“ even if this process will certainly show that all patients suffer from the fear of castration and fear their own drives and impulses. (Freeman Sharp, 1943, p. 71 in the German edition).

Candidates should be encouraged to acquire a supple technique capable of coping with sudden emergencies. A correct technique will—in her view—allow adjustments to the specific requirements of particular cases and may leave the path of the standard rules, but

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it should be carried out on the basis of the fundamental suppositions of psychoanalysis. Admittedly she also warns that one cannot formulate the principles of the technique of treatment basing them on exceptional cases and in this respect she is convinced that it is important first of all to learn the standard technique. Child analysis in this outward sense of the term technique is only possible, as we all know, by using technical modifications of the process used with adults, even when we use the classic analytic setting with frequent sessions. This makes our task as child analysts more difficult in some points, because we are much more involved in the immediate actions that take place and we can hardly allow ourselves a break to be able to think. But this change does not affect the core of the psychoanalytic process if one sees it as a communication from unconscious to unconscious, as an interplay of transference and countertransference, or, as Antonino Ferro repeatedly termed it, a bi-personal field in which two psyches try to make themselves understood to each other. To retain this core also holds, if not taken to extremes, for all further modifications of the outward conditions—although I need to qualify that, in that one always has to keep an eye on the question of quantity, of dosage. Quite other, less classic settings, too, work with the central elements of psychoanalytical thinking particularly in the understanding of unconscious processes: from psychoanalytically reflected crisis intervention, milieu therapy approaches, treatment in hospital, or psychoanalytical social work. If the vanishing point is always to have recourse to the unconscious such modifications are in fact more a question of quantitative then qualitative differences. The crucial thing is to ask how large the dose should be and what general conditions allow a genuine psychoanalytical process to be realized or in fact tend to be prevented. 2 Technique can also be understood as the entirety of the means used to enable the therapeutic relationship, to set the therapeutic process in motion, and to reach an empathetic understanding of the inner distress of the patient On the importance of the therapeutic relationship, which is very largely conveyed through empathy and the faculty for self-reflection—qualities that are themselves closely connected— practically all the schools of therapy are in agreement. Empirical

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research has also widely confirmed the significance of these factors for the success of a therapy and they have taken their place in concepts of a “generic model of psychotherapy”. We psychoanalysts see ourselves as having a particular competence in this respect since we do not only connect to the patient’s conscious thoughts but above all to unconscious wishes, fears, defence structures, to everything that is not allowed into the realm of conscious thought. In this respect one could call psychoanalysis the method of empathetic understanding of the unconscious and of training in self-reflectiveness. Ferenczi pointed out at a very early stage in his paper “The elasticity of the psychoanalytic technique” how decisive “psychological tact” is. He equated it with the ability to empathize. Nothing is more harmful in analysis than the schoolmasterly or even authoritative tone in the doctor’s behaviour. All our interpretations must therefore have the quality rather of suggestions than of assured claims and this not only in order not to irritate the patient but because we can truly be in error. The merchant’s long-established custom of adding S.E. (salvo errore—save for errors) to every bill should be added to every analytical interpretation. Our trust in our theories should also only be conditional for this might be the famous exception to the rule or there might even be a need to correct the theory as it stands so far (Ferenczi, 1927/28, p. 389).

This shows that he regarded psychoanalysis as a process of development, a perception that is certainly familiar to us as child analysts. In the London Freud/Klein controversies various stands were taken on the question of the therapeutic relationship and it was seen in connection with the “attitude” of the analyst. Sylvia Payne emphasized the attitude of the analyst in her “Memorandum on Technique” of 24 November 1943 in the following way: … since this attitude is decisive for the effect of the technique— however it may be applied. This is why I wish to say that no analytic technique is the right one however it may be applied, if the analyst regards it as the only method to save the patient and regards it as an exact procedure, on the exactitude of which the success of the analysis will depend (Payne, 1943, German edition p. 78).

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For this reason I am convinced that the complex technique we use—namely constant reflection on unconscious processes, on the transference and countertransference relation and on the infinitely varied forms of defence—is above all a means to an end. This is how we manage to remain connected to our patients even and in particular when they land in a state that prevents them from thinking and when their capacity to form links and deal affectively with raw sensual data is impaired and hampered. We need this technique on the one hand as a kind of protective skin so that we do not fall into the same blankness when we are mentally linked to patients who have fallen into a blank state of mind, and also to be able to keep our own thought processes functioning and in this way offer the patient a chance to learn something from us. Only if we are willing to acknowledge that our patients also examine us with an intensity at least equal to our own—and we can only do this if we have built up this protection of our thought processes through identification with the psychoanalytic technique—can they benefit from our work. Seen from this point of view technique is paradoxically something highly complex designed to enable us to maintain something quite simple even under difficult circumstances: a process in which two people are connected in feeling and can exchange thoughts about this. 3

The technique of treatment is centred above all around the question: with what means, with what form of intervention can I achieve the desired effects, namely the establishment of a therapeutic relationship, the insight into the unconscious and the fostering of an analytic process?

The choice of means will be determined by fundamental convictions I have on theory and technique. It was, in fact, the theoretical controversies between the different schools of psychoanalytic thought that led to arguments over technique. In this it seems to me—at least given the knowledge we have today—that the debate on technique between Melanie Klein and Anna Freud over child analysis in particular was basically focused on the wrong questions. To pick out just one example for each: Anna Freud claimed that children were not capable of transference and concluded from this that the analyst possessed significant value as a real object and that therefore educative elements were equally important. This is the result, in my opinion, of an over-narrow and over-technical

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conception of transference, which for reasons connected with theory saw detachment from the parent figures as the precondition for a patient to develop a later transference, in the real sense, to the analyst. In contrast to this view, today we understand transference in a far more dynamic way as the unconscious attempt to substitute the limitless realistic perception, e.g., of the analyst, at least partially through the reviving of inner objects and with this of interconnected interaction structures in order to reduce fear and insecurity. If one further includes the dynamic interplay of transference and countertransference in the picture there can be no doubt that children are able to develop a transference neurosis just as well as adults and that this is the case completely independently of the extent to which they have been able to relativize the possibly idealized parent imagined in the course of their development. This does not mean that teaching and learning do not take place constantly, in the context of a psychoanalytical process too, and it certainly does not mean that they should be avoided. Education as offering learning will always happen whenever a person seriously turns their attention to the inner situation of a child and gives this child the opportunity to feel that it is taken seriously and can engage with an adult, can enter into dialogue and identify with this person (Günter, 2002). What it does mean is that education in the sense of guiding towards desired forms of behaviour cannot be at the core of the psychoanalytical process, but at the most—according to the situation—a more or less important and necessary extra or even a source of disruption. In this respect child analysis borders on other therapeutic techniques but in its core it goes beyond them. As regards technique we need to discuss to what extent, in which situation, and with what type of problem such forms of guidance may be necessary and helpful, to what extent a psychoanalytical process could not be started without them, and how far such interventions hinder access to the unconscious conflict or may even be the undoing of the psychoanalytic process. This, however, from my point of view, is not a question that can be answered as a matter of theory but rather one that needs to be solved pragmatically as being a matter of the illness, the parameters within which treatment can and must be offered, and the child’s inner and family situation. In this respect we still have need of considerably more research on the theory and practice of technique.

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What has been said so far also certainly corresponds to the fact that we are always a real object for the child and adolescent whether we wish to be so or not. Even if we show the greatest reserve, the mere fact that we as analysts, as adults, play with children and concern ourselves with their questions, psyche, desires, and conflicts, leads to the child or adolescent cathecting us and using the engagement with us, in the sense of having a social space also, to develop their autonomy. Beyond the function of transference object we also acquire an important function as a real object for the child who can develop something of his or her own in the interplay of orientation to and rejection of adults who offer models different from the parents. In adult analysis the setting means that one can more easily harbour the illusion that this aspect of the therapeutic relationship plays no role. The child or adolescent will not allow this illusion partly because of the more direct form of interaction but also because of his or her need to engage with adults: a need inherent in the process of growing up. Nevertheless the core of our work remains in the reflective concern with transference and resistance and not in any kind of lecturing. I would like to contrast this with Melanie Klein’s conviction that one ought to interpret the transference explicitly and straightaway, in order to reach the deeper aggressive–destructive fantasies and negative transference associated with them. This act of making interpretations explicit is founded for its part on an insufficient understanding of what interpretation really is, a misunderstanding strongly influenced by the way one treated adults at that time. The psychoanalytic treatment of children was only just starting. This misunderstanding particularly stemmed from the over-emphasis, still current at that time, on cognitive insights as opposed to a comprehensive understanding of the dynamic interplay of transference and countertransference. This—in turn—means that today interpretations are regarded as interventions of a very much more complex nature. Unfortunately, as a result, the questions arising from this fact have equally become more and more complex and today they are certainly much harder to answer. Angelika Staehle pointed out (chapter two in this volume) that, for instance, thoughts on how an interpretation should be offered in terms of technique brings up genuinely difficult questions.

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Should an interpretation be given explicitly in words? Or should it not rather be introduced into play—perhaps through some minimal variation of the story-line? Or could it be hinted at through reflective, cautiously worded talking-to oneself? Our psychoanalytic, technique-focused super-ego will of course most likely be satisfied by an explicitly given, correct interpretation of transference. But we will often find that this is met by the child with incomprehension, a shaking of the head or some gesture of resistance implying “Don’t yak, let’s play” and so serves no purpose. By contrast, interpretations expressed in actions within the frame of the game and which are often not consciously reflected on by the analyst are frequently considerably more effective, since they reach the child at a level that he or she can understand and that fits his or her mental horizon far better, most particularly in the preconscious layers. This corresponds to the attitude that assumes (with Winnicott): that the significant moment is that at which the child surprises himself or herself (italics in the original (M.G.)) It is not the moment of my clever interpretation that is significant … Interpretation when the patient has no capacity to play is simply not useful, or causes confusion. When there is mutual playing, then interpretation according to accepted psychoanalytic principles can carry the therapeutic work forward. This playing has to be spontaneous and not compliant or acquiescent (italics in the original (M.G.)) if psychotherapy is to be done (Winnicott, 1971b, pp. 59–60).

It is similar with adolescents who can often react extremely allergically if one relates their acting-out to the transference in the classic manner and interprets it. If the analyst on the other hand can bear the thought that the analytic situation may be the trigger for a reactivation of infantile conflicts, but that he himself is in no way “meant”—since this would be completely opposed to the adolescents’ reasonable efforts to detach themselves—then they may be able to overcome their wounded pride and accept that things are acted out in the outer world but are no less fruitful for the psychoanalytic work of finding insight (cf. Günter, 2008). We have had to, and we still have to, learn painfully that “strong” interpretations even if correct in technique are in fact

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weak interpretations which only convey what it is all about in an unsatisfactory manner and may perhaps have their greatest and most useful effect in marking a difference: a difference between the analyst’s thinking and that of the patient, which can act as triangulation, a difference between conscious and unconscious psychic processes, a difference between familiar or everyday and the discovery of the new. Interpretations mark in this way that this can “mean more”, that there is something else involved. One could even say that the fundamental function of an interpretation is that of a cut. Independent of its content, what I say in offering an interpretation is, “I think this means more than what we have been talking about. I think that you want to tell me something which lies beyond what you are actually saying. I think there may be sense in something that appears senseless to you.” In giving an interpretation I name and hold onto the fact that there are psychic realities beyond outward reality and that these are of significance. Interpretations are, in my view, primarily a means to mark these differences and only secondarily something that discusses contents, clarifies, makes conscious etc. Such an understanding of interpretation holds two advantages: On the one hand one avoids setting up a fundamental opposition between explicit verbal interpretation and what I call processinherent interpretation, expressed in action as is also the predominant form of communication in the squiggle game (Winnicott, 1971a; Günter, 2007). The question as to what forms are appropriate in a specific situation and can therefore be regarded as correct technique is thus shifted from being a question of principle with a tendency to become ideological to an empirical, pragmatical question of what technique will best serve a patient’s need. Secondly, in this way it becomes possible without any forcing of the issue to establish the different levels of psychoanalytical work that Angelika Staehle referred to. Interpretations in the sense of the providing of an inner space and of an alpha function must be of a radically different structure from those that facilitate oscillation between paranoid-schizoid and depressive positions, between container and contained, and these in their turn function in a fundamentally different manner from the interpretations of neurotic conflicts, which can most easily be grasped at a cognitive level. What is common to them all is, however, as already mentioned, the marking of a difference, the

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holding onto the meaningfulness of an unconscious psychic process, and the attempt to make these moments fruitful in the transference relationship. Seen in this light, technique in child analysis serves to help our patients to explain to us how they function and to give them the opportunity to examine how we function psychically. It serves to get in touch with the inner experience of the child and in doing so to set processes of change in motion. This is the sense in which I understand Winnicott’s words when he says “[P]sychoanalysis has developed into a highly specialized form of play in the service of communication with oneself and others” (1971b, p. 48).

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CHAPTER TWO

“Lillifee thinks she’s an arsehole.” Three levels of technique in child analysis: containment, transformation, interpretation Angelika Staehle

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y topic is technique in child analysis. My specific interest here is in the analytical thinking which is our instrument and in how it is realized in the wide variety of therapeutic fields of child and adolescent treatment. What these very differing fields have in common is, in my view, the identity of the analyst which rests on an internalization of the analytical method. It is by using his or her understanding of the unconscious that the analyst is enabled to set a psychoanalytical process in motion. Only in a process of this kind can unconscious processes manifest and it is they that allow one to approach the infinite entanglements of psychical experience that characterize psychic illness. Freud did not, as we know, have a child patient in analysis. But it is to him that we owe the account of his treatment of “Little Hans” via the father. Actually this represents the first example of psychoanalytical supervision. The reason that this case was so important to Freud was that it allowed him to test out his theories on the development of infantile sexuality and the Oedipus complex, theories which he had developed in analysing adults. And for us the case of Little Hans is important because it offered us that first access to pre-verbal 13

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children’s play, and to the drawings, dreams and phantasies which serve as the foundation for the technique of child analysis today.

Particular features of child analysis First of all I should like to look at a few of the peculiarities of our work in child analysis. Children are not patients who come to therapy of their own accord. The initiative comes from others: it stems from the plight of the parents, the insistence of nursery school teachers, school teachers, or educational authorities. Children are thus “sent” to us and often do not feel psychological strain and may not have any direct access to their suffering. Our experience shows us how greatly the phantasizing and thinking of toddlers differs from that of a child of kindergarten age, in latency or even more in adolescence. In order to help children of such differing ages and stages of development we need to get in touch again with the whole range of our own childhood phantasies, fears, and terrors. Only by doing so can we enter the world of the child in question—in order, in the next step, to regain our distance and return to our adult world. Further I would like to stress that analytical work with children always includes work with the parents. Being a parent starts even before conception and birth with the conscious and unconscious phantasies and fears which are enmeshed with ideas about being a mother or father and what one wishes for one’s child. Parents will inevitably transmit aspects of themselves and roles to the child. These will only lead to illness or disorder in the child if they are fixated, rigid and allow too little room for the child’s development. If such unconscious projections and transferences stem from the parents’ own undigested traumatic experiences, if these are inaccessible to them and so cannot be relativized, they will be handed on to the children. This is how the “ghosts in the nursery” arise, these unwelcome visitors from the unremembered—but acted-out—past of the parents described by Selma Fraiberg (1975). They are also referred to as elements transmitted from one generation to another. Child analysis or psychotherapy is only pursued as long as the parents can tolerate it. For children are dependent on their parents and every treatment can be broken off, can fail over the parents’ resistance or inability to understand—or over the lack of empathy with them on the part of the analyst. For this reason it is the most urgent

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task of the analyst to win the parents over to cooperation. There are a number of different concepts for the setting. One possibility is the “separate setting” in which two different child analysts or therapists work one with the child and one with the parents. In the “combined setting” parents and child are seen by the same analyst. Both settings have advantages and drawbacks. In Germany the “combined setting” is most prevalent. This is a field I cannot cover in this paper but I refer the reader to the reference section on the subject (Tsiantis et al., 2000; Novick & Novick, 2001; von Klitzing, 2005; von Klitzing, chapter 7 in this book). The child analyst is at the intersection of several real and phantasized levels of relationship (Begoin-Guignard, 1987): the child, its parents—on whom it is dependent in many ways, and the analyst, who is expected to support and “hold” the inner objects of the parents and those of `the child in him or herself. This demands sufficient triadic competence on the part of the analyst (von Klitzing, 2005). He or she must be able to take on the fear, guilt, and narcissistic wounds of those who are forced to ask for help with their child. He or she must acknowledge their pain and feeling of failure even if they express it in the form of reproaches and projections. The art is to be able to identify with worried and angry parents. The difficulty for the child analyst lies in having to take in the transferences of parents and child without allowing these to become confused in him or herself. Even if the analyst does not see the parents so often he or she remains the object of their transference and is affected in his or her own countertransference. Child analysis is carried out in a highly complex field with very particular dynamics between outer and inner world. Three circles overlap: the family of the child, the school, and the child’s development which is still in flux. Before the start of analysis it is necessary as far as possible to clarify whether the child’s difficulties are already internalized or whether they are caused principally by ongoing pathogenic influences from the real family and social relations. The child’s difficulties may have a function in the family system and the resistance to changing them is grounded in highly complex family relationships. The child is therefore very dependent on how the parents perceive and understand its problems and how willing and capable they are of granting these problems importance. It is frequently difficult to decide what is the responsible course to take. Should one refuse to take on analytical treatment of a child or, after

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all, to take it on in full awareness of the difficult family situation and limited possibilities for change? This was the dilemma with Mira’s case which I shall be describing later.

On the setting for child analysis First of all it is the concrete setting which is modified for child analysis to accommodate the child’s need to communicate via the medium of play. A child, particularly if it is a younger child, is not likely to stay seated on its chair expressing itself in words but will do so in play and actions. So the consulting room must be suited to the task. This does not, however, mean that it needs to be a regular “playroom” with all the usual variety and abundance of playthings. The child only needs a small number of objects to play with, above all for making things, for creative play to express its ideas and phantasies in play. Basically the room needs to be set up in such a way that the analyst or therapist does not constantly have to make sure things will not get broken. One must be able to move the furniture around and have the kind of table that can take a few knocks or scratches so that one is not too constrained in the work of thinking and feeling by having to worry about the furniture. Otherwise the analyst would not be able to register what the child is expressing and what this evokes in him or her (Joseph, 2008a). But not only the consulting room—the analyst, too, has to be able to “put up with” a great deal in terms of what the child brings into the analysis and what it inflicts on the analyst. Only then will he or she be able to understand and interpret the feelings for instance of fear and despair so expressed. Melanie Klein described this with great clarity in the following words: This implies that the analyst should not show disapproval of the child having broken a toy; he should not, however, encourage the child to express his aggressiveness, or suggest to him that the toy should be mended. In other words, he should enable the child to experience his emotions and phantasies as they come up. It was always part of my technique not to use educative or moral influence but to keep to the psychoanalytical procedure only, which, to put it in a nutshell, consists in understanding the patient’s mind and in conveying to him what goes on in it (1955, p. 129).

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On play and playing Play is rooted in the early relationship between mother and child. The first games together are in the form of making faces and producing sounds. In this way affective states are conveyed through what one could call projective identifications between infant and mother. The child’s projections expressed without words in gestures and facial expressions, body movements, and sounds are taken up by the mother, metabolized, and transformed in her reverie. These primary relations create the basis for play and playing. In Freud (1920 g), the child’s game (Freud observed how a oneyear-old boy threw a bobbin on a thread over the edge of his cot, where it disappeared, and then pulled it up again with a delighted “Da!” (“There!”)) represents the repetition of repressed experience combined with the child’s pleasurable attempt to make itself master of the situation. Not long after the publication of this paper of Freud’s, Melanie Klein developed her technique of child analysis basing it on children’s play, which the Berlin psychoanalysts found somewhat hard to understand. At the same time Anna Freud began to interest herself in analytical work with children and when she fled to London with her father in 1938 she met Melanie Klein and the two pioneers of child analysis became involved in heated arguments over the most appropriate technique for treatment. Melanie Klein regards play—at that time in contrast to Anna Freud—as the equivalent of free association (Klein, 1927). Her aim was to discover through the use of play at what points fear and shame block the child’s development. The heated arguments between Anna Freud and Melanie Klein that lasted years were of course based on feelings and personal rivalry associated with the person of Sigmund Freud. Nevertheless in their conflict it was a question also of very interesting aspects regarding the child’s ability to develop a transference and the ability of the analyst to use this in interpreting. Donald W. Winnicott, who was initially in supervision with Melanie Klein and later further developed her concepts in his own way, saw play as a transitional space. The aim, according to Winnicott, is for the child to use this transitional space and “make use” of the objects in it. In contrast to Winnicott who, in his psychoanalytical work with children, laid the greatest emphasis on creating a space within which

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to play, Klein tried to bring what is unconscious into consciousness through interpretation. She discovered how important deep, early interpretation is: such interpretation, in her view, greatly contributes to reducing the fears which cause inhibitions, but also to clarifying the negative transferences which impede the analysis. Additionally Klein showed us that the interpretation of transference plays an important role in setting up the analytical space, which is what Freud alluded to with the term transference neurosis that he saw as a space between being ill and being able to live. Wilfred R. Bion, who was in analysis with Melanie Klein, and took over, extended, and transformed her concepts, created a radically new approach to our understanding of the analytical situation in describing the prerequisite for a person to be able to learn from their emotional experience. He begins with the pre-verbal origin of experience, that is with the proto-emotional experience and traces its development to its naming in language. His abstract epistemological model emphasizes the importance of the early relational experiences. Other authors, namely Winnicott and Melanie Klein, had underlined the relevance of this experience before him. More recent contributions such as those of Daniel Stern (1985), Thomas Ogden (1992), and Peter Fonagy et al., (2002) have extended our knowledge of the early structuring of the processes of symbolic thinking. They all agree that the structuring of thought begins with the “digesting” of sensory data rooted in the earliest body experiences, and thus in the relationship between the mother and her baby. Bion (1962, 1963) is less concerned with the content of thinking than with the psychical apparatus that enables thought to emerge. What is important is not first of all to work on repression (as in Freud) or on splitting (as in Klein) but—in his view—we need to work on the place or indeed create that place in which thoughts can be thought. This means that work is needed on the “container” itself before we can concern ourselves with what is contained in it. Bion assumes a continuously unfolding process of transformation that leads from the most primitive contents to beta, then to alpha, to symbolization, and finally to pre-conscious verbalizations. With the terms affect regulation and mentalization, Fonagy et al., (2002) describe processes which are the necessary precondition for classic interpretations to be in a position to lead to insight and change at all. Mentalization comprehends the emergence of the ability to experience the self and others through thought, to reflect

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on the self or to be aware of and understand the thoughts of others. It is a question here of how it happens that children first of all experience an affect as their own and secondly are able to think over their own sensations, feelings, and affects. In order to acquire this ability the significant other must mirror the affect, marking it in some way, i.e., by exaggerating it, repeating it with feeling in the voice, or playing with it ironically. Then the infant can become aware of an inner state it could (previously) only perceive diffusely or not at all. The infant thus gains a picture of its own state through the reaction of another. Such interactions create patterns which when repeated then lead to the formation of representations that foster the regulation of affect states. The concepts of the group around Fonagy make interdisciplinary exchanges easier and emphasize the aspect of development. If used simplistically they do however harbour the danger that unconscious processes may be neglected (Bovensiepen, 2008). Space and time in the analytic sessions create the framework which enables the child to use toys as malleable material of the outer world and to inform them with its imagination—presupposing it possesses the ability to symbolize. Play accordingly acts as a bridge between inner and outer world (Günter, 2007, p. 9). The mental presence and ability of the analyst to sense and understand the child’s affects, in particular its fears and unconscious phantasies via the figures introduced in play are important prerequisites for the establishment of a psychoanalytical process. In a variation on Winnicott’s formulation one could say that there is no such thing as a patient or child in isolation, there is only a child with an analyst and with his or her explicit and implicit theoretical background.

Interpretation in child analysis Interpretation in child analysis is no easy thing. It frequently poses a problem in that it interrupts the continuity of play. An interpretation can either take place within the framework of the child’s play using the language of the game itself, or it can be given from outside with the risk of interrupting play. There is a further possibility and that is that the analyst, as it were, steps outside the field of the game and uses some kind of verbal means, cf. Mira’s case, to catch the child’s attention yet without interrupting

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what is going on. Thus the interpersonal process, i.e., what goes on between patient and analyst, and the way the analyst can work on this with his or her mental equipment, is in my view of absolutely crucial importance. What develops in the analytical session is “pairspecific” (Ferro, 1999, p. 40) which Ferro speaks of as the bi-personal field (ibid, pp. 49ff.). One can find many traces of Winnicott’s thinking in Ferro’s conceptualizations. The concept of the “good enough mother” and “holding function” correspond to Bion’s formulations or anticipate Bion’s models of reverie and the relation of container to contained. Winnicott’s transitional space comprehends what Bion calls “everything which is not saturated” in row C of the grid “Dreams, Myths” etc. Winnicott’s “true self and false self” are analogous to Bion’s concepts of “truth and lies”. Winnicott’s concept of breakdown (1965) also resembles Bion’s idea of the “catastrophic change”. And Winnicott, who warned against overuse of interpretations, commented that it had often proved important to resist the urge to interpret. This comment points to a similar perception of what Bion and Ferro refer to with the concept of unsaturated interpretations. One could say that Winnicott had anticipated the notion of the field when he says that there is “no such thing as a baby”, only a mother and her relation to her baby—although one ought not to forget the father. What counts is not only the interpreting, “uncovering” activity of the analyst but rather his or her transformation of the patient’s projective identifications. In Ferro projective identifications are seen as a model of relationship: in this he follows Bion. The focus is on how we manage or fail to process the emotional experience and thus enable symbolization. The process of symbolization is associated at all stages of human development with psychical pain—the feeling of being separated, depressive feelings of guilt, and Oedipal pain—with the result that this development can be obstructed at every stage. I find it makes sense—as I have put forward in another paper—to differentiate between various “unconsciousnesses” (De Masi, 2000; Staehle, 2004). For this reason it is necessary to analyse the type of disruption in the analytical communication between the two involved, both at the start of treatment and repeatedly in the course of the sessions. Basing this on Bion and Ferro (Ferro, 2003b) I would see the disruptions in communication “allocated” to various areas of dysfunction. By these areas I do not mean permanent structures in the whole

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person but rather various states of mind which may be more or less rigid or flexible. If these areas of dysfunction are rigid they are often encapsulated and occur simultaneously alongside and simultaneously connected with other, e.g., neurotic, parts (Bion, 1957). I find such allocations a helpful “theoretical backdrop” for observation, for gaining insight, and for the choice of my interventions in the psychoanalytical treatment of children, adolescents, and adults.

The various pathologies 1. Autistic pathologies which can be traced to a deficit in alpha functions: there is no perception that the other has an inner space. These patients have a significant defect in alpha function so that to begin with the analyst has to take on the whole work of transforming beta into alpha elements. 2. Borderline and narcissistic pathologies which can be traced to an inadequate development from paranoid-schizoid to depressive position. Here it is first of all a question of working on the missing psychic functions, that is on the lack of a container capable of receiving as also on the deficit in PS<> D oscillations— (the arrows showing the flow in both directions). 3. Neurotic pathologies: here the alpha function is present and there is an inner representation of a receptive psychical space (enough container). But there is an overload of undigested facts (neurotic conflicts). Here classical interpretations of content and of the transference can have effect. Using three examples from the treatment of children I should now like to illustrate how these differing pathologies manifest in the sessions and the differing ways in which the analyst has to make him or herself available to the patient as an analyst.

Clinical vignettes First vignette: Mira Nine-year-old Mira was presented to me on the initiative of her teacher. The parents reported that their daughter had attended the pre-school class at a school for children with speech- and sight-impairments because of retarded development on perception,

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speech, and gross and fine motor skills in conjunction with extreme short-sight. She had repeated this year and was now in the first grade. At this point the teachers had approached the parents describing a variety of signs of psychological problems in Mira, above all in her social contacts with both adults and children. She would burst into tears without apparent cause, answer teachers’ questions with stereotype replies. She could not seem to set up appropriate contact with other children. For example she would chase a younger boy around in the breaks hitting him on the head. Countless stacks of reports of examinations from the Child and Adolescent Psychiatric Clinic, from ergotherapy and other examinations are piled onto my desk. In this way I first of all receive accounts of Mira through the eyes of others. The situation seems altogether too much for the mother: she shows on the one hand exaggerated worry and concern and on the other the highly ambivalent wish to free herself of the demands made on her by Mira. Mira’s father seems more detached but is nevertheless obsessively concerned with Mira and the progress in her development. He makes notes of every word I utter in the interviews. With the mother I am given the feeling that I am to understand everything exactly as she interprets it. She complains that Mira takes her over completely and is always wanting her to play role plays that go on and on and that she can’t seem to stop. When I ask what kind of role play I am told that mother and daughter had, so to speak, created a second child, the doll Lilly. Mira talks to her as if to a real person and the mother joins in this game. She feels, says the mother, that she has encouraged this game too much, as she had so much wanted to have a second child. I support these misgivings and remark that she and Mira are entangled with one another over this doll and that I have the impression it is all too much for her now and that she feels overwhelmed. I mention that it is not something that would foster Mira’s further development. The mother appears to be able to take in the first part of what I said. From the way in which she had talked about the doll, Lilly, it was clear to me that this was not a game on the “as if” plane but that phantasy and reality were confused. Further details emerge showing that Mira had problems sleeping through the night and had slept in the parents’ bed to the age of five and was still sleeping in their bedroom up to the age of seven. It is not until I have an interview

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with the mother on her own that I am able to gather something of Mira’s early development. Her own mother, who had always been deeply depressive, had died while she was pregnant with Mira and this had weighed heavily on her. Mira had been a quiet baby but she had had to carry her around the whole time. They had noticed when the child was ten months old that she was extremely short-sighted and she had been given glasses to wear. I remark “So she won’t have been able to recognize your face when you were nursing her”—a comment that the mother takes in with surprise.

The first interview with Mira Mira is a girl of normal size for her age, wearing glasses with strikingly thick lenses. She leaves her mother surprisingly easily and comes up to me with apparent trust. But there is something strange about this air of trust, something gluey and sudden: her behaviour does not seem appropriate for a first meeting. She asks me “How are you?” looking past me. I look at her and say “Would you like to come into my consulting room and then we can go on talking there?” On coming into the room she stands there motionless, with her head hanging and I get the feeling I have to offer her something. Finally she takes up the little dolls, the ones one can put into a doll’s house. I can feel the strength of the pressure she exerts on me and feel the urge to tell her what she can do, what she is to do and to guide her hand. She builds a house with a children’s room and bathroom and then she takes the children and the baby and plays that the mother has gone away. She dribbles profusely and steadily like a very small child so everything gets wet. It does not seem to worry her a bit and I have the impulse to wipe her mouth as if she were a two-year-old. In the story she is playing another woman comes in and hands over her baby to be looked after. Finally Mira takes all the little dolls and babies there are in the box and squashes them all into the children’s room. That makes a lot of children in there. Then she keeps making the little Mama doll go away. It all takes quite a long time because Mira is very hesitant. The scene with the many, many children who, so to speak, fill the empty room and with the mother who keeps going away touches me very much. I wonder what Mira is trying to show me. Is she showing me that there is a “ghost mother” in

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her inner world who wants to have many phantasy children to fill her void and in doing so abandons her real children? At this point I remember the feelings I had in the first interview with the parents: the mixture of over-concern with powerful pressure to “make” a normal, well-adapted child out of Mira. I say—rather to myself than directly to Mira—“Oh, this mother wants to have masses of children, the beds are absolutely packed full of them, they are all so close together, and then maybe she begins to feel too cramped and she goes away”. I had the feeling Mira wanted to be so close up to me that there would be no space between us, like the scene she had created with the room stuffed full of children. She then scribbled a picture which I experienced as an expression of her feeling lost.

The figure hangs in the air in an envelope, there is no contact with the ground, no roots. The oval shapes where the arms would be could be seen as stunted wings, the head is crossed out and so gives an impression of being damaged.

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At a later stage I hear in talking to the mother that Mira was her third pregnancy; before her there was a miscarriage and a tubal pregnancy and when Mira was three years old a further tubal pregnancy. She had the feeling, she said, that her family was not a complete family with only one child. In her home the house has always been full—this was added in a later conversation. The mother’s history produces a desolate picture. Mira’s mother’s mother had been repeatedly hospitalized with a psychotic depression and lived in a folie-à-deux relationship with her younger daughter, who committed suicide in adolescence. The father died young in an accident. Mira’s mother had certainly been left very much alone and frequently confronted with a “dead mother”—that is an emotionally unattainable mother. After a further session with Mira and a number of conversations with the parents I decided to take Mira into analysis. She had touched me, had somehow got through to me. I had reservations because of the parents: I suspected that Mira’s problems served some function for the mother and also for the father and that there would be considerable resistance to any changes in Mira. In the therapy, which was carried out over two years with three sessions a week, Mira set up a very close, “adhesive” form of relationship to me. She followed me around like a shadow, repeated what I said and I had to play that I was her twin sister. I understood this as the only way she had of banishing the experience of being separate. The adhesive form of the relationship led to her holding onto a fusionary state of unity between child and mother since the experience of difference between the self and the other was unbearable. At times “sticking” to me would switch suddenly to aggressive fits in which she attacked me or maltreated her doll. This would happen in situations in which the experience of separation suddenly, so to speak, attacked her. It often happened at the end of a session or when the mother brought her too late or when a session was cancelled. At the beginning of the next session she greeted me as if there had been no break by calling me “Lisa” and picking up the “doubling” game exactly where we had left off. The particular focus of my attention was on Mira’s affective-body states: she felt overwhelmed by her feelings and had no means of regulating them, of linking them to people or relationships or of naming them. As long as I stayed in the framework of her “primitive

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role plays” Mira allowed me to put her affects and fears into words. Over a long period we “played” Tim and Lisa. She was Tim and I was Lisa. It was not a game on the symbolic level, in displacement, no, she was Tim and I had to be Lisa. From this moment on she called me Lisa throughout. As long as I said anything about Tim’s feelings Mira was able to bear it. But as soon as I addressed her fears more directly or tried to show a connection she put her hands over her ears, screamed, or began to cry. She rolled herself up into a ball on the floor and stayed there for the rest of the session. This showed me that I moved on too fast and that she felt overwhelmed by me. Now it was I who had become a traumatizing Other, making her relive the earlier experiences with her many disabilities, the medical examinations, and all the talk about her condition, all the naming associated with them. For Mira my words were not symbols representing something but signs associated with moments flooded with unprocessed emotion. My words, instead of naming something, were experienced by her as if they conjured up what I had named. In this analytical child therapy it was first of all a question of enabling Mira to understand and regulate herself. In a further step it was to help her to cope better with her constraints but also to develop abilities, to recognize her bodily reactions as expressions of fear or of overtaxing, and to recognize and name the various affects—i.e., give them a “handle”. Her abilities to master her self states and find a name for them and learn to understand them did indeed grow.

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Before therapy Mira had lived in a permanent state of stress-reaction. In the work on the transference countertransference relationship the analyst herself often slipped into inappropriate forms of regulation but this frequently offered a key to an understanding of the little patient’s state. Bit by bit the work on this relationship enabled a better regulation of unbearable experiences through the finding of a name for them. I noticed that the musical qualities of my speech were of key importance to Mira and for a long time I had to tolerate and live with Mira’s states without being able to understand them. In order to survive Mira had retreated into a mad, grandiose world in which no differences or boundaries existed. This was the world with her doll Lilly. It was into this world with its clinging and unseparated relationship that I entered with the therapeutic relationship. Here I had to suffer it with Mira and then find words that gradually allowed her to leave it. Here was the interface with the pathology of the mother and also of the father, whose effect on Mira’s psyche was that of foreign bodies or in Bion’s sense “bizarre objects”. To give a clearer picture of the overpowering feelings I was repeatedly exposed to I should like describe a short excerpt from a Monday session in the second year. Mira arrives punctually holding her doll, Lilly, in her hand. She asks me: “How are you?” then she begins to laugh in a rather crazy way and holds out the doll to me. She then says: “I’m going to throw Lilly in the bin” and does so. I remark: “Hm, perhaps Mira feels as if she had been thrown away during the time she wasn’t here.” Mira says something I cannot understand, then begins to talk about shitting and pissing, saying she wants to piss on Lilly and also on me. Then she says: “Lilly thinks she is an arsehole. Frau Staehle is an arsehole, too.” Then she draws something and puts it away in her drawer. She follows this with: “Mira is stupid, she has nothing but rubbish in her head. Mira is a stupid, stupid shit. Mira is made of shit and nothing else and so is Frau Staehle.” She repeats this a number of times. I have the feeling she is getting more and more aroused the more often she says these swear words out loud. I comment: “Mira is really worked up, what can be the matter?” I say this, talking to the room as if to myself. So then she picks up her doll and says: “I want Mira to cry. Mira wants to make Frau Staehle angry.” Then she comes at me threateningly, grabs me by the arm and says: “Frau Staehle has to cry too.” Then she shouts: “I want you

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to cry. I want you to cry.” She rushes at me, yelling “I want you to cry.” The pressure I feel is enormous and I am on the point of reacting with rejection. I then say: “I think you are trying to find out what you can make me do, what it is like if I cry, if I also think you are stupid and I don’t want to have you [here] any more.” Mira calms down and for the first time in a session she makes a picture of herself that has colour in it.

She starts the next session with “Have you been waiting for me? Did you know I was coming?” I have to point out here that Mira had all the times and dates of her sessions in her head. Over weeks these sentences became her ritual greeting at the start of the session. These questions were her way of expressing her need to have a place in my life and be expected by me. She no longer needed to get rid of the feelings that persecuted her by dumping them with me or pressing them into me (“You are to cry”) but, rather, began to notice that these feelings belonged to her. I would like to return to the beginning of the session just described to explain a point of technique. I understood Mira’s statement—that she was going to throw her doll in the bin as the description of how she felt treated by me. Her violent state of excitation resulted—I think—from her misunderstanding me. She must have heard that

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I was going to throw her into the bin. It might have been better to say “You want to be sure that I expect you” or “You can’t believe that you are important to me even if you are not here.” “Mistakes” such as these can hardly be avoided and it is important to observe how children react to them. Again and again we need to put things into words even at the risk of frightening a child. In the sessions with a child of this kind it is not a question of bringing unconscious content into consciousness and make it accessible to insight. Here what is needed is to register the child’s experience and try to discover a rudimentary sense in it. It is a question of holding in Winnicott’s sense and of containment as defined by Bion, i.e., of linking beta elements, so far devoid of meaning, to feeling and meaning (Staehle, 1999, 2006, 2007a, 2007b). The following drawings Mira made perhaps convey something of the gradual changes that appeared.

The analytical therapy with Mira unfortunately only lasted two years but it helped make some of the obstacles in her relationships to others and to herself less daunting. The work with the parents in this case was hard going. The aim was to realize and acknowledge a loss and a caesura both for the parents and Mira. The parents had to learn to accept that they had a child with specific disabilities who could not be compared to the child of their phantasies, the child that was to compensate them for the losses they had suffered. In the sessions with the parents it was extremely difficult, especially in the case of the mother, for us to tackle her highly ambivalent feelings

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towards Mira which stemmed from her own internalized history of relationships, so that she should not continue to project these into Mira and act them out with her. Mira had to tussle with the problem of her limited abilities— which set her so drastically apart from other children. It was a very touching and painful phase in the therapy in which she repeatedly played a game with me that she had invented called “Who’s allowed to go to the party, can disabled children go too?” It was almost a working through. Saying goodbye to her finally was equally moving. In the concrete manner she always had she managed to convey something of the change in the relationship to me. She had developed a great interest in snails and we had made snails a central theme over many sessions. So in her last sessions she brought me two snails, handed them to me and said she wanted them to stay with me when she herself could no longer come. She wanted me to look at them carefully and we put them on the little table in the consulting room and let them crawl there. The snails approached each other without shyness.

We observed them and I said to her “Yes, though they get quite close to each other they afterwards go their own ways and each one can withdraw into its own shell and is completely protected, but then they can come out again and meet each other. I think that is something very important.” Mira beamed at me and said: “Yes,

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actually I would like to go on coming [here]”. That was a really painful moment. After a little pause Mira said in a very thoughtful tone: “I would like you to come to my birthday party. Will you do that?” I told her I would not forget her and that the snails would stay with me a while. I took it that it was important for her to be able to believe I would remember her. I must say I was left with anxious feelings over what her future development might be.

Second vignette: Jacob Nine-year-old Jacob was referred to me by the out-patient section of a child and adolescent psychiatric institute, the acute grounds being that he had tried to strangle himself with a belt. The parents reported that he threw a kind of fit nearly every day, that he could not tolerate the slightest frustration. He would get physically worked up, throw himself on the floor, bury his head in cushions, hit himself on the head, on the forehead, scratch his own face, pinch his cheeks, and keep saying he didn’t want to go on living, he wanted to be dead. Apparently he had always suffered from violent mood swings. He often cried and frequently said “I’m all mixed up”, “My soul is in a bad way”. Conflicts and any deviation from accustomed habits unleashed extremely violent reactions. He had difficulty calming down, getting to sleep, and getting going in the morning. He complained of stomach aches and headaches. He showed little initiative to meet up with friends. On top of all this he was highly susceptible to infections, had pneumonia practically every year, and suffered from bronchial asthma. Jacob’s mother had been told that she could probably only have a pregnancy through artificial fertilization, which had put the couple under great pressure. It was clear to me that the mother was extremely quick to take offence and had very shaky self-esteem. After a smooth pregnancy it was a great shock for her to hear that the birth would have to be by Caesarean. She experienced the Caesarean as a narcissistic wound. In the mother’s account of things the father was completely missing. The second pregnancy, when Jacob was two years old, was under a cloud of anxiety as the parents had been told that there was a 50% risk of disability. The mother became depressive and the father took refuge in his work. At three years of age Jacob started to go to kindergarten shortly after the birth of his sister.

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Extremely difficult phases followed: he began to run away, started to suffer from pavor nocturnus—the parents were in a constant state of alarm. In our first interview I find myself opposite a boy who looks his age but is very, very slight in build and thin. He picks up the drawing paper that has been laid out and asks if he is to draw something. I tell him that he can draw whatever comes to mind, if he would like to. And he asks, “What about knives and swords?” So he begins very slowly and carefully to draw a Chinese sword explaining it in detail as he goes. He details the ranking of the war lords and the swords belonging to each rank.

It takes him a long, long time and it all looks very obsessive to me. I remark that he is probably wanting to find out if it is alright for him to draw knives and swords here. After a while I ask if he ever fights and then perhaps gets very angry. His answer is “Yes, when I have stress,” and he falls silent. Quite a lengthy silence follows. Finally I ask him “So … what does the stress feel like?” He responds with a

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picture of a figure with a sword in its belly—at first it has no arms or feet. Then after that he draws a stress knight armed to the teeth. The limbless person under stress looks very angry.

His comment is that he and Mama were always getting stressed. But then he falls silent, closes up and does not speak again. After a while he takes the scissors and cuts the paper in two, leaving the beautiful sword on one piece and the stress knight and stressed person on the other. He then asks me, in an almost relieved tone, “Can I play a bit now?” First I understand this as an attempt to protect himself against his aggressive phantasies and beyond that as an attempt to prevent people on the receiving end from getting hurt. Later I think it is also an attempt to free himself from the mother’s projections and the only way to do this is in a violent, aggressive manner. I get the impression that in the earliest relationship between Jacob and his mother there was a great deal of fear and that this was countered with enormous efforts to do everything well and do the right thing. Meantime Jacob has been in analysis with four sessions a week. The following is an excerpt from the first session after the summer break, after a quarter of a year in treatment. Jacob comes into the

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room and sits down on a low stool. He says he’s very tired and he really does look pale. Then he shows me a plaster on his knee and tells me that he fell and hurt himself. After that he asks after the knights he had played with before the summer break. I tell him they are in his drawer and that I have kept them there over the summer holidays. He opens his drawer with a little glint of pleasure and looks at the knights. Then he takes them out and puts them down on the floor. Returning to the drawer he takes out a little sack of marbles and begins to set up the soldiers. While doing this he tells me about his holidays. He asks me if I have ever been to a concentration camp, saying that he had been to Sachsenhausen in the holidays. I am somewhat shocked at such a thing for a holiday activity. I tell him I do know concentration camps but wonder how it was for him to see one. He tells me his parents had taken him and his sister to Dresden and Berlin and that they had then driven to Sachsenhausen. While he is talking about it I can see a mixture of fear and shock in his face but also a certain fascination. I have to keep a tight hold on myself to control my feelings and not let myself be too outraged over the parents taking their really fairly young children with them to a concentration camp particularly at a point in time when Jacob is so absorbed in his aggressive phantasies and fears or at times overcome by them. He goes on talking about his holidays and the museums they had been to see in Berlin. The tone of his account is a bit precocious and much too serious for his age. Then he devotes himself to the soldiers and builds a castle and a boat with the building blocks.

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After that he sorts the soldiers into light and dark. The dark ones are the baddies and the light ones the goodies. He builds a tower, places a soldier at the top and says: “That’s me. But I’m all the others too. I’m also the ones on the boat who are bombarding the fort.” I comment: “That’s difficult—having to be both the attackers and their victims at the same time. Perhaps it is often like that when you are angry and feel bad. But at the same time you want to be a good person and do good.” He listens to this with quiet attention but does not say anything. Then he asks me what I would like to be. I think about it and then say that I could take over the pirates’ part for a bit. But to this he says “No, I want to play their part too.” In the end he plays the game against himself, throwing the marbles at the boat until it is completely shattered. I notice a powerful feeling in me rising and taking me over—one that is in fact not appropriate to the real play situation—and I hear myself saying “Those poor people!” He responds very quickly: “No-one is going to die. And whatever happens none of the horses is going to die. Only the boat is going to be destroyed.” And he continues with the attack until the boat and the beautiful fort are in ruins. Then everything is destroyed and he looks really cheerful. He keeps looking at me and I get the feeling he is testing out my ability to take his aggressive phantasies. I am very conscious that I am in fact finding it hard to bear watching such beautiful constructions being so violently destroyed. All I can say at the end is “So tomorrow we’ll see how the game goes on.” In the next sessions he draws pictures of his inner battle between the aggressive phantasies that threaten him and his fight against them.

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What I wish to convey with this excerpt from a session at the beginning of a child analysis is how one provides a space, a relational space in which the world of the inner objects of the young patient in his relation to the therapist manifests and can be played out. It is important here for the analyst to observe his or her own feelings. It was as if I was standing next to myself and suddenly heard myself saying, “Oh those poor soldiers, getting killed and those beautiful buildings being ruined!” It seems to me that I experienced then something of the almost unbearable conflict between an unrelenting demand for beauty and perfection and a powerful urge to free oneself from it—a manic warding off of feelings. Something of the relation to one another of Jacob’s inner objects found expression here and was later to be elaborated. Much was already clear in the first session in the drawing of the exquisite sabres with their potential to offer protection but also to be weapons of aggressive attack, and in the way the stress knight and the stressman had to be protected from the weapons when he cut the paper in half. I have already pointed out that it is important for the analyst to pay attention to his or her own reactions and utterances and to see them as being part of the relationship between child and analyst. For in child analysis there is a danger of interpreting the material with reference to the parents or to the child’s other real “significant others”. I meantime had a lot of information on Jacob’s immediate and wider family. It was a family in which everything had to be ideal.

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Much of what burdened their lives—as for instance the mother’s warded-off depressive moods and the father’s acute depression— was experienced by the parents as deeply shaming. Dealing with their susceptibility for narcissistic wounding demanded great empathy. In child analysis the damage that can occur if interpretations are made with reference to the parents is great, as the parents then feel threatened and the relationship between child and parents is then in jeopardy.

Third vignette: Jana Nine-year-old Jana was referred to me by her mother’s therapist. The account of her was as follows: she had withdrawn more and more and was becoming almost like a baby, with violent fits of anger if constrained and otherwise not to be persuaded to undertake anything. The mother had to lay out her clothes for her as if she were a small child and pack her satchel. At school she was an able pupil but the teacher had asked for an interview with the parents because Jana was seeming more and more distracted and withdrawn. Jana was reported to be particularly difficult when she got back from fortnightly weekends staying with her father. She was very attached to him but there were now constant conflicts since he had started to live with his new partner. The mother was very worried because, on the one hand, Jana behaved like a baby but, on the other, she played the princess for whom laws or limits did not apply. She had been a lively, outgoing girl four years ago before the separation of the parents. Now she had more night-time fears and panics (these had begun after the separation when she was four years old). In addition she had developed tics and seemed very downcast. She had always had allergies and skin problems, as also bronchitis. But all these conditions had grown worse: such was the account given by the mother in the first interview. Jana lives with her mother who has no partner and the girl goes to a day-care centre after school. She visits her father every fortnight. He fetches her and she stays the whole weekend. She and her father share a love of horse-riding. Jana’s parents’ separation occurred at the height of the child’s Oedipal phase. There had at first been a close relationship with the mother, who had nursed Jana for 16 months. When the mother’s

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father fell ill she reacted with a depression. Jana was four years old at the time. At exactly the same time, connected with a change in the father’s work, the family moved abroad. This move was a last attempt to save the marriage. Jana had always been, as it were, the tie binding father and mother. On the one hand she was too much the centre of attention for her parents but on the other hand she was frequently shunted off to the respective grandparents. The separation of the parents with the mother’s depression must have been experienced by Jana as the loss of the most important object and on the Oedipal plane as an unconscious wish fulfilment. But now her father had put a rival in her place and all her fury and disappointment were projected onto this person. In the probationary sessions her phantasy of an idealized family appeared in play. She set up a family with grandmother, mother and two children. Everything was set up with great care to look beautiful and it struck me that she was almost exclusively attending to setting up the outer arrangements, such as furniture and flowers; it was only at the very end that the people were added. I understood this as an attempt to exert omnipotent control to rebuild her destroyed world—or maybe by magic to undo what had happened. In the second session she brought with her a highly complicated game of her own and I was introduced to Jana the dominant, Jana the discontented. It was with authoritarian accents of command that she told me what I was to do and how I was to play. In the third session she then sat down on the couch and began to tell me sadly about her difficulties with mother and father. I could, however, quite clearly sense that behind the pain and disappointment she conveyed to me there seemed to lurk an omnipotent phantasy. I had the feeling she wanted to convey to me that one absolutely had to get the parents back together again. In interviews with the parents together it emerged that the father was unwilling to see any difficulties in Jana and at first regarded therapy as in no way necessary. In the course of ensuing talks I did manage to get through to the father and he agreed to an analytical therapy. In the sessions that followed Jana first of all demonstrated her phantasies of omnipotence and grandiosity by controlling and dominating me. Her furious disappointment and pain showed in somatic complaints in the form of toothache and stomach cramps. Jana was a girl who was (well) able in play to present her phantasies in symbolic

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form. When playing with the dolls—in a variety of role plays—she showed me her longings and her expectations that she would be the princess who would set everything to rights again. She felt herself to be the best and sole partner for her father, his true “wife”. It also became clear that she hoped to find an ally in me who would aid her in making her grandiose phantasies come true. As it became increasingly clear that this plan would not succeed and she realized, painfully, both that I did not have the power to make it happen and that I would not let myself be used in this way, she became extremely angry. She was capable of spending entire sessions refusing to speak with an expression of grim determination on her face, and did so. I had to put up with this treatment over a number of weeks and had to keep reminding myself that what she was demonstrating to me was not only how powerful she was but also how hard it was for her to accept that she could not achieve what she wanted. The death of her beloved rabbit from cancer made it possible for us to speak of her pain and feelings of guilt. In one session she made a clay rabbit for its grave, and there set in a period of intense grieving for the rabbit and for the loss of the phantasized perfect family. Jana stayed on in therapy until she went to Gymnasium (secondary school). I was told at the close of our work that she had managed to get into a special form for players of stringed instruments and that she was very happy to be there. She was extremely musical and so was able to give her phantasies of grandiosity a realistic form and to use her talents.

Concluding remarks The disorders and the obstacles to communication in the children discussed here fall into the already mentioned categories of disorders: In Mira we see a deficit in alpha function. She had no notion that others might have an inner world capable of taking in her feelings at all. There was an absolutely fundamental lack of ability to form inner images and representations. In her case it was a question of communication in the most elementary forms—a striving through movement towards the object, through a movement whose goal was still utterly undefined. The task was to give her a container (often in absolutely concrete form), then to invite her into the analyst’s own mental workshop and finally to support her in working

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through contents—the last being possible to achieve only to a limited degree. Jacob’s problem belongs to the field of narcissistic pathologies. His development had led to depression. Here one can say in the Kleinian sense that it was a case of inadequate development from the paranoid-schizoid to the depressive position. It was a question therefore first of all of working to strengthen psychic functions he did not possess. He lacked a receptive container and there were deficits in oscillation between paranoid-schizoid position and depressive position. Expressed in simpler terms, he needed to learn to tolerate frustrations and to mourn without developing severe symptoms. The central areas to analyse with Jacob were the effects of the sudden withdrawal of his mother’s cathexis, caused by his difficult, Caesarean birth, the endangered pregnancy leading to the birth of his sister, his mother’s ensuing depression, and his father’s manoeuvres to avoid depresssion. A void, as it were, had appeared in his psyche and he had identified with the absent mother. By identifying with the aggressor and with manic forms of reparation Jacob had escaped from feelings of narcissistic void and worthlessness. In Jana’s case we see a neurotic pathology. The alpha function was present and there was an inner representation of a receptive psychic space, so—sufficient container. But there was an overload of undigested facts (neurotic conflicts). Here too in treatment it was a question of making it possible for her to understand and to feel the loss of the parents-as-couple with its attendant fears and denied psychic pain. To escape these insights and feelings Jana had fled into an Oedipal illusion that she was the true wife of her father and that only she had the power to bring him back. I should like to emphasize here again the importance of involving and of getting through to the father. The significance of the fatherly function and the involvement of the real fathers in interviews with parents is another, crucial topic which I cannot, however, go into any further here (on this, cf. Trowell & Etchegoyen, 2002; Dammasch & Metzger, 2006). Let me say once again that child analysis is not simply an application of psychoanalysis but rather a realization of psychoanalysis, parallel to adult analysis and its peer, the common ground between them being the psychoanalytical method of attaining insight.

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The main concern of this paper is to emphasize and show that in many cases work is needed on the basic prerequisites for learning from experience. It is only when this has been done that psychic change and psychic growth become possible. What counts is not only the interpreting, “uncovering” activity of the analyst but far rather his or her transformation of the patient’s projective identifications. In my understanding the essence and distinguishing feature of psychoanalysis with children, adolescents, and adults is the way the analyst refrains from supposing him or herself in possession of final truth and instead unremittingly pursues the search for sense and truth, well knowing that this will always be fragmentary and incomplete. I should like to close with Freud’s last sentence from “Little Hans”: “For the rest, our young investigator has merely come somewhat early upon the discovery that all knowledge is patchwork and each step forward leaves an unsolved residue behind” (1909b, p. 100).

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CHAPTER THREE

Clinical and technical problems in child and adolescent analysis (following in Bion’s footsteps) Antonino Ferro

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o be capable of “living” the emotions, of experiencing them, is one of the greatest difficulties we humans have if there are deficiencies in mental development. To “live” emotions demands continuous work and this work presupposes the integration of intact apparatus to assimilate, manage, and contain emotions. It is perhaps this aspect that explains my stressing the lack of specific instruments in the equipment of my analytical “kitchen” for using transference. The problem, at least as regards severely ill patients or rather as regards the deeper-seated or archaic states of mind, seems to me to lie in the way emotions are treated and sometimes in their transformation from proto-emotive states to emotional representations. I therefore think of transference less as a neurosis transference with all its vicissitudes, but rather as an all-pervasive state which obliges one to dream the present, continuously to work on internal and external stimuli. I think of an extended concept of transference as a necessity in the human race or in an individual to create stories, to create history out of whatever permeates from the proto-emotive point of view. To create a feuilleton (Luzes, personal communication, 1988) is what 43

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we know best how to do in life, and I believe that the analyst can be regarded as someone who stitches together the fragments of stories. Or he could sometimes be seen as setting the type or again as rearranging the pages into a fresh sequence. This narrative activity, this constant poetic myth-making I believe to be a characteristic of our species as is testified in prehistoric graffiti. This path from graffiti (visual pictograms) to narrative is also the path in which our mind continuously follows. The work of the analyst is also one which can consist in taking apart accumulations of indistinct proto-emotions or split-off aspects and sorting them into simple entities so that they can, once transformed, restructure themselves or create new narratives. What is always present is the risk of transference from analyst to patient. I would call this the danger that the analyst’s mind may create transformations in hallucinosis so that what is “seen” in the patient’s mind is what the analyst projects into him based on his own theory, his own emotional needs, his own narrative urge.

A. Externalizing The proto-emotions can be compared to a stock of tiny “pin-points” (punte di spilla) (I refer here to the sensory perceptions out of which they are blended), that have been processed to different degrees. Even in the best of situations (those in which there are functioning mental structures) these proto-emotions are, however, present in superabundance as can be seen particularly clearly in group phenomena. Without wishing at this point to describe the specific ways these proto-emotive states might be “cooked”, or be amenable to being amalgamated or contained, I would like to offer a few reflections on the extent to which externalization of emotions represents a mental process whether we are patients, analysts, or simply human beings. When one mode of externalization prevails clearly over others we speak of it as a symptom. We can have recourse to mechanisms of evacuation, i.e. the projection of these “pin-points” into the external world, and in this way we find phenomena such as paranoia, hallucinations, forms of delirium, forms of autism. We can evacuate emotions into the body (producing psychosomatic maladies) or into the social body (producing anomalies of character, delinquency, collective stupidity).

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Such proto-emotions can be contained in spaces of the mind if the pressure is not too great (or where there is the capacity for greater containment). Compacted aggregates of proto-emotions form phobia if the strategy is to isolate them, obsession if the strategy is control, hypochondria if the strategy is to exile them to one organ of the body, and so on. Let us look at some operational strategies for externalizing emotions (or rather their undigested precursors) in a number of clinical situations.

B. “Living” the emotions “Living” the emotions (by which I naturally always also mean dreaming dreams and thinking thoughts) is the final point in a series of operations. Sometimes the first step is when a story begins to configure in the mind of the analyst. He then begins to expand it into a scenario in which functions which had previously been split off can come alive at least in the analytical field. The analytical field evokes transferability to a high degree. There is no field here in which transference does not take place.

No gazelle without a tiger: Timidity and persecution Luisa is a pleasant girl with an air of gentleness but seeming a bit lifeless. She is studying literature: detective novels are what she enjoys, particularly those in which the culprit is caught through investigations in the style of Agatha Christie. She has been suffering for years from agoraphobia, social phobia, she cannot bear to be seen in a bathing dress, she always wears two pairs of underpants, and suffers from excessive perspiration; she has a protruding lower jaw. She also suffers from panic attacks. She has a number of obsessive symptoms shown in repeated checking of doors and windows from a dread of the intrusion of strangers. She has cleanliness rituals consisting of numerous baths and showers every day, she washes her hair daily and uses deodorants constantly. For preference she eats a vegetarian diet, never “meat on the bone or innards”. At night she always has to sleep alone “because she fears that her mouth may open in a strange way”. There are sufficient elements here to lead me to think of the existence of a split-off part of herself which I imagine as a panther,

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tiger, or wolf. I am reminded of the film La Donna Tigre, and then of Verga’s novella The She-wolf. From what I have heard it seems to me that I can already form a hypothesis: Luisa is persecuted by the split-off part of herself, or rather by the emotions which have concentrated in the split-off part. This part returns in the image of a ferocious wild beast, where the emotions cannot be controlled. Luisa fears that this “secret” of hers may be exposed and this explains the frequent showers, the washing that cleanses her of the emotions continually re-forming in her. But to ban these emotions to the outdoors is just as dangerous and threatening since the emotions which are dispersed, splashed into the outer world spread information about her and pollute the outside world and take on “tigerish” characteristics. The gazelle has to keep running to flee from the tiger: she does this through her search to appear perfect, but how she sweats! I can hardly believe my ears when I hear that Luisa has found a boyfriend who, although she likes him, creates a number of problems for her: “Leo”! At this point Poirot might well consider himself fortunate: the case, at least in cognitive terms is solved: but how to start on the subsequent work? To undo the threads of which Leo is woven and weave in the threads of which Luisa is made? In Luisa’s account of Leo he has a puppy with little pointed teeth that she is learning to trust and she is losing her fear of him. Here I will stop my account, but the work with Luisa will consist in being able to integrate the genetic inheritance of the gazelle with the genetic inheritance of the lioness. This could be done by introducing a Darix Togni (director of the traditional Italian circus Il Florilegioden) function into the analytic field. What is needed is the introjection of an analytical function capable of transforming the jungle emotions which terrorize the patient and so enable her to integrate tenderness and passion under the vigilant eye of the “tamer” who will take over the weaving, narrative function of reason.

C. Reflections on the mind Normally one can think of man as a further development of a previous life form and who, thanks to the development of mind, has become capable of harnessing the instinctual and drive aspects that he has in common with the other primates. I maintain with Bion

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a further standpoint: the presence of mind in the human species is a major disturbance factor in the functioning of instinct and drive, which viewed on their own are absolutely intact. It is only if the mind has developed in the best possible way that it can be regarded as fostering and enhancing the maturational process. But in cases in which the mind does not function correctly it has a deregulating effect on fundamental functioning of the drives—that otherwise would have functioned perfectly well. Mind is the best but also the worst attribute of our species; it is a gift of evolution but also a weighty and risky legacy for further evolution. Following Bion’s theories, I have already described (in Ferro, 2004) the potential faultiness of the mind, and the way in which in its capacity and functioning it can interfere with the proper functioning of the body and with the proper functioning of the “social body”, that is society. If it is true that the “functional capacity of the mind” is what marks out our species, this implies a series of consequences of which we are not yet clearly aware. It could be put in another way: if on the evolutionary scale there is a continuity between ourselves and the species that preceded us then there are neither major problems nor are there major caesurae. If, on the other hand, there is a leap, i.e. the sudden emergence of the mental, then we do indeed have something of a specific and special nature, namely the “psyche”. Let us take sexuality as an example: here we can think of it as purely physical sexuality and from this point of view it is easy to define what is heterosexual, male homosexual and female homosexual. This is no longer the case if we regard all sexuality as the way in which one mind pairs with another (Winnicott, 1971b). Seen in this light male homosexuality would—in —represent Contained seeking to pair with Contained, to be subjugated to it or to give it gratification; female homosexuality—in (Container Container)— would represent a relationship of peaceful homogeneity with the proto-emotions remaining split-off. The heterosexual relationship would be represented only by , or Contained uniting in a fertile manner with a Container that allows its development, and also continues to develop in its turn. But this would mean that homosexuality or heterosexuality would be primarily rooted in the way the respective minds functioned. A couple consisting of two men could have a heterosexual mode of functioning

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if their minds paired in a creative way, but could also function homosexually in a male or a female manner. The same would be true of a couple of phenotypically heterosexuals whose mental functioning might be homosexual in a manner, a constant clashing, or fusional manner … and so on. The more significance we accord to the mental element the more effect its cognitive faculty will have—once it has established its dominion. Another consequence of having a mind, as it has already been stressed, is the consciousness—frequently felt as unbearable—of our mortality. Our ignorance and inability to find answers at this moment in evolution merely allows us to ask questions and if the absence of answers cannot be tolerated this leads us to an anaesthetized state, to one of necessary lies as we are reminded in Bion (1970) in his work in defence of liars.

D. Reverie and projective identification There is in my view a constant basic activity of reverie which is the way in which the mind of the analyst continuously holds, metabolizes, and transforms whatever reaches it from the patient in the form of verbal, para-verbal, and non-verbal stimuli. The same reverie operates in the patient in response to every interpretative stimulus issuing or not issuing from the analyst. The aim in the analysis is primarily to develop this capacity for thinking in images (images which remain in a state in which they are not directly recognizable). The access to such images can be indirect through the “derivative narratives” of day-dreaming thought (Bion, 1962; Ferro, 2004). This fundamental activity of reverie is the very heart of our mental life and it is on its functioning or malfunctioning that sanity, disease, or psychic pain depend. The same is true of the existence of a fundamental activity of projective identifications which are the indispensable activating factors for every reverie. There are situations, in which explicit and significant reverie is triggered by optical stimuli, by images seen. This, though, is not exclusively dependent on visual stimuli.

E. Reverie and après coup I listen to the presentation of a clinical case as if the account of the case were preceded by an “I had a dream about this patient”.

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This mode of listening does not differ greatly from that which I adopt in analyses with patients: the beginning of a session always contains an implicit “I dreamt …” on the part of the patient whatever may be the content of the narration. This naturally refers to my work in my “analytical kitchen”, as opposed to in the “analytical restaurant”. In the contact with the patient the interpretative “dish” can be presented in a great variety ways, also—if needed—with the “sauce” of a mulling over of the content narrated. The modulation of an interpretation will depend on how I take in the patient’s responses to every interpretation: in this way we have a series of micro après coups which guide us in further interpretative formulation.

Luigi and reading Luigi is a child with the diagnosis of “severe dyslexia”. He is a restless, hyperactive child, often irrepressible at school. The interview with his parents takes a sudden unexpected turn: the mother talks of having been herself a dyslexic child and then suddenly tells us in high-pitched tones of her “terrible experience with the vice-head of the school where she had been teaching, who had persecuted her, had had it in for her, had made her life impossible without showing the least understanding for her situation. Things had reached such a pitch that she had taken early retirement. The father played all this down saying that he was only preoccupied with things that merit preoccupation, namely their mortgages which he was constantly worried they might not be able to pay. It is clear to me that the minds of both his parents are not open enough to take in thoughts of Luigi and his anxieties. They seem like rooms where there is no calm, like rooms without space or silence but in which whirlwinds continually blow around, disrupting everything. It is as if papers lying on a table came to be whirled around the room in such a way that they could not be read: the only emotions that can be read and recognized are the sense of persecution in the mother and the father’s fear of a catastrophe. The alphabet the parents are using seems to be made up of two different kinds of letters, impeding every emotional reading of life around them. Consequently it is only in hyperkinesia and restlessness that Luigi can evacuate his mental states as he is not in a position to read them. If one cannot “read” one’s own mental states then one finds oneself in a kind of fog which renders all signs, all letters, all alphabets

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indistinguishable. First the alphabet of the emotions must be learnt and then the cognitive alphabet, at least where the latter is based on the former. The sessions, too, show a characteristic tendency with Luigi: he arrives in a highly unconcentrated state of mind, moving around non-stop, then he calms down and “organizes” himself in the main part of the session (when the analyst begins to “read” for him the emotional states of the persons in his game and constructs a sort of emotional syntax in progressively facing the most complex links between the emotions). Finally at the end of the session he becomes increasingly unconcentrated. If we take a typical session, to begin with Luigi smears an incredible number of sheets of paper with every colour there. Then some figures begin to appear—little by little the analyst intervenes, containing Luigi’s anxiety. A “face” begins to take shape, of which the analyst says, “The person seems angry, but also frightened and desperate.” Then Luigi draws a boat, a little man, and the sea. The analyst proposes reading the pictures as a sequence: “This is perhaps the face of a man in the sea, maybe the man has been thrown into the sea and he’s frightened because he’s afraid of drowning.” The analyst stays with the manifest text when he creates links and connections, in reading what he sees. He refrains from making a premature reading of the transference aspect, such as “When we don’t stay together I feel you sinking into a sea of anguish and you are desperate,” (for this would be the equivalent of making a child study logarithms in the reception class at primary school). Luigi continues to draw and tells the story of an excursion in a boat with his parents. He talks of how threatening the great waves were, and of his fear that the boat might capsize and then one would need life belts and lifeboats. In terms of emotion Luigi’s response is logical and coherent. The session proceeds with a narrative co-construction always based on a text relating to boats, ferries, dangerous crossings, huge waves, the risk of shipwreck—all of which are exact descriptions of the emotions “lived” in the consulting room. Towards the end of the session Luigi draws sea storms, the game becomes faster-moving, he speaks of pirates “who don’t obey laws”, and from that moment on it becomes impossible to read the emotions present in the narrative and in his playing which becomes only turbulent evacuation. Two sessions continued in this form, and the link so important for survival which had established itself between Luigi and his analyst

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became more and more evident until it finally seemed appropriate to send out the “lifeboats” at least three times a week.

The Minotaur in petrified tree form Nicolo is a seven-year-old child whose parents bring him to therapy to be treated for selective mutism and inhibited behaviour at school. He suddenly clams up at home, even with close family members, and he seems at these moments to be severely “blocked”. His father appears manic while his mother is “lifeless”, depressive. After one fairly easy-going session, Nicolo suddenly started to speak again at school with, however, very guttural, ugly sounds: as the parents said, it sounded like a sort of “strangled bellowing”. In the first picture he drew (fig. 1) there seems to be a sort of tennis match of one against two players, where the second opponent is in fact invisible. Commenting on the second picture (fig. 2), he says, “When I look in the mirror I always have the impression I am seeing someone else.” The Doppelgänger theme appears straight away, a double who is “dumbstruck”, “condemned to silence”, “immobilized”.

Figure 1.

Figure 2.

The third drawing (fig. 3), made several months later, shows a robot inside which there is a little child. The fourth drawing (fig. 4), made some months later still, shows a world lacking any ground or support; there is no ground on which buildings or houses could stand; people walk in the air. There is only a little road which seems to allow small cars to travel in both directions (is this something which is beginning to be exchanged in therapy: the flow of projective identifications with a receptive analyst?).

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Figure 4. Figure 3. The tale related during the consultation, more fluently now, reveals two classmates: to the right is Matteo, “top of the class”, irreproachable, but who from time to time has sudden fits of crying. To the left is Alessandro, the class “tough guy” (“bullo” in Italian) who is irrepressible, unmanageable and who destroys everything whether objects or relations with his classmates and the teachers. While talking about Alessandro, Nicolo suddenly says, “I’m afraid of clamming up again,” and he makes a drawing (fig. 5)

Figure 5. in which you can see, at the bottom, a child with a tree-like structure above it branching out in profusion. It is then that I associate the tough guy Alessandro (the bull) with the strangled groanings and bellowings and I “see” in the upper part of the picture the bullhalf of the Minotaur as it were “petrified” in wood. I see Nicolo clearly as part child, part bull, or at least that is how I tell myself the story of his world: a world in which he has not been able to find containment or any support and where he has remained suspended in the air; an experience which has forced him to immobilize those

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parts of himself he cannot contain in wood. The symptoms of mutism and inhibition correspond to this blockade, this lignifying, just as circus animals freeze, suspended in action in the absence of the ring master. What is required above all, I feel, is to reactivate the image-creating, poetic containing function of the “lion tamer” to make the whole circus come to life again. Next came sessions when Nicolo told how he had drawn “a dangerous ocean with lots of fish on the sea bed”, then one day a drawing appeared (fig. 6) in which he is firing a rifle protected by a big tree (just like the branching tree of the Minotaur), and from that day onwards he began to talk more freely and his behaviour became more “explosive”. Strong feelings emerge and he becomes very attached to his school friends and especially to a girl he meets in karate lessons. The final drawing (fig. 7) reveals the painful side concealed behind Nicolo’s earlier rigidly wooden or explosive behaviour. It is not easy to follow the

Figure 6.

Figure 7.

progress from inhibition to recovery of contact and to the containment of emotions, or to see it reeled off like a filmed sequence. In his pictures and story-telling we can observe how the cast of players is chosen to act out exactly what needs to be staged and told at that moment. Normally and in other situations, we may only have a few “stills” from a story, e.g., those of patients who “talk about something else”, patients who replace mutism with meaningless talk.

Luca’s inner turbulence Luca is in therapy as a child who is totally incontinent, at home, at school, or in the street. He suffers from encopresis and is prone to

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sudden vomiting. He shows alternating periods of constipation and mutism. The dynamics of these swings from incontinence to hypercontinence and back are instantly obvious: the father is violent and often caught up in brawls; the mother, abandoned by her parents, was brought up by nuns in a convent. These two threads, violence breaking out and enclosure in a convent, appear to be acted out in Luca’s behaviour. Arriving for therapy, he seems captivated by the toys: he fills a lorry with heaps of Lego till it topples over, which straightaway brings on stage the theme of excessive load that cannot be evacuated. Next he moves on to a more physical game of jumping, tumbling, and running about in the room. The game is a sort of hide-and-seek. Evacuation is more or less restrained during the session and he sets about drawing geometric shapes into which he places little bits of paper, crudely cut out. His emotions would appear to have found a place in which they can be contained. He begins the following session by building rails with Lego and then sets about playing with wild animals, after which he says, “Now we’re going to play two warriors at war.” An idea seems to be taking shape; strong emotions find a kind of channel and it is now possible to create a space for play. He then starts making the sounds of explosions, aerial battles, tanks, and guns. After this the game shifts to the jungle where a tiger devours lots of animals till a lion (leone in Italian) comes along and re-establishes law and order. These explosions of emotion, with feelings jostling violently with one another, find a sort of ordered calm in the presence of the analyst/lion, in which the new pope, Leo X (Leone X), confronts the hordes of Ghengis Khan. At this stage, the analyst links up the different elements of the story; the struggle in the jungle starts to take on more structure and begins to show an outline of rules and especially a hint of motivations. The presence of the analyst and the story he tells begin to have an effect and are able to contain all the emotions which up to then had exploded in an uncontrollable fashion. War scenes and stories of the jungle will remain for some time the backdrop of this analysis. In what way would regarding these explosions and battles as explanations of the primal scene have made any sense, I wonder? How many “transformations in hallucinosis” we have carried out (projecting

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our theories into clinical findings—and then “finding evidence” of them there) each time that our common sense, born of simplicity and intuition, is obstructed by an alleged, theoretical knowledge that predicts and saturates all! After several years of therapy, Luca has become able to manage his emotions when they are at a normal level; when emotions are suddenly excited (missing a session or an interpretation which sets off minor emotional tsunamis), Luca once again shows signs of incontinence which make him miss sessions or even lead him to accuse the analyst of treating him badly or with violence. I feel that Luca has learned to navigate well enough through calm or reasonably agitated seas but if something triggers those minor emotional tsunamis, he feels “attacked” by the waves and accuses the analyst of engulfing him and “invading” him. Time will tell whether the analytical field offered will be able to provide Luca with the skills he needs to navigate with sufficient mastery even when faced with emotional storms.

Raul’s incontinence Raul is seven and comes for analysis as a result of behavioural problems: at school he bites other children, hits them, then masturbates, and ends up falling down exhausted. In some ways, he is extremely mature, showing striking intellectual ability. He lived first with his grandmother and then with his aunt because his own mother was at an important stage in her career in which she could not have the distraction of caring for a child. As for the father, he was often “absent” on business trips. His mother’s childhood was marked by abuse from her father and from her maternal uncle. Raul suffers from primary enuresis. Variations on the theme of incontinence are played out in a number of scenarios. Raul seems to have a container with many holes in it through which his acting out escapes. The enuresis is an effective metaphor for this incontinence. The is in reality a leaky container, with holes telling of the absence of the mother and the withdrawal of the father. The container is besieged by emotions of such violence and such kinetic energy that they (too) contribute to “piercing” it. At night, Raul often wakes screaming, having dreamed of being attacked by monsters. He is pulled about by emotional states, not

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sufficiently differentiated and which rape and terrorize him. He is as yet unable to “digest” them sufficiently. He also suffers from a number of tics, which are evidence of mechanisms he has at his disposal for evacuation. It is as if he had two modes of functioning and oscillates from one to the other: RAUL ↑↓ UL R A We see here first, one Raul contained—and then another Raul where the elements “R for rage” and “A for abandoned” “fall” outside his ability to control them. Or it is a question of three stages of functioning, if we use what we have heard about the father. The father is either absent, and when present either rigid or obsessive. Right from the beginning of therapy, Raul has played a game where he tries to stop up the holes in the keel of his family’s boat. In dressing, Raul insists on putting on two pairs of socks, as if to show he needs to prevent his acting out escaping, just as he needs to stop his wee escaping. The most significant feature is his persistent late arrival at therapy, becoming a constant over a long period: this gives way to very quiet sessions in which he draws a lot and plays in a calm and disciplined way. He even offers explanations for his behaviour (but at a very high price, that the most turbulent side is left out of the picture). Gradually, more childish and more “incontinent” games appear; he plays cowboys and Indians where the Indians attack the cowboys in their circle of wagons. A nucleus of identity is learning to protect itself against the swirling beta elements which used to well up in a way that could not be contained. Here I have to stop my account of this clinical panorama; I would like to emphasize that in all the cases described above it is possible to form a provisional Gestalt, which can arrange the facts, the experiences, and the personalities into a possible narrative, which in turn offers a “fresh opportunity” of metabolizing what the child could not digest “there and then”. The “here and now” becomes that space or time in which the unthinkable can be thought and where sections where the weft is broken can be rewoven. But even more so—and

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this is the point and purpose of the analysis—this “here and now” will allow the introjection of the function of “spinning yarns”, of “narrating emotions through using memories and personalities”, something which I have called elsewhere the “inner narrator”. As for the analyst, he has to join in creating the stage set by introducing and modulating the characters in the story who often combine in themselves agglomerations of blended emotions, but it is important that it should be the patient who brings in the greater part of the “tangle of narrative threads”. Fundamentally, it is better to stand back a little from this process of facilitation rather than force the direction by introducing story threads which carry with them elements of the analyst’s psychic apparatus, his defences, his theories instead of allowing reverie. In my opinion, Bion’s thoughts have not only extraordinary theoretical and clinical implications (Ogden, 2005; Grotstein, 2007; Ferro, 1999, 2002, 2006, 2008), but a series of technical implications, too. The problem of similarities and differences between child and adult analyses cannot be gone into at this point but has been discussed in detail in Ferro and Basile (2006). If the symptom, the psychic pain, and the illness are a consequence of an excess of beta elements (whether stemming from sensory perception or proto-emotions— beta 1 elements, or from emotive truth and ultimate reality—beta 2 elements), and it has been impossible to transform these through reverie (with the help of the alpha function or dreams), it follows that the aim of the analysis will be to encourage the capacity for digesting-through-dreams which, once it has established itself, enables emotions to be felt, thoughts to be thought, and dreams to be dreamt. The first step, therefore, is one that enables the dream quality of the session to be enhanced. A first tool which has become the heritage of all analysts (since Bion) is reverie. The analyst’s negative capacity constitutes the second instrument: thanks to the non-saturation of his interventions and above all of his mental state the analyst facilitates transformations in dreaming. At the most elementary level, it is as if we could or should precede every communication with the patient with the words: “I had a dream in which …” (on the one hand, this helps us to distance ourselves from external reality and on the other we can enhance the dream quality of the session).

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A patient says: “When I was a little girl, no doubt I was abused by my father who fondled me too intimately.” These words can be “heard as a dream” as something which tells us of an abuse which the patient feels emanating from primitive parts of herself impossible to contain. This is something that tells us that she experiences the analyst as raping her—in that he is suggesting a relation (or a form of interpretation) of an intensity she finds unbearable. The patient’s “response” to every intervention made by the analyst can be “heard” too as the patient’s dreamed response to the analyst’s interpretations. Bion provides us with the theoretical framework within which to express this: the interpretative stimuli are dreamt in real time thanks to the patient’s alpha function and they are communicated through the narrative derivatives. Seeing these responses as a dream allows us not only to adjust our next intervention (the patient becoming at this point our “best working partner”, the person who can give us a clear indication of how the work of analysis is progressing), but it also enables us to increase the dream dimension of the session. If, following an active interpretation the patient begins to talk about a car that was tailgating her on the motorway, it is clear that this reflects the emotional situation in the patient’s “dream”. At this stage, instead of giving an explicit interpretation bearing only one meaning we could offer a non-saturated response. Obviously, it is the patient’s next response that will indicate where we stand. In this way we become the co-authors of a dream which will lead to different settings, to different scenarios, with different casts which we can regard as holograms of the analytic couple. The way the analytical field or the analytical session functions is the instrument that enables the patient to introject this method and ultimately to develop his alpha function and also his (and our) capacity to dream. Bion has led us out of a psychoanalysis of content towards a psychoanalysis of instruments, of tools and apparatus which enable us to dream, metabolize and digest emotional experiences and the impacts of reality. Thus analysis takes up a particular position; in Winnicott’s words we could think of a transitional space or of a game, even if it is very serious. In this way we no longer have historical or narrative truth but we do have a subjective emotional truth, to which we need to come as close as we can on our journey to “O”. This can be done provided we respect the tolerance thresholds of pain and frustration, both in the patient and in ourselves. In this way the analytic field

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“breathes”, in oscillation between “O” and “K”. We ought also to speak of the concept of “field” since it takes us beyond the concept of relationship; it permits a high degree of non-saturation and above all it leads us to emphasize two things: a. the mental functioning/malfunctioning of the analyst in his relation to the patient is just as important in the session as that of the patient b. a third structure is created, which is neither the patient nor the analyst, but is rather born of their encounter inside the setting. Within this field there will, of course, be a forward-driving force and a force opposing it, two equal and opposing forces representing the wish for change and the fear of it. The field also allows the use of new tools such as those linked to non-saturated interpretations, the space to dream in, the play with the characters in the cast, and the expectation of fresh casting to come.

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CHAPTER FOUR

What about the transference? Technical issues in the treatment of children who cannot symbolize Maria Rhode

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hroughout the history of psychoanalysis, the question as to whether any given group of patients could benefit by it has centred on the nature of the transference that those patients developed and on the need for technical modifications. These debates have proved fruitful for theories of mental structure as well as for theories of technique. Child analysis was perhaps the most important early example of the widened scope of psychoanalysis, along with the treatment of psychotic patients. Work with children has of course itself been greatly extended in the past 30 years, so that the “normal neurotic” child hardly figures in our practice, certainly not in the public sector. Instead, we see traumatized, abused and refugee children, children in foster care, children on the oncology ward, psychotic or borderline children, or those with autism or with serious developmental delay and learning impairment. All these children tend to be overwhelmed by primitive anxieties concerning physical and psychic survival. Because of this, they resort to extreme measures to protect themselves, and they may experience a therapeutic approach as an additional threat. My aim in this chapter is to consider a number of technical issues that arise in work with children whose capacity for symbolization 61

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is impaired, for whatever reason. This impairment obviously affects their ability to play, as well as their capacity to speak and to make use of spoken interpretations. It also has important implications for the handling of the transference. The transference is, after all, a symbolic area of experience: we relate to our analyst as though he or she were a parental figure. However authentic the emotional experience, there remains the capacity to think about it: with one part of our mind, we can engage with our analyst who is acknowledged as being separate from us, in order to understand the experience of another part of our mind. This capacity to enter into a triangular relationship, to take up what Britton (1989) calls the third position, is at best rudimentary and fleeting in children whose symbolic capacity is incompletely developed. For one reason or another, they have not been in a position to go through the process that, as Hanna Segal (1957) has suggested, provides the foundation for symbol formation: namely, working through ambivalence in relation to another person who is recognized as being separate from themselves. This means that they remain in the realm of symbolic equations as opposed to that of symbolism proper. In this realm, there is a failure fully to distinguish the symbol from the object symbolized, self from other, internal from external reality. Separateness is experienced as catastrophic to self and other, so that differences are smoothed over and similarities are exaggerated. The quality of “pastness”, which, as Freud (1895d) pointed out, is essential for the patient to recognize in order to stop suffering from reminiscences, easily becomes blurred, so that memories can take on the terrifying quality of flashbacks. All this means that a child with problems in symbolizing is unlikely to be able to benefit from conventional transference interpretations. In order to establish an emotional connection, and express what we have in mind in a way that the child may find helpful, we will have to modify our conventional technique. I think it is essential, however, to be clear that such modifications are only a step, however necessary, on the road towards the more conventional kind of work that becomes possible once the child’s symbolic capacity has developed. Ultimately, we are working towards a situation where verbal interpretation of the positive and negative transference will become possible and sufficient. In this, I find myself very much in agreement with Michael Günter’s position with regard to the Squiggle game: an invaluable technical device that can allow us to establish

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therapeutic contact in cases where this might not be possible by verbal means alone, but which, we hope, will lead to contact on a verbal level (Günter, 2007). Such a position in fact gives us much greater freedom to experiment with technical variations where that may be necessary, and to distinguish between helpful flexibility, on the one hand, and enactment, on the other. As is well known, Bion (1962) thought that the process of containment led to the generation of alpha elements, which are the building blocks of symbolic activities such as dreaming, thinking, and remembering; and that there were three main components to containment. The first of these is receptivity: the mother or therapist must be open to the emotional communication of the infant or patient. The second is transformation, in the course of which the mother’s or therapist’s unconscious reverie acts on beta elements, “inchoate sense impressions”, to generate alpha elements and meaning. The third is “publication”, by which the result of this transformation is communicated (Mitrani, 2001). Different aspects of the male and female functions of the therapist interact at all stages of this process. While receptivity may be seen as stereotypically female and publication as stereotypically male, Bion emphasized the central role of the mother’s love for her baby’s father in the process of unconscious reverie that makes transformation possible. We could therefore think of a helpful technique as embodying the situation in which the child, or patient, can be helped to integrate aspects of his personality within the framework of an Oedipal couple whose separate and complementary functions he can learn to tolerate and identify with. The setting will ideally contribute to the process of containment both by virtue of the limits it presents and by virtue of the support it provides to the therapist. It is hard to provide a sense of stability, let alone to think, if one is rushing around the room trying to protect too many shared toys from being thrown out of the window. Within such a setting, and supported by her relationship with her own internal objects, the therapist will strive towards the right Oedipal balance, in which the child’s experience of her receptivity makes an interpretation—the masculine function of “publication”—feel like a source of strength, not like a hostile invasion or projection. I agree with Moustaki’s (1994) formulation that anything serving to support the right position of the patient vis-à-vis the therapist-as-a-couple may be regarded as

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an interpretation, whether it is delivered through the medium of words or the medium of actions. In contrast, anything that disrupts this Oedipal balance could be viewed as action, or enactment, even if it is mediated by words. After all, physical containment or holding is the natural means of communication with babies and small children. Conversely, we can all think of times when we have used words to relieve our own feelings, even if what we said seemed to possess all the formal characteristics of an interpretation. The two groups of children with impaired symbolic capacity on whom I wish to focus are children on the autistic spectrum and children whose behaviour suggests borderline psychosis. I would like to highlight two main contrasts between these two groups, and to suggest that they have important implications for technique. The first contrast concerns the question of the child’s distance from the Oedipal couple whom the therapist represents. Very schematically, one could say that the autistic children are too far away— Frances Tustin (1981) used to call them “shutters-out”—and need the therapist’s help in bridging the distance that Donna Williams (1992) called the “death gap”. Borderline children, on the other hand, are “drawers-in” (Tustin, 1981): they relate in a way that obliterates distinctions, whether between self and other, between different aspects of their own personality, or between the symbol and the thing symbolized. There is the additional complication that autistic defences are often deployed against psychotic anxieties (Rhode, 2002), but this falls beyond the scope of this chapter. The second contrast is related to the first: it concerns the way these different groups of children relate to bodily experience. Children with autism, as is well known, use self-generated bodily sensations as a means of encapsulation, to cut themselves off from other people (Tustin, 1981). This means that some forms of bodily contact have long been recognized as a necessary way of attracting their attention (e.g., Meltzer, 1975); and indeed it may also be necessary in relation to anomalies of their body image (Haag et al., 2005). Frances Tustin (1981), for example, describes holding an autistic child’s flapping hands at the same time as interpreting, “Tustin can hold the upset”. In contrast, psychotic and borderline children, in my experience, often become over-aroused even by verbal contact, which can feel to them as though it were physical and erotized. As many workers have noted, interpreting an impulse can seem to

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have the effect of strengthening it, so that the child appears to be taken over by it and swept up into acting it out (see, for instance, Kut Rosenfeld & Sprince, 1965). This means that the therapist working with such children will need to rely even more than is usually the case on the physical and temporal boundaries provided by the setting.

An unhelpful transference interpretation I would like to begin with a vignette of a transference interpretation that went wrong. During the first assessment session, when he was alone with me after some sessions together with his mother, I had been pleasantly surprised by the symbolic capacities displayed by Charles, a nine-year-old boy with autism, who played communicatively with dolls inside the dolls’ house. Then he switched to using the ball: rolling it in my direction so that I could roll it back, then rolling it under the chairs and tables and crawling underneath them to retrieve it. Several times he brought it close to me, and then moved away again. All this time I described what the ball was doing—exploring different places in this new room, coming close to the lady and going away again, moving back and forth between Charles and me. Eventually he wedged the ball between the wall and a central heating pipe that ran along it, made sure he could get it out again, then put it back with every appearance of pleasure. I said first that the ball seemed to have been looking for a nice, warm place to be, but that it was important to be sure it wouldn’t get stuck there. This seemed to make sense to Charles, who continued to play at lodging the ball between the wall and the pipe and taking it out again. Then I made a mistake: I said it was important for Charles to feel that he could get close to me and wouldn’t get stuck. In spite of my phrasing this carefully, he dissolved in panic, screaming and crying in terror. Nothing I said could keep him in the room, though possibly, if I had provided a humming-top, we might have managed without needing to find Charles’ mother. I can only suppose that Charles’ symbolic capacity broke down when I made the transference interpretation: that referring to him and myself, without mentioning the ball, made him feel that what Britton (1989) calls the triangular space necessary for reflection and thought had collapsed. When this happens, any “pretend” element gets lost, and feelings

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become statements of fact. Charles needed the ball as a third object: it was not sufficient for him that, as Alvarez (2000) has stressed, I had been careful to focus on what he needed, not on what he was afraid of. I shall return shortly to the importance of this phenomenon for children with autism.

Establishing contact: Bridging the gap or establishing distance The processes involved in establishing contact with a child will be different according to whether the child’s predominant anxieties and defences are psychotic, autistic, or borderline. In each case, though for different reasons, interpretations about the child’s feelings are often insufficient and sometimes unhelpful. The most important aim, I believe, is to establish the presence of an observing function—the therapist’s—that is focused on what is happening within the room, no matter in which member of Ferro’s bi-personal field (1999) the experience may at any point appear to be located. This is the line of thought that led Bion to emphasize the importance of “it” interpretations (“It feels so sad”, for example, rather than “You are feeling sad” or even “You need me to understand how sad you feel”). Again, a premature transference interpretation is avoided (Blake, 2001). With children on the autistic spectrum, the first task is to establish a shared frame of reference: to find a way of bridging the distance between child and therapist. This may involve interpreting in the countertransference, though this is often more difficult than it is with children who can symbolize. This is because the countertransference may manifest itself as a bodily experience; even when it is a feeling, it may be harder to clarify its specific quality. It often takes a long time to recognize it as a communication (of despair, for example) rather than a realistic view of the situation. Mostly, in my experience, interpreting in the countertransference and describing the child’s behaviour are both essential, but they are often not enough to establish contact at the beginning of treatment.

Bridges: Toys and stories While such verbal interventions could be understood as an expression of the therapist’s receptive, feminine function, I would agree with Didier Houzel (2001) that the therapist’s active drawing the

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child into contact—Alvarez’s “reclamation” (1980)—is an expression of masculinity. Taking the initiative in this way is made easier through the use of appropriate toys. It can be very useful to provide toys that are particularly relevant to areas of anxiety that characterize an individual child or a particular group of children. For example, ever since a boy with autism made creative use of the tiny mirror on a piece of dolls’ house furniture, I have made a point of providing a hand-held mirror when I see children for whom existential anxieties are important, and whose need for mastery makes it difficult for them to rely on the therapist’s mirroring function. For children without speech, I have found a transparent, musical humming-top that contains small animals particularly useful: the structure of the toy makes it possible to address the phantasy that the therapist’s words and voice are a function of figures that live inside her. I would understand this in terms of Bion’s idea (1957) that patients whose own capacity for symbol-formation is undeveloped have to wait, sometimes for years, until the outside world presents them with an ideograph that is capable of embodying the issue that concerns them. Sometimes it can be fruitful, where possible, to provide a toy that links to a specific reference a child has made, by means of a song for example. Children’s references to songs and fairy-tales, as we know, are not in any way arbitrary or meaningless. In contrast to the way one might handle this with a neurotic child, where the aim is to elucidate each individual child’s response to a given fairy-tale, I believe that it is important in treating a child on the autistic spectrum to show that one is familiar with the songs, nursery rhymes, and television programmes that are a part of everyone’s cultural experience. (With a borderline child, this generally just heightens the confusion between self and other). The fact that both child and therapist can attend to a toy, song, or story— that it is not the exclusive property of one person only—helps to modify the dangerous world of predators (Tustin, 1986) inhabited by children on the autistic spectrum, in which either everything belongs to them or they feel that everything has been torn away. (Later, once this necessary foundation has been established, the therapist can go on to differentiate between this kind of universally shared knowledge and those television programmes that the therapist could not be expected to know about unless she happened to be present when the child watched them: but this recognition of difference requires a background of shared reference to make it manageable).

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For example, Anthony, a child with fairly severe autism, spent most of his assessment sessions oscillating between being the Giant from Jack and the Beanstalk and a helpless, terrified victim. Over and over again he fell off the desk, struggling to reach the safety of a chair: he held onto the drawstring of his trousers, as though that could keep him safe, and his mouth was twisted into a tortured shape. Even when he stood high above me on the desk, growling “Fee, Fie, Fo, Fum” in the Giant’s threatening voice, I had to be careful to make sure he did not fall. It was understandable that a child for whom falling and being dropped presented such a catastrophic threat should blank out anything—including my role as an adult— that could undermine his position as an all-powerful Giant. One day, however, Anthony hummed fragments of the theme song for Postman Pat, a cartoon programme on children’s television.1 The words soon faded out into incomprehensibility, but still aroused powerful feelings in me. The last line of the song is “Postman Pat’s a very happy man”; and, although Anthony did not sing the words, what he did sing conveyed a yearning for the sense of order and simplicity and happiness in everyday events which, at their best, children’s television programmes can conjure up. Of course there was no way of knowing whether this was a tentative communication, or simply associations of my own; and when I spoke about Postman Pat, Anthony completely ignored me in a way that crushed hope. By chance, some time later, I came across a little toy van with Postman Pat and his cat, and I decided to add it to Anthony’s toy box. He gave no sign of noticing it; he did not even sing about Postman Pat anymore, so there was no opportunity to link the toy to the song. I felt I might as well not have bothered. But whether it was accumulated disappointment and exasperation when for the hundredth time he tipped out the contents of his box as though it were rubbish, or an obscure feeling that the brutal, contemptuous Giant needed standing up to, I found myself not talking in the way I normally did about how the toys should get out of the way; what rubbish they were; what rubbish I was; how powerful the Giant was. “Look,” I said to Anthony, “here’s Postman Pat. You used to sing a song about him, do you remember?”—and I sang some of the song before talking about Postman Pat who was a happy man, and how much perhaps Anthony wanted to be that himself, one day. Anthony

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came over to me, looked at the Postman Pat toy, and began to play with it, pushing it along the desk. I wondered aloud where Postman Pat was going with his black and white cat; whom he was delivering letters and parcels to. The moment did not last long. Anthony soon moved back to the familiar position of being the Giant, standing high above me on the table. It would not even really be accurate to say that this had been a moment of shared attention; but it had been a moment in which the two of us had paid attention to the same thing, and it was brought about by an assertive action on my part, not by a containing comment. The next shared moment was also mediated by a song, and was just that bit easier: I did not have to provide a concrete realization of something Anthony had been referring to, or to assert myself and my viewpoint. The song was Pat-a-Cake, and developed into a pattern whereby Anthony would sing about the cake, “and put it in the oven for Baby and me”, or later, “for Mr Rhode and me”, while my role was always to sing, “and put it in the oven for Anthony and me”. This became an important point of reference for Anthony, so that, when he was at his worst and most unreachable, it was often enough to ask, “Do you want to sing Pat-a-Cake?” to re-establish contact. Clearly he would not have been receptive at such moments to a complicated verbal interpretation about the possibility of retaining a place of his own without being pushed out by a father or sibling, or pushing them out himself. These two vignettes illustrate the usefulness of toys and shared references in establishing a helpful Oedipal balance for a child on the autistic spectrum. Not surprisingly, the technique that contemporary Freudians have called “interpretation in displacement” can be particularly helpful: it involves elaborating on the emotions that a character in a play scenario or a story might be experiencing. Echo Fling (2000), the mother of a boy with Asperger’s syndrome, describes her amazement at discovering that her son could give a detailed account of everything that had happened at school once she introduced a toy puppet: something he had never been able to do in a one-to-one situation with her. This of course links with the example of Charles’ need for his ball. I have the impression that many therapists sense intuitively what a child with autism can tolerate in respect of a “you-and-me” situation, and that, accordingly, they may sometimes address the child as “you”, and at other times use the

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third person as though they were a parent talking about him to the other member of the Oedipal couple. It is also interesting to think about the point at which it is helpful to move out of interpretations in displacement, as well as about the point at which a shared story stops being helpfully imaginative and becomes something that needs to be limited. For example, a girl with Asperger’s syndrome obsessively drew pictures of the characters in a cartoon series, both in her sessions with me and elsewhere. She responded with great interest and involvement when I elaborated on the emotions that the characters might have felt, and it was clear that she was changing the actual storyline in ways that helpfully communicated her own preoccupations. The habit of obsessive drawing, which was something that she could turn to anywhere and at any time, seemed to be providing a necessary safety net, so that she could risk thinking about feelings. However, when, at length, she told me that the character with whom she was particularly identified was able to speak but chose not to, this seemed to me to indicate that she was herself choosing to do less than she was capable of. Her incessant drawing, which had previously served to support her capacity to communicate, was now getting in the way of her development, since she was using it in order to blur the difference between times when we were together and times when we were apart. When I explained why I would no longer allow her to draw in the sessions, she attacked me physically in ways that she had previously alluded to as occurring in the cartoon series. Though of course it is essential to question one’s own motivation in such situations, subsequent developments strengthened my belief that this opportunity for containment on a physical level was important, and helped her to take a step forward in relating to me as a separate person. Indeed, my own view is that this stage of physical containment forms an essential part of work with autistic and borderline children, and that it cannot be missed out if improvements are to be consolidated. Turning now to borderline or psychotic children, I would suggest that the immediate task is not so much to establish a bridge as to create a safe setting. One boy I heard about recently, who systematically attacked everything in the room, became even more destructive when his therapist interpreted that he was angry with her. One could understand this as an example of the familiar pattern

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by which addressing an impulse—particularly a destructive one—in a borderline child seems to confer added strength on that part of the personality (see Kut Rosenfeld & Sprince, 1965). But one could equally understand it as the desperate heightening of a communication that had not been recognized and addressed the first time—in this case, a communication of what it felt like to be invaded by concrete projections of chaos. When the therapist interpreted how important it was to feel that she could keep the child, herself, and the room safe, he began to settle down, though naturally this point had to be re-worked over and over again. But she was surprised by the amount of cooperation and reflectiveness that another part of his personality was capable of, and by the degree to which it soon became possible to link the irruptions of chaos to the end of sessions and to breaks between them. Caspar, an eight-year-old borderline patient of my own, was referred for consistently making family life impossible and for not being able to use his intelligence at school. At the very beginning of treatment, he communicated by means of drawing, and seemed both surprised and touched when I suggested that perhaps the heavily armed soldiers he drew in front of a castle needed their weapons in order to feel safe. Very soon, however, he stopped drawing, and instead systematically set about discovering every weakness in the room, in the rest of the setting, and in my state of mind. He tore blinds off the window, pulled electric wires off the wall, smeared faeces around the lavatory, and blocked it with too much paper. He did his best to make me feel soiled in other ways as well, trying to get his hand under my overall even though I always wore trousers, while he talked about “women’s secrets” with a perversely ecstatic expression on his face. If a safe castle had been available, I would happily have taken refuge in it. As for Caspar, he seemed to be ensconced behind unbreachable fortifications. For a long time, words did not get through to him at all, except when I talked about the despair and disappointment I was supposed to feel whenever his attacks started up again after a few minutes of relative calm. “That’s right,” he would reply with a laugh, “you’re supposed to feel like crying.” What did get through to him, finally, was the discovery that I would prevent him from destroying the room. I removed toys and furniture, clarifying that this was to keep them—and us—safe, and that they could return later. I explained to his mother that for a while

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I would need her to work with me by waiting in the car outside, so that there was somewhere to take him for a few minutes’ breathing space if he looked like getting stuck in a mad, destructive spiral. At the same time, I conveyed the importance of not telling him off for behaving “badly”, since we were attempting to create a setting that could withstand the worst he could do. Very gradually, he began to feel safer. This, I think, came about through a variety of factors, including the robustness of the setting, the example of cooperation between his mother and me, and countertransference interpretations of my feelings of helplessness and despair that made it clear that this communication was being received. He began to be able to show some of his vulnerability, as well as his own experience of not being able to get through emotionally. He would enact banging his head against the wall and falling over, or huddling on the mattress under the blankets, like a tiny creature hiding from enemies and unable to move. In line with his growing appreciation of a setting that endured, he began to use the lavatory appropriately instead of interfering with its proper function. When it began to be possible to describe his own behaviour instead of limiting myself to interpreting the despair he conveyed to me, I found it useful to say, for instance, “You are showing me someone who wants to stop us working together”, rather than “You want to stop me working”. This seems to me important for a number of reasons. It acknowledges that there is a constructive aspect to the child’s personality as well as a destructive one; it shows that the therapist continues to remember and to speak to the constructive aspect; and it avoids pushing the child further into an unhelpful identification with the destructive part. Like the other apparently borderline child I referred to, Caspar turned out to have been traumatized by systematic physical abuse by his father. I would understand his behaviour as an attempt to test out whether his own aggression, stimulated perhaps by a cruel experience of helplessness which he seemed to associate with being excluded from the Oedipal couple, was in fact so powerful that it got into his father and was responsible for his violent behaviour. In this way, the physical abuse led to a spiralling confusion between self and other, good and bad, from which the child despaired of escaping and that was compounded by erotization. Interpretations in the countertransference of helplessness and despair, which for a long

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time were the only ones that he did not block out, were presumably experienced as a sign that a receptive, “feminine” aspect of me was open to his communications. In contrast to the situation with autistic children, where the active, masculine aspect of the therapist (what Alvarez has called reclamation) is devoted to bringing the child into contact, the masculine aspect of the therapist working with borderline children supports the recognition of differences. Anything to do with the masculine, boundarysetting function needed to be achieved by means of the setting: Caspar seemed to experience any verbally-expressed firmness as a physical manifestation of a powerful and cruel sexual father, and this instantly fed his identification with the aggressor. In contrast, the more impersonal boundary-enforcing aspect of the setting allows a borderline child to test out whether his impulses can be managed. In this way, it supports the recognition of differences—between self and other, between internal and external reality, and between parts of the self. It is an obvious point that interpretations of the need for a safe setting will not be useful unless a safe setting can actually be provided, and that a child like this will need to witness actual cooperation in his interests between his parents and his therapist, not just to receive interpretations about a helpful parental couple. Equally obviously, in view of the pervasive erotization, it would be more than unhelpful to make use of one’s own body in ways that might be useful with an autistic child.

Some grammatical and non-verbal aspects of interpretation Finally, I would like to offer some very brief remarks on phrasing interpretations, as well as on some non-verbal interventions. First of all, in contrast to our practice with neurotic children, I think it is important not to present oneself as a reflecting surface: not to use a verbal child’s own words in an interpretation. Both autistic and borderline children need to feel that there is another person who is different from themselves and whom they can come up against. I find it much more helpful to make it explicit that the child is showing me something, or making me think of something: this has the additional advantage that it emphasizes that the child has the power to have an effect on a separate person. Secondly, I have already referred to Alvarez’ point (1992) that it is dangerous to talk about a child’s fears, since he will take us to be

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stating that they are facts. This is a feature of any patient who cannot manage the difference between self and other. In borderline and psychotic children, it is a function of excessive projective identification, as in the adult schizophrenics whom Rosenfeld (1952) describes. In children with autism, it is a function of the adhesive identification that is so characteristic of the condition (Meltzer, 1974). Either way, it needs to become second nature to be careful with phrasing: to say, “You need to be sure something won’t happen” rather than “You’re afraid something will”. As the example of Charles illustrates, however, this is often not enough. Non-verbal components of speech have an important role to play: the use of musical motherese, of the voice to perform the function that Stern (1985) calls affect attunement, as in a descending A-a-a-a-ah, that levels out, to convey the experience of falling in a controlled way and coming to rest. This can be an effective intervention with a child who could not listen to the same idea expressed verbally. Equally, imitating the child’s actions, singing body-image songs, playing rhythmical tapping games, and so on, can make it possible to link with autistic children when words cannot. Like physical contact, however, I have generally found this kind of intervention to be both unnecessary and counterproductive with borderline children. Attempting to theorize our technical practice is both essential and endlessly fascinating. The contrasts I have emphasized for the purpose of this discussion are of course exaggerated and schematic: some children, whose anxieties and coping devices fluctuate, will require the therapist to change tack many times within a single session, while others may move in the course of treatment from being “shutters out” to being “drawers in” (Rhode, 2002). In this chapter I have touched on a few areas only, which I hope may serve as a basis for further reflection.

Note 1. This material has previously been discussed in another context (Rhode, 2001), and is reproduced by kind permission of Taylor & Francis.

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CHAPTER FIVE

Identity and bisexuality: thoughts on technique from the analysis of an adolescent girl Helga Kremp-Ottenheym

Introduction “I always wanted to be like my brother. I looked up to him and did everything the way he did it. When I was 12 I discovered that this wouldn’t work for me as a girl. I lost the ground under my feet. I no longer knew what I was supposed to be.” These are statements an 18-year-old patient made a few weeks after she had begun her treatment with me. In saying this she was recalling the time of her puberty which was when the problems that led her to me had first arisen. She came to me shortly before taking her final school exams and told me of her painful sense of failure which she saw as, above all, connected with her body, how it felt to her and how she perceived it. At 14 she had discovered that she was too fat. She felt she was not attractive enough to be able to find a boyfriend. The failure of a number of attempts to establish relationships through sexual experience, which she initiated herself and which were accompanied by feelings of despair and fear, served to confirm what she had expected, namely that no-one would like her. Full of self-hatred and contempt for her body and desperately unhappy about her situation, she felt condemned to remain alone for the 75

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rest of her life, describing vividly how she felt she had failed in the central task of adolescence: in the words of Blos she had not managed to achieve “the heterosexual object finding, made possible by the abandonment of the narcissistic and bisexual positions” (1962, p. 87). This means that many patients who seek treatment in their late or post-adolescence have not been able to find a satisfying solution to the conflicts around bisexuality. The insoluble conflicts over the choice of sexual object are preceded by a failure to integrate bisexual urges or tendencies (Blos, 1962).

On bisexuality in female adolescence Sexual identity and the corresponding choice of sexual object are determined by biologically and physiologically founded bisexuality. As Freud wrote, in a footnote to the paper “The Transformations of Puberty”, on the observation of existing masculine and feminine individuals: “Such observation shows that in human beings pure masculinity or femininity is not to be found either in a psychological or biological sense” (1905d, pp. 219–220, footnote 1). How a person’s biological, sexual, given form is finally shaped is thus dependent on what happens to identifications in the course of development and in particular to identifications in the context of the positive and negative Oedipus complex. The engagement with father and mother that results—irrespective of what final choice of sexual object it leads to—is only possible because the child is able to identify with both male and female (Reiche, 2000, p. 20). The preceding pre-genital, early experiences with dependency provide the background to the Oedipal drama. The child loves and hates father and mother, it wishes to be father and mother but it also wishes to win against them and detach itself from them. To be able to identify bisexually therefore means engaging with father and mother as significant objects. Adolescence is seen as the time in which all these experiences and the feelings associated with them are reactivated and dramatized in the now adult sexual body. Already before puberty, in pre-puberty, a girl enters this process of development with a surge of activity termed the expression of bisexuality. It is, as it were, with a mobilization of her powers that a girl reacts to the hormonal and body changes which are just starting and though, not as yet visible, are already unsettling. “The girl’s

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‘thrust of activity’… constitutes an attempt to master actively what she has experienced passively while in the care of the nurturing mother; instead of taking the pre-Oedipal mother as love object, the girl identifies temporarily with her active phallic image” (Blos, 1962, p. 70). The identification with the phallic mother is an expression of love for her and at the same time a defence against this love. In drawing close to the mother a girl secures her own competence and unassailability while neediness and the experience of dependency recede. “The girl’s transient phallic illusion gives this period an exalted vital tenor which does not lack a danger of fixation” (Blos, 1962, p. 70). Such a danger does exist if the identification with the power of the pre-Oedipal mother is made to serve as defence against the longing to love and be loved, early desires for physical closeness and care, and/or early disappointment, in other words when in this identificatory acquisition of strength the act of wishing itself has to be suppressed. The active little girl, the little Amazon of pre-adolescence, “by a decisive turn to reality” (Blos, 1962, p. 67) expresses, develops, and strengthens her phallic qualities. With the onset of the physical changes of puberty she is confronted with the task of combining her active strengths with the physical changes themselves and her developing femaleness. With physical development progressing “the girl is equally pushed toward the development of her femininity” (Blos, 1962, p. 74). The fact of being at the mercy of these physical changes revives the earliest experiences of dependency on the caring environment, on the caring mother. Harking back to early experience in which the mother was responsible for harmony in the baby’s and young child’s body, the adolescent tries to make the parents or parental substitutes (the analyst in the transference) eliminate the sources of excitation and calm, the fear, aggression, chaos, and insecurity which the sexually mature body create in youngsters. Moses and Egle Laufer term these unconscious ideas and manoeuvres “central masturbation phantasy”, a concept that relates the Oedipal and pre-Oedipal early experiences with the parents of childhood to the physical changes of adolescence (Laufer & Laufer, 1984). Against the background of the revived conflicts around early dependency a girl is torn between male and female elements of identity as also between the active and passive wishes she needs

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to integrate. If she finds no solution to these conflicts as described at the beginning of this paper a breakdown in late adolescence will follow. The necessary integration of male and female elements can only succeed if the girl can ward off the “threat of the pre-Oedipal mother” and the fears of dependency associated with her. Only then can a girl risk taking her mother as a model for her own development towards womanhood and allow her mother to be an available, caring female object. In early adolescence these wishes to orient herself find expression in “crushes” on other women—not the mother. In being drawn to these idealized women the girl develops her image of herself as a woman in the protective shell of a non-sexual, homoerotically tinged relationship. Active and passive tendencies along with the associated ideas and fantasies about her own person can be combined, tried out, and integrated. To sum up, it can be stated that the way relationships are shaped in the context so far outlined takes up three different aspects of the internalized image of the mother: enter the omnipotent, caring, pre-Oedipal mother of the period of early dependency. This image is supplemented and further elaborated with the fantasies and ideas connected with the perception of the difference in the sexes to form the image of the phallic mother. The mother of the Oedipal position then enables a drawing of boundaries and identification, rivalry, and love. The various aspects of the image of the father—father in the mother, father of separation as guarantor of triangulation and Oedipal father—are merely named here. They would have to be examined in a separate paper.

From the treatment 1. The start, the development of the relationship and the breakdown When I saw the patient for the first time I was both impressed and disconcerted: I saw a tall, long-legged young woman with strikingly large breasts; she was not really fat though certainly a little overweight. She had long, blond hair and delicately drawn features. She was wearing jeans and a short, flowered, very fashionable, childlike T-shirt. Her movements were forceful and unbridled and she walked over to her place taking large, decided strides. She spoke in

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a loud voice, forcefully and rapidly, her speech broken by occasional sobs. The patient described her problem: not being able to find a boyfriend. She associated this problem with her body, lack of attractiveness, and being fat. She was afraid she was unlovable, that there was something about her that was not “right”. She was afraid that this fear might be confirmed if she lost her superfluous pounds. If she didn’t have this flaw—being fat—she would have no excuse to herself for not being able to “find a man”. Embedded in these fears was a general anxiety about the future and the fear she might never find her place in the world. In her urgent desire for closeness, in her wish to be noticed and supported she felt rejected by her mother. She thought she would not be able to live up to her mother’s expectations and at the same time felt at her mercy, felt taken over and controlled. The patient began by reporting an illness she had just got over in the course of which she had often been awake at night and would like to have gone to her mother. Her mother however did not allow this. She had taken refuge with her father, who in this way took over a quasi “caring mother” function. She presented herself as a needy little girl in regression who did not feel “held” and accepted and yet had only her parents to turn to. These wishes were linked with the idea that she was not finding the right love, care, and attention she really needed. The refuge her father offered was experienced with great ambivalence. Anger and disappointment and also confusing Oedipal fantasies masked the fundamental desires for a relationship. At the same time the patient was under great inner pressure. Her desire to be loved and the desperate fear—even certainty—that this wish would never be fulfilled led to a kind of driven restlessness in her. In her relationships the patient swayed between masochistic submission and furious protest. Behind these struggles lay the hope of drawing even with her brother one day, of being like him and so gaining her mother’s attention. But these hopes had lost their stabilizing function now she was faced with the reality of her woman’s body. Her position as the eldest daughter, as a girl, as a woman, was marked with all possible disadvantages and weaknesses in her imagination. Being a girl and discovering she had a female body was moreover connected for her with traumatic experiences with this body in childhood: between the ages of two and six she had had several severe accidents which had involved lengthy treatment.

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She experienced her development as a broken line: she found she could not rely on her body; she could not risk trusting herself to her body; nothing simply worked of its own accord. At the same time, with these accidents she had forced her mother to turn her attention to her and to her body. It was only through some catastrophe that she could gain the attention and the love and care of her mother: damage to her body was the price she had to pay for this. Turning to the mother who would satisfy her needs and care for her appeared dangerous—just as her wishes themselves later became threatening. As to her own impulses and wishes, these accidents in childhood are also pointers to uncontrollable expansive desires and destructive aggression and hatred, which had to turn against her own person in self-punishment and self-destruction. Any image of the father of her childhood only appeared on the fringes, somehow impersonal like a “comfortable piece of furniture”, nevertheless in such a way that the patient experienced his presence as a source of security in public, outside the home. It is disconcerting and may sound denigrating to see the father as an inanimate piece of furniture, but the notion of her being able to find a “snug” place offering peace and quiet came to outweigh this in my perception of this term. The theme of bisexuality presented itself in non-verbal form at first, for instance in the way her clothes were girlish but her movements were those of a boy. In her large-scale, forceful gestures and “Who cares?” style, and the way she spoke with the threatening stance of an injured, aggressive youngster, the patient showed her identification with her brother: she was unhappy about her large, inharmonious body which she presented thus simultaneously in contrasting, unconnected versions. Whereas at first she came across as a young man, the impression changed the next moment and she seemed feminine, seductive and—despite the powerful body—delicate and vulnerable. At the same time she tried to press her large, swelling body into a childlike, little girl, cute T-shirt. She had obviously not found an appropriate form for her present adult body shape. She was trying to gain control of her arousal and general excitation, fear, and aggression in catapulting out her words. At the same time it was clear that the intensity and violence of her feelings exceeded her ability to shape or control her means of expressing them.

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Commentary: Despite the indication for a psychoanalysis—of which I was quite certain—I first of all suggested a two-hour psychotherapy as the patient’s plans for the future after her Abitur (school leaving exams) were completely unclear. We would have had only half a year to her Abitur. My decision here was made out of consideration for the patient’s life-situation. In view of my thoughts on her fear of dependency it seemed important to me not to cut across the patient’s own plans prematurely. The feeling on my side, that I had no choice but to be available to this patient as her object, was one that I had had right from the start, and it was to recur frequently as an important one in the course of the treatment. It represents, so to speak, in transference the equivalent of the patient’s urgent wish to receive the attention, love, care, and support of the mother. My descriptions, such as “the patient monopolized me” or “the patient has swallowed me” characterize the urgency and dangerousness of these wishes as we both seemed to experience them. In her response the patient accepted the offer with a touching, and what seemed childlike matter-of-factness. In treatment she was seeking the support she had so often longed for. Focused in the treatment on the thoughts and ideas around her unloved body, seeing things as under a bad omen from the perspective of having failed, the patient was overwhelmed by her erotic and sexual desires. Overaroused, full of fear and with the subjective certainty that she would fall headlong into disaster, she felt at the mercy of her body. She linked her unhappiness again and again with a desperate bewailing of her fatness: to be fat was to be ugly. This was connected with the experience of greedily gobbling down her food which stemmed from sibling competition over getting enough to eat. In oral terms a significant aspect of the relationship to the mother emerged. The pattern of desire and satisfaction as derived from early oral experiences took the following shape: the hungry child is fed; then, when it is satisfied, it is laid on one side and disappears from the scene; connection is broken; it is forgotten, dead. This is the aggressive aspect of feeding. Tallying with this, the following idea came up in treatment: if a sexual encounter does occur, then the relationship will be over. All wishes are fulfilled—it’s all over. My intervention, “If something felt good—one would like to have it again and one can do something about getting it again”, surprised the patient: she had never thought of this as a possibility.

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Commentary: This interpretation is developed on the basis of a reconstruction of the early oral experience and in content refers to the aspect of drives in the patient’s personality problems. The interpretation describes the patient as a person longing for things and helps her to expand her ability to imagine possibilities. Subsequently the patient fell in love with a young man and started a relationship with him which showed similarities to the sadistic fighting relationship she had with her brother. In the violent attacks she made on him she scared the new boyfriend so much that he very soon withdrew from her—a connection which only later became clear to her. The patient found herself in the situation she had so feared and expected: she was not loved, she was abandoned, and she was alone. In addition, after her Abitur it turned out that her other plans were not realizable: she gave up her wish to go abroad. She thought that in giving this up she was doing what her mother expected of her. She reproached herself with having given in to her mother’s ideas. She had the feeling she had thrown away any chance of a life of her own. The more so as, when term was about to start and she had decided for a university place away from home, she had been tortured by violent attacks of fear and had to give up all ideas of starting her studies. She found herself in violent disagreements with her parents, particularly with her mother. In moments of losing control she had wanted to hit out at her mother; she had run away, thrown herself on the ground; once she had shattered a glass door. She told me of thoughts of suicide but assured me in the same sentence that she wouldn’t do such a thing, she had far too much fear of pain. At the same time she was in despair with herself that she had not managed to carry the suicide through. In this situation I made her the proposal that she should come for frequent treatment, that is four times a week. The patient agreed.

2. Working on dependency and discovering the father In sudden rebellion against giving up her university plan—a renunciation that hurt her feelings and which she saw as a defeat—the patient rang me on a Sunday and pressed me to agree that it would be better for her to start with her studies straight away. We talked for quite a while before I put the question of why she wanted to do this

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right now, seeing that she had only just decided for the therapy and for letting herself have some much needed time. This intervention calmed her down instantly. Afterwards I was shocked to notice that I too had been playing—at least in my thoughts—with the idea of questioning the decision for analysis. I was much more disturbed by this than by what she told me of her thoughts of suicide after having these arguments with her parents. Commentary: Looking back on it, it seemed to me that the patient was trying to “seduce” me into sending her away to do her studies. It was as if she wanted to establish a conspiratorial closeness to me by breaking into the privacy of my Sunday which might enable her to fulfil her desires for independence without the work of therapy. I had the impression that her ideas of how to become intellectually and socially successful would have corresponded to her mother’s wishes—and it was her shoes the patient so wished to slip into—a wish that simultaneously sent her into a state of panic and fright. As I thought later, she wanted to make me allow her to take part in the primal scene—while excluding the father, naturally. With this urgent eruption of unconscious fantasies the patient was simultaneously testing me to see if I was willing to stand by her through the difficult time of a moratorium—and the possible danger of accidents and their results as a way of repetition. It was a question in the analysis of sounding out whether it would be possible to contain the overflowing hatred and unbridled love which had so often triggered self-destructive acts, and give them a liveable form. That this was possible was precisely the aim of my reference to the setting and her agreement to carry out psychoanalysis. It seems to me as if the patient was trying her hardest to ensconce herself with me at the outset of her treatment in order to risk a total breakdown during treatment in my presence, a collapse that had been signalling its advent for some time and that the patient expected and un/subconsciously feared. In the course of the treatment I gained an increasing impression that my proposal of analysis meant to the patient that I had retained hope of improvement for her, that I could imagine she might have a future. Formulated in terms of adolescent development and problems, the expectations she thus placed in me corresponded to the idea that I was to have the care and bear the responsibility for her life like the mother of childhood.

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Later on when the patient was preoccupied with her failure and I formulated her feelings, hopes, and fears—accompanying her engagement with these themes—it happened again and again that she was unable to understand my interventions as descriptions and attempts to clarify. She did not feel understood in her unhappiness but rather pinned down. She experienced me as being like her mother: monopolizing and devouring her. The position of the mother in the transference lent my utterances a quality of magic. By thinking that I had caused her painful feelings in naming them the patient was behaving like a small child who makes her mother responsible for the pain she feels. For instance in this context the patient had thoughts about whether the analysis was going to help her at all. When she was feeling at ease she avoided speaking about this (as she told me later) for fear of destroying this flow of happiness or of having me destroy it. It says a lot for the resources of this patient that she herself was able to express this “misunderstanding” of my words. It became possible gradually to resolve this “misconception” of our interaction. We were able to re-establish the potential space of trial action. After that the patient began to engage with the father. I had not forgotten the piece of furniture—as she had called her father—and was relieved that he was emerging. To her surprise the patient discovered his library and his intellectual interests—which she had up to then presumed to be in her mother’s field. She told me that her father had chosen her first name after a woman writer he liked. The patient liked this name. I commented that her father had set up a special connection between himself and her and given her something that was precious to him. She now felt recognized by her father in a way she had never felt before. She was able then to distance herself from an image of her father that she had felt was denigrating—as she had heard and understood it from her mother. “I think I have always seen my father through my mother’s eyes.” The differentiation of the parental couple—the triangulation—enabled the patient to reach a decision about the subject she wished to study, namely the same subject as her father’s, and she decided to continue with the analysis. At that point she took a long summer break which lasted until she reappeared at the beginning of term and we were able to continue our work.

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Commentary: The patient’s desire for caring support on the one hand and her great fear of not getting it or of having to pay for it with the forfeit of individual opportunities—such as another accident or the breaking-off of the treatment—is mirrored in the moves made at the start of analysis. The patient was able to “use” the analyst and let herself get involved in the analytical relationship. At the same time she proved her ability to act independently by taking a long summer break. As if in a phase of rapprochement, she confirmed to herself that she had her own power to make things happen. As with the decision for analysis which she took herself, the experience of organizing the interruption of the analysis had a distinctly stabilizing effect. The moral of the story could well be: being active does not necessarily lead to catastrophe. The aggression which was needed to assert herself (separation, individuation) did not destroy the analytic relationship and did not entail any overwhelming eruption of instinctual urges. The experience of being able to set up a relationship, shape it, and interrupt it enabled the patient to let herself get involved in the mutual dependency of a relationship and to confide her wishes to a significant other person—in analysis and outside it. The analytic relationship provided the holding setting for this. It was possible to tame the devouring, instinctually-driven connotations of the mother transference so that the potential for tenderness and affection which could support tendencies for identification could be used for the further treatment. Jacqueline Godfrind formulates it thus: “In their counter transference position analysts [must] make capacities available to the female patient which bring together female containment— the bearer of attachment—and the male quality of distance—the bearer of otherness” (2002, p. 121).

3. Male–female With a gradually increasing security in the relationship the patient realized that she was enjoying her studies. She made friends with other women and entered into explicitly non-sexual relationships with men. She became able to name her fear of sexuality. To be slim—like her mother—was still linked to femininity in her mind but the femininity of the mother was still coupled with the activity

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and power of the pre-Oedipal phallic mother. As to her own body the patient still could not cathect it positively. The identification described above with the “physically unimpaired” big brother who has the power to gain the affection of the mother is supplemented by the possibility of identifying with a mother who is strong and powerful, demanding and tough. Apart from the difference between fat and thin (the thin mother and the powerfully-built brother who is physically like herself) these versions of male and female hardly seemed to differ. The patient was in a state of confusion because of the similarity between the two concepts. Whatever direction she turned in the goal always looked the same. Remembering a course of psychotherapy she had had as a child she told me she had only asked questions that made no sense. For example, “Why do Roman soldiers wear skirts?” Using this memory of her childhood and adopting the child’s perspective I answered: “Of course that interested you. Children are always interested in that. Here they see soldiers who have a willy and yet wear skirts. How can you tell if this is a man or a woman—it’s confusing.” Looking back at childhood from now it was possible to name the confusion. With growing vivacity the patient began to focus on her ideas of what is masculine and what is feminine. She had always been aware that she came across as somehow masculine; now she could begin to play with it. It became an acceptable goal to lose weight in order to wear beautiful dresses—this was different from losing weight to make herself more attractive. The latter aroused ambivalent feelings and still seemed to be threatening. Gradually she began to look around for men. She was now looking for someone who was kind to her, who did her good, someone quite different from the young man with whom she had been entangled in this fighting relationship mentioned earlier, on the model of her relationship with her brother. These new relationships allowed the patient to approach erotic play, something which she had not allowed herself up to that point. She made the acquaintance of a student in her semester whom she assumed would not suit her family’s ideas. Nevertheless she enjoyed the flirt, which stayed on a verbal level. Afterwards at a dance party she permitted the affection and erotic confirmation which ensued. She commented: “It was like being in England. To begin with I always

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heard my own accent and then after four weeks I heard that it was ‘coming out right’, I was speaking like English people. When we were dancing it was just like that, it was right now. H. even kissed my hand.” The patient had felt happy with self, body, and erotic experience in tune with one another. At this point I should like to finish the description here of the treatment, which had of course to be continued and was so.

Looking back and some thoughts on technique The patient can acknowledge and accept being a woman, she can give up the delusional option of having a male body, of being a man: as Egle Laufer wrote, “to view herself as not having a body that enables her to become a man which is how I understand the term ‘castrated’” (1993, p. 71). At the same time she can have masculine and feminine sides, be aware of them in herself, use and enjoy them. I did not take the male identifications of the patient exclusively as defence against female elements; I did not interpret them as defence. The patient’s challenge I saw in the necessity of developing an idea of herself as a woman from her masculine and feminine elements. Reiche formulated this in the following way: “The path leading from fantasized bisexual omnipotence (being simultaneously male and female) to a workable sexual balance (having male and female elements), which not only demands happiness as its right but is capable of enabling it in moderation, is, as a rule, reached via a stable bisexual identification” (2000, p. 48). The section of the treatment depicted here describes the path the young woman had to tread before she could begin to position herself between the male and female poles and approach a feeling of “That’s who I am”. This work, which Reiche terms an organizational task of differentiation for the ego (2000, p. 27) demands the ability to function in a triangular space, which is only possible if the early conflicts around dependency, which manifest in the way the body is experienced and treated, have been solved or moderated. As a result the transference situation is initially marked by dynamic factors stemming from experiences in the primary relationship. Outbreaks of “driven-ness”, over-excitation, getting out of hand, and panic fears demand “holding”, and “containment” to counteract any breakdown in the patient’s ability to symbolize.

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Jaqueline Godfrind, who works on transference shifts with adult patients who have had problems similar to those of the young woman I have described here, writes about the analytical work needed in such cases: “It is the work of connecting, of giving meaning, of securing with the use of accompanying words: words that name affects, that qualify actions and set up connections in the transference … the interventions of the analyst follow in principle with desexualized intention … [This work points] to the attaching and holding qualities of the mother” (2002, p. 118). The patient can then be supported in regaining the ability to function in triangular space. In the case of my patient, she gained the space to detach from her mother. What she desired of her mother lost its threatening quality. Her wishes became apparent. In the next step—I refer again to Godfrind—“an encounter with the femaleness of the mother can take place. A mother who is rehabilitated in her function as a woman and who is rival, loved one and for the first time object of female identification” (2002, p. 116). This person is the mother—and in transference it is the analyst— who can act as orientation as I have depicted it for early adolescence. This mother supports “… the identificatory movements which form the foundation for sexual identity and the potential for a personal affirmation contained in it as also the access to a sexuality which expresses—through the pleasurable enjoyment of a woman’s body— the pleasure of being a woman in the arms of a man” (Godfrind, 2002, p. 112). The section of the treatment described here is intended to illustrate at the point at which this report breaks off how the patient approached these questions.

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CHAPTER SIX

Some thoughts on psychoanalytical technique in the treatment of adolescents: on the development of body image, body ego, and ego structures Elisabeth Brainin

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he perception of the external world is closely linked to the perception of one’s own body and of the changes it undergoes. The starting point for this constant back and forth of inner and outer perception is the stage of “pure pleasure-ego” as Freud called it in Instincts and their Vicissitudes (1915c, p. 228, German original). In a child’s development, with the increasing mastering of motility and possibility of motor discharge, one can observe the emergence of an apparatus of defence which wards off drive impulses that seem dangerous to the ego. Otto Fenichel describes how introjection, projection, and denial develop, the last of these on the basis of negative hallucinations—as he names the “ignoring of unpleasant outer circumstances” (1937, vol. II, p. 52, German). I regard the development of the body ego and the accompanying development of the apparatus of defence as the foundation of what is referred to as mentalization in currently prevailing psychoanalytical theories of development. Psychoanalyses offer us the opportunity to observe body phenomena which take place pre-consciously and which unconsciously serve drive gratification. These can become a source of resistance 89

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in the psychoanalytic process. The following are my reflections on the question of how young people manage to take possession of their bodies and what role the body ego plays in the shaping of the ego. These themes are then developed with reference to the treatment of adolescents. Psychoanalytic treatment cannot be seen as separate from the thinking on ego development and ego structures.

The development of the body ego As a starting point my observations on development and body ego take Freud’s thought that our ego “is first and foremost a bodily ego” (1923b, p. 24), which finds its unconscious expression in phantasies and dreams. Phenomena such as defence and resistance in treatments are often connected with bodily symptoms. Their pleasurable character remains unperceived and hidden not only from the patients. Today there is also interest among neuroscientists in body sensations and the representation of current states of the body in the various cortical and subcortical structures. As I see it there is a relation between the question, which Antonio Damasio poses, of where the neuronal basis of the self lies and Freud’s concept of ego structures as grounded on the one hand in consciousness while on the other hand being influenced by the Id. A neuroscientist, Damasio speaks of “primordial representations” of the body, background states of the body, and states of feeling which cannot be separated from one another. “The background body sense is continuous, although one may hardly notice it, since it represents not a specific part of anything in the body but rather an overall state of (al)most everything in it” (1994, p. 152). He believes that “the images of body state are in the background, usually unattended [to] but ready to spring forward” (ibid, p. 234), particularly so in moments of emotional turbulence. Differentiating emotions (such as anger, fear etc.,) from feelings (cf. p. 149), Damasio describes feelings as relating above all to the body “… because they offer us the cognition of our visceral and musculoskeletal state” (ibid, p. 159). “By dint of juxtaposition, body images give to other images a quality … of pleasure or pain” (ibid, p. 159), and in this process our notions of good and bad become linked with pleasure and pain.

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The significance of body ego symptoms and their psychical processing With the help of a number of clinical observations in psychoanalyses I should like to highlight the importance of body ego symptoms, bodily sensations, and their psychical processing. To underestimate or neglect them in our clinical work would mean leaving an area of the unconscious or of unconscious fantasies untouched in analyses. Defence and resistance are all too often linked to bodily phenomena. We are familiar with this the other way round: frightening unconscious fantasies and memories can trigger a regression which we observe as physical symptoms in analyses, which become the expression of defence precisely because their pleasurable character goes unperceived, remaining hidden. The tendency of the pleasureunpleasure principle, namely to reach out for pleasure and avoid unpleasure, can too easily be forgotten. Inner narcissistic balance depends on the ego being able to create a libido balance. Such a balance is also, in its turn, subject to the pleasure principle.

From the analysis with Alexander Alexander was in analysis because of his extreme shyness which was coupled with massive castration anxieties. He felt his penis was too small and misshapen. He was constantly afraid that he might wet his pants without realizing it. In order to protect himself he used a paper handkerchief which he wore like a diaper in his pants. I have written elsewhere about the small child’s sense of loss when nappies are given up, which they can experience as the loss of a part of their body, making such loss the equivalent of castration (Brainin, 1999). Alexander used the “tissue nappy” quite consciously to counter his fears and feelings of smallness. The fear of losing control of the sphincter was connected to this and accentuated his feelings of insecurity. In particular, he was afraid of turning up at the analysis session with wet pants or of losing control during the sessions. Sexual excitation and the fear of castration were compounded. The feared loss of sphincter control affected him like a threat of castration. There is in puberty a drastic shift in the relative power of psychical instances. The drives are more pressing than ever before, stirring up inner conflicts. Levels of libido and aggression surge upward

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and infantile drive interests are re-awakened. In comparison with earlier periods of development the ego is much more consolidated, making use of all the defence mechanisms available. In this situation there are two outcomes: either the ego is overcome by the sheer power of the drives or it conquers them and is able to keep them in check, demanding a high expenditure of energy. Anna Freud described this outcome as one of permanent damage, the “… ego instances usually remain unrelenting, unassailable and not open to the revisions which changing realities would require” (Sandler with Freud, 1985, p. 338, German version).

Thoughts on technique My understanding of psychoanalysis leads me to analyse the defence and ego structures first, in order to find a technique that is appropriate for working with adolescents. In the case of the young man already mentioned, what stood out first was his shyness, while it was not clear to what extent it was linked to aggressive fantasies. The sado-masochistic elements in his character manifested in castration fears and wishes which aroused great anxiety in him. His desire for exhibition was not accessible to consciousness which meant that I could not offer an interpretation of it until he was secure enough in the transference, and so could be in a position to take in and benefit from interpretations in an ego-syntonic manner. The transference fantasies centred on me and my body, my breasts, hairstyle, and make-up, a long period of treatment being, of course, required before these fantasies could be articulated and finally interpreted. The reconstruction of these in interpretation, which, in turn, would have touched upon fantasies about his mother, was too threatening. It was not until the end of the treatment, in fact in posttreatment sessions, that all of this could come to light. Anna Freud comments on this “there are imaginings of direct sexual possession of the mother and of her body, devoid of any attenuation/softening”. And in a further passage she says “such (ideas) were rejected and simultaneously accepted” (Sandler with Freud, 1985, p. 351, German version). Anna Freud states moreover that aggressive wishes are far less frightening and so less likely to be warded off, although, in the case of a young man with intense fears of castration, we meet an equally powerful defence against aggressive

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feelings. In this state Alexander resorted to sado-masochistic fantasies in which he played the masochistic part. This, in turn, had consequences for the treatment. In his transference fantasies I became a cruel domina punishing him for his sexual desires. It was not until Alexander’s feelings of shame over his masochistic position had been worked through that speaking about the fantasies and the ensuing work of interpretation became possible. The prerequisite for being able to develop a transference neurosis is that the adolescent is able to face and bear with an inner conflict (see Sandler et al., 1980, p. 124, German edition). The required separation from the parents entails defence against fresh regressive dependencies—such as the intense relationship with the analyst. This, in turn, makes the analysis of the countertransference more difficult. In most cases it is only towards the end of adolescence that a transference neurosis develops which can be compared to that of an adult. With young girls one possibility of working on the above-mentioned early “feeling of castration” caused by the removal of nappies, as I have described it a number of times, comes after the event when menstruation first sets in. Young girls often experience the menarche as a loss of sphincter control. Regardless of how concretely and well they have been informed about the female body functions, the experience of the first menstruation can be accompanied by the idea of losing control of the sphincter. As in early childhood the nappy or sanitary towel, or napkin as it is called for adult women, can help and fulfil a similar function.

A case of a tic: giving a little cough and clearing the throat In the course of analysis of a young woman I was able to observe a body phenomenon which allowed us to reconstruct her body experiences as a small girl. During this patient’s sessions it struck me that, while speaking, she kept giving a little cough, slightly clearing her throat. The frequency with which she did this varied greatly. Sometimes it sounded aggressive and irritated, sometimes more embarrassed, but I could never quite understand it. Directly, it served as defence in that it further stopped the flow of her speech, which was at times very halting. For a long time I read this little cough as an anal expression of diffuse states of excitation. As Otto Fenichel describes it.

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“Coughing could be a … substitute vent to mitigate an inner pressure caused by repression” (1943, vol. II, p. 270). Clearing her throat was like an act of cleaning, relieving her of the phlegm that caused the impulse to cough and preventing her from speaking. She experienced this clearing of the throat as cleaning out the throat. Would we all not be reminded at this point of the “chimney sweeping” in Freud’s patient? What manifested in this action was the transference resistance and it was directed at “inhaling the same air as the other person”—which can mean union with that person—“whereas breathing out signifies separation” (Fenichel, 1943, vol. II , p. 271) At the same time it had the character of a tic which was directed against the exhibitionist gratification of speaking in the analysis. The tic now became the “… automatic bodily equivalent of an emotion … no longer felt” (Fenichel, 1943, vol. II, p. 274). This patient showed a marked anal erogeneity fixated by various experiences in infancy. I saw the little cough primarily as displacement of excitation from below to above but got no further. From here it was not far to an assumption of feelings of genital excitation but they, however, from her account showed primarily in the urethral region. It was particularly when she was agitated that she needed to urinate frequently and from various memories and dreams I was able to draw the conclusion that the urethral area was strongly cathected. Just as in the analysis of patients with perversions the real symptom that serves the illusory compensation of castration anxiety remains hidden in that the patients fantasize the possibility of gaining satisfaction independently of the object. Masud Khan speaks of “… strong libidinisation of defence and/or erotic exploitation of body organs in the place of egotism” (1979, p. 40 in German edition). In the case of my patient the libidinous fixation developed into a transference resistance in the psychoanalytic process. Holding onto the “little cough” as a masturbation equivalent allowed her to remain under the illusion of possessing a penis. The patient used my lavatory markedly often both before and after the sessions. Body phenomena such as these are registered at pre-conscious level, and are opposed by massive resistance not least because they are experienced as deeply shaming. The shame is associated with the fact that these body processes take place unnoticed and serve gratification. Ultimately—under the primacy of the pleasure principle— they can lead to a loss of control over the body processes. Defence is

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directed against the giving up of a pleasurable activity and against the sense of shame.

Sphincter spasms in a young patient woman Another very young female patient whose analysis was marked, like the one just described, by long periods of silence, suffered additionally from frequent sphincter spasms. Fenichel describes the meaning of sphincter spasms, in his work “Organ libidinization accompanying the defence against drives”, as the typical way to deal with the conflict between the pleasure of excretion and the pleasure of retention. Retention—as he says—provides great narcissistic sense of power such as is also apparent in refusing to speak. Self-control is experienced as a new source of pleasure (see Fenichel, 1928, vol. I, p. 122): “In retention the original safeguarding against forbidden pleasure becomes itself an added source of pleasure. This safeguarding and this added pleasure are also apparent in sphincter spasms—that is in muscle innervations carried beyond what serves the physiological purpose”. Anal retention can become the equivalent of masturbation, whereby the excitation remains in the anal region and does not spread to the genital area—such extension of excitation would then lead to sphincter spasms in my view. The conflict between the pleasure of retention and the pleasure of excretion was expressed in the sessions not only in frequent, persistent silence on the part of the patient but also in her posture—she lay motionless and stiff as a board on the couch. Her entire body seemed to be stiffened into a phallus.

The “pleasure-physiologic body-ego” Robert Fliess describes the “pleasure-physiologic body-ego” (1961, p. 206) as an element of the body-ego that has been sexualized. Any part of the body can in this light become a part of the pleasure-physiologic body-ego. Displacement, conversion, body symbolism thus find a home in a concept that includes the pleasure principle. The anal spasms of the patient were a pointer to the fact that, for her, the anus could become a part of the pleasure-giving physiological body-ego whereas the genitals could not be integrated in it to the same degree.

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Freud mentioned that parts of the ego and super-ego remain unconscious. Correspondingly Fliess describes the pleasure-physiologic body-ego as a part of the ego which nevertheless obeys the laws of primary process in its function. This explains the possibility of displacement, symbolization and multiple determination of an element of the body or of a body function—such as is only possible in primary process. Robert Fliess repeatedly pointed out the way in which each sphincter could take over the libidinous cathexis of another. In The Ego and the Id Freud says “A person’s own body, and above all its surface, is a place from which both external and internal perceptions may spring. It is seen like any other object, but to the touch, however, it yields two kinds of sensations, one of which may be equivalent to an internal perception” (1923b, p. 25). The sphincters represent the boundaries between inside and outside and are described by Paul Schilder as the transition point from inner to outer perception. In addition as the sphincters offer the possibility of control over what one allows to enter or leave the body they acquire particular importance. He describes how the sensory perception of these real body boundaries lies a few centimetres before the actual body orifices which in turn explains the particular cathexis of mucous membranes as boundaries between inner and outer world. The possibility of the displacement of cathexis from one body region to another throws a new light on phenomena which at first sight appear to be typically female. The rectum in its proximity to the inner genital can—when full—lead to a stimulation of the portio and upper parts of the vagina. This might be an explanation for the widespread incidence of constipation in women, in that it suggests it might represent an equivalent to masturbation. We could then examine anal fixation in women from this perspective. Also, from this point of view the fantasy of an anal penis should be re-examined. The feeling of autonomy that the patient sensed in remaining silent—she was only able to report this much later—gave her a feeling of superiority and invulnerability which she enjoyed greatly during the sessions. This brings up the question of technique: how can we bring in an interpretation—what is the right moment for it? What might the difference be compared to interpretation when working with adults?

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The setting cannot be controlled so strictly as with adults. For instance asking the patient to lie on the couch is not always possible; it may vary from session to session. There may also be a change in setting over the course of the treatment. At a later point in this paper I describe the treatment of a girl who cut herself. She was 14 years old at the time. In the first years of treatment she always sat opposite me. She neither felt the need to lie on the couch, nor did I suggest it to her. She recalled dreams and talked about them; her associations were not infrequently accompanied by acting out, which repeatedly led to her harming herself in the intervals between sessions. Interpretations alone brought no relief; inner conflicts were reactivated by conflicts with her real parents, which triggered fresh excitation that she could not cope with. The transference relationship was not sufficiently secure to withstand the real conflicts of the moment. The immediate gratification and discharge of excitation which Christine felt was in cutting herself and in the bleeding of the open wound. This had the appearance of an addiction and became stronger than the working alliance and transference relationship. In the psychoanalytic community there has for years been a controversy over the development of female sexual functions. One point repeatedly brought up (particularly by feminists) is Freud’s view of the role of the vagina in the psychosexual development of girls. In Freud’s opinion the clitoris held a predominant position in genital masturbation in small girls and that it was not until coitus that—as it were “with the help of” the penis—excitation was carried over from clitoris to vagina. Thus, according to Freud, the vagina only becomes the leading organ of sexual excitation through the penis. If we regard this thought sine ira et studio (leaving anger and zeal out of the discussion) we know that among small girls there are vaginal masturbation practices which at least bring introitus vaginae and labia into play and through which the vagina may well experience a similar cathexis.

The perception of the inner gentalia in girls and women We know from neuropsychology that a part of the body with all its functions can only be integrated into the body schema, into a conscious representation of its existence and function, if this body part experiences inner and outer stimuli. It is the function of an organ,

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in the widest sense its active use, that makes it perceptible. To my mind, the same holds true for the perception of the uterus, the uterus contractions and the lower sections of the vagina nearer the portio. Uterus and uterus contractions can probably first be perceived with the menarche. Menstruation problems and pains might fulfil a function for the young girl, namely to enable her to perceive the inner genitalia consciously. In addition there are the regressive needs of young girls who wish for particular care and attention from their mother during menstruation. In violent menstruation pains fears of punishment and unconscious wishes for punishment can manifest in young girls. These have to do with the daughter’s feelings of triumph over the mother. The daughter still has her reproductive life ahead of her, the mother’s is over—as the daughter’s fantasy perceives it. The lower sections of the vagina vault probably only become perceptible in the act of coitus. The fact that the first perception of a baby’s movements comes earlier with the second pregnancy than in the first is understandable for the same reason. The fact that an organ exercises a function plays an important role in neurorehabilitation.

“Outside and inside” In her studies of psychosexual development Judith Kestenberg has worked on “outside and inside”, the unconscious sexual fantasies of children and adolescents about the inside of their bodies and how these, in their turn, influence both their fantasies about the outer and inner sexual organs and their perception of the outer world. She attributes the externalization of perceptions of the inside, of body perception, to the fact that adolescents protect themselves from being overwhelmed by excitation—which Egle and Moses Laufer (1984) describe as adolescent collapse. Judith Kestenberg describes similar phenomena to those given by Schilder, who, as already mentioned, emphasizes that the sensory perception of actual body boundaries lies a few centimetres before the body orifices. This is significant for the susceptibility of an organ to excitation. Above all it is the introitus vaginae and the upper sections of the vagina, which lie nearer the portio, which play a role in the susceptibility to excitation and spread of excitation to the other parts of the female genitalia.

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Because of this it becomes clearer why the mucous membranes enjoy a particular cathexis as erogenous zone, as the border zone between inside and outside. Kerstenberg describes displacements of cathexis in adolescents of both sexes from lower genital organs to organs and regions more associated with discharging excitation in the pre-genital period. Anal, urethral and also oral zones serve this purpose.

The particular role of the skin In neuro-psychology the skin is accorded particular attention. The transition from inside to outside does not only preoccupy psychoanalysts. The neuroscientist Antonio Damasio comments, “… a representation of the skin might be the natural means to signify the body’s boundary because it is an interface turned both to the organism’s interior and to the environment with which the organism interacts” (1994, p. 231).

Case study: Christine Adolescents who cut themselves again and again offer us clear pointers to the role of skin. The young girl I have already mentioned came to a first interview and told me of her urge to cut herself. In her case not only the upper arm but also thigh and back. Christine experienced cutting as a great relief. She did not feel the razor cutting through the layers of skin, the wound felt pleasant to her, the blood came flowing out warm and wet. While she was relating this she appeared very embarrassed. She clearly felt ashamed when depicting her feelings; she also felt guilty and finally assured me that she could not promise to give up this symptom. She could not control it, she said, although the parents had already hidden all knives and razors. Over many years the mother had wanted to, and in fact did, secure access to Christine’s genitals. She continued to apply lotions to her daughter’s body including the genitals until Christine was 12 years old. In cutting herself Christine symbolized something like autonomy or independence of her mother—her mother had no control over the cuts. She was fascinated by the sight of the wounds, oozing out blood. Apparently the wounds symbolized her genitals. The description made me think of sexual actions and this was confirmed

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in the urgency of the action. It was in this context that she told me of the birth of her younger siblings. She had been present at the births, they took place at home, and Christine had been more or less forced to watch the process. Cutting was the symptom that worried me most in Christine’s case. It seemed to me to be multiply determined: – The cutting I took to be unconscious identification with the mother’s genitals she had been able to watch during the births. – She had suffered all her childhood from neuro-dermatitis and this had offered her mother the opportunity to manipulate Christine’s body. (I have seen a number of young girls in the last two years who cut themselves and who had also suffered from neuro-dermatitis from early childhood on. This phenomenon which corresponds to a particular cathexis of the skin seems really important to examine further). Didier Anzieu sees the “mantle of pain” in which the patients envelop themselves as recreating the encompassing function of the skin. This had not been perceived by Christine’s mother. It is not until there is pain that the body becomes a real object. Eczema—dermatitis—is, in Anzieu’s view, an attempt to feel the body surface of the ego from the outside. Alongside the pain, it warms and creates a diffuse erogenous excitation. “The skin ego represents the basis of sexual excitation … the skin ego binds libidinal cathexis over its entire area and in this way becomes the envelope of a global sexual excitation” (Anzieu,1989, p. 53, German edition). René Spitz suspects that “in eczema the child somatically creates for itself the stimuli that its mother has not given it” (quoted in Anzieu, 1989, p. 53, German edition). Cutting was the symbolization of Christine’s pre-conscious desire to shed her skin. It became the expression of a battle to regain control over her own body and its sensations. It symbolized a fantasy of defloration and finally became an equivalent to masturbation in which she destroyed the hated, excited genital and at the same time created new ones in other parts of the body. Until then there had been no real experience of onanism in her sado-masochistic universe, in which she could find release from her excitation in a satisfying manner. The purpose of the cutting was to release the impulsive feelings of tension she frequently suffered from. There was never any doubt in my mind that these were of sexual origin.

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Adolescence as a phase of development Adolescence is the second phase in the development of sexual life. Freud emphasizes this two-phase development: We have found that the sexual life of man unlike that of the animals nearly related to him, does not make a steady advance from birth to maturity, but that, after an early efflorescence up till the fifth year, it undergoes a very decided interruption; and that it then starts on its course once more in puberty, taking up again the beginnings broken off in early childhood … This factor owes its pathogenic significance to the fact that the majority of the instinctual demands of this infantile sexuality are treated by the ego as dangers and fended off as such, so that the later sexual impulses of puberty, … (which in the natural course of things would be ego-syntonic), run the risk of succumbing to the attraction of their infantile prototypes and following them into repression. It is here we come upon the most direct aetiology of neuroses. It is a curious thing that early encounter with the demands of sexuality should have a similar effect on the ego to that produced by premature contact with the external world (1926d, p. 155).

This quotation from Freud shows the problems in the treatment of adolescents who are tossed back and forth between the violent demands of drives and repression. As if navigating between Scylla and Charybdis the analyst has to find a sufficiently ego-syntonic way of introducing interpretations so that they do not strengthen defence or lead to repression. Freud’s view of the “… elasticity of mental processes” (1905a, p. 265) is certainly comparable to the findings of modern neuroscience on the plasticity of the brain. Biological maturation in puberty is the time when the maturing of the frontal lobes is completed, myelinization is concluded, and in all cultures rituals of social maturity are performed (Goldberg, 2001, p. 144). Adolescence is described as man’s second chance. A person’s psychopathology is not finally determined until adulthood. Offering psychotherapy in adolescence means using this chance to avoid or undo the fixation of conflicts and their repression. K.R. Eissler speaks of a dissolving of earlier structures during adolescence (1958, p. 250). It is not always easy to perceive the difference between crises

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in development and neurotic disorders. Peter Blos (1962) and Anna Freud (1937) point out the demands made on the inner life of adolescents which are specific to the phase, the necessary destabilization of psychic structures, the pull of regressive forces on the adolescent which emanate from Oedipal and pre-Oedipal strivings, and the great adaptive demands in the social field which are made on the ego in this phase of life. The frequently stormy passage through adolescence and the characteristic inability of adolescents to tolerate delay or denial of gratification, moreover also entail a number of difficulties for technique which I shall go into more fully later.

Questions of technique in treatment As a psychoanalyst working with adolescents the rigid use of one particular technique is out of the question. One has to turn to a variety of techniques, to adapt to the shifts and changes in pathology— which can, by the way, even occur within one session. Many analysts who have been involved in the treatment of adolescents feel that it should be carried out primarily on the level of object relations. There is a danger with reconstructive interpretations, if offered at unsuitable moments, that they may unleash major crises. In adolescence the intrapsychic demands made on the ego are greater than in most other periods of life. Moses and Egle Laufer (1984) have pointed to the importance of the central masturbation fantasy in adolescence. In terms of technique this is not so easy to analyse, given the ego’s condition just described. The same is true of body phenomena which we need to bear in mind during the course of treatment and find a way to speak of at the right moment. The hardest thing seems to me to be the use of interpretation of transference processes for reconstruction. Young people who are just beginning to separate from their primary objects may experience interpretations of transference as an attempt to keep them imprisoned in fresh bonds and dependence. In the same way any acting out of transference feelings is not easily accessible to interpretation. We have to assume that such acting out points to a weakness in defence and this can have consequences in adolescents we would wish to avoid. Christine, mentioned above, repeatedly showed signs of homosexual transference which expressed themselves at home with her mother in violent

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quarrels. In our sessions she did everything to avoid mentioning such feelings, particularly if they concerned me. And when material of this kind emerged in her dreams and I tried to interpret it, the consequences were terrible: Christine began to cut herself again in a state of extreme excitation. The interpretation of homosexual transference feelings did not become possible until Christine consciously became aware of them outside the analytical sessions; she was then already older. One can ask, as did Anna Freud, whether it was that her homosexual transference was strengthened or whether her homosexuality was liberated in the analysis and expressed itself outside the setting (see Sandler et al., 1980, p. 175, German version). In Christine’s case I would prefer to speak of a liberation of her homosexuality; she later had a long relationship with a young woman which she experienced as less conflictual because she had spoken about homosexual feelings in the analysis and they no longer created conscious super-ego conflicts in her. In adolescence the difference between the sexes is recognized as definitive. Childlike feelings of omnipotence disappear with sexual maturity and this is accompanied by painful feelings. Most often this leads to a blurring of the boundaries in clothing and style which very much supports the unconscious needs of adolescents. We know, however, how rapidly this picture can change. The young girl we meet one day looking like a boy is hard to recognize the next day when she appears as a seductive sylph. What fun it is to be taken for a member of the other sex, most particularly when one is really sure of one’s own sexual identity. These phenomena in the behaviour of adolescents are an expression of unconscious conflicts over deciding for one of the two possible sexual identities and making the step of turning to the other sex. Homosexual episodes in adolescence do not necessarily offer the key to later sexual developments. They are the expression of a search for sexual identity, often the expression of defence against heterosexual feelings and the fears of castration associated with these. Fetishistic tendencies are frequent and accentuated by so-called youth culture. Particular clothes, shoes, brand names have the character of sexual attributes without which an adolescent feels completely “out”. They can, however, also mean more, and be an indispensable precondition for the person’s own sexual excitation and for their being accepted by others. These “fetishes” lead to a feeling of narcissistic expansion,

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allowing a sensation of completeness and intactness that is designed to compensate for fears of castration. Giving up infantile desires for omnipotence does not exactly make it easier to give up pre-genital infantile sexual strivings. These can be as urgent as in early childhood and finally break out as serious symptoms when linked with infantile theories of sexuality. In the pre-genital period of childhood postponement of an instinctual gratification is not tolerated: such postponement of gratification is the result of “education” or “upbringing”. Urgency, the sense that what is felt cannot be put off, experienced as youthful impetuosity, is however a characteristic of adolescence and is the expression of the urgent demands of the drives, which the defence mechanisms, the ego-functions, cannot conquer or control. This last, incidentally, produces a further narcissistic wound. The timing of the start of addiction in adolescence is certainly connected with this. Taking consciousness-altering substances serves not least to keep the rising pressure of drives in check. At the same time, with the help of the drug, addiction grants some gratification— although of dubious nature—without postponement of a instinctual gratification. I do not propose here to go into other aspects of addiction, such as its character of initiation or self-medication. A further characteristic of adolescence are the rapid and dramatic mood swings typified in Goethe’s words “himmelhoch jauchzend und zu Tode betrübt” (now shouting in triumph, now sunk in despair). Just as greed and bingeing can swing to dieting and asceticism, so further opposites appear in pairs: slovenliness and disorder swinging to pedantry, or enjoyment in and preference for own body dirt being suddenly replaced by complex washing rituals which can escalate to become obsessions. In the same way sluggish passivity and restless activity take turns to dominate. It seems as if youngsters are at the mercy of their infantile drives, yet these can equally serve to ward off any genital feelings. Young people’s pre-occupation with their faces, in girls particularly with attention to make-up and skin impurities, points to a displacement from below to above, from the genital area to face, mouth, eyes, and nose. For girls, not only the face but the genitals, too, cannot be visually perceived except by means of a mirror. Face and genitals are however absolutely central for the development of a person’s own body image, own identity. For a body part to be

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integrated a variety of perceptions are needed. These are determined through both inner and outer stimuli. Visual perception acquires outstanding significance. It is in this sense that the long hours spent in front of the mirror can be understood (the behaviour is similar in both sexes). It is not only a narcissistic need to gaze at and admire themselves that keeps adolescents at their mirror. Not infrequently it is fears of psychic disintegration, a deep-seated insecurity, that they are trying to get under control with the help of the mirror and their mirror-image. The changes in the genitals and with them changes in feeling and sensations are supposed to be “set straight” symbolically in manipulations of the face. With girls a wide variety of eating disorders dominate the scene. Bingeing is followed by strict diets which can lead to severe anorectic or bulimic states. Preoccupation with body weight rules the lives of many women from puberty on. Losing and then regaining weight can depend on the hormonal cycle but it contains an important psychic component. The woman’s own body is cathected as a phallus, alternately fat and thin as in erection and detumescence of the penis. In this light, vomiting in bulimic states may symbolize ejaculation. There is a further aspect to the weight problems experienced by many young girls. The feeling of being particularly fat and having a shapeless, dumpy body will depend on how little girls experience their mother’s body. The mother’s breasts, belly, and hips are oversized and over-powerful in comparison to the little girl’s body. To become sexually mature means to the little girl developing a body as over-sized as that of her mother. Becoming like the mother, powerful, large, voluptuous, omnipotent would correspond to an unconscious identification with the mother expressing itself in very bodily terms, while dieting and the desire to be slim would represent the defence against this wish. Another aspect of starving would be the unconscious identification with the father and his penis. Avoiding female body attributes would accommodate the unconscious wish to become a part-object of the father, namely like his penis. Fenichel speaks of the phallus girl. At the same time this allows the girl to avoid the Oedipal conflict and, as a sylph, to remain in a homosexual bond with the mother, thereby avoiding rivalry with the mother. The young girl remains an asexual being without the curves of a female figure.

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Of course perception of the body changes during puberty. In this it is not only the visible, secondary sexual characteristics which develop and so change perception, it is also the sensations in the genitals that change. In boys with erection, pollution and ejaculation at night, the signs do not first have to be seen, they are felt with immediacy, being triggered by outer and inner stimuli. They are accompanied by conscious and unconscious fantasies and in the best case with excitation, pleasure, and satisfaction. The arousal is also clearly visible to others as an erection which can lead to acute feelings of shame in a reaction-formation. Blushing, the feeling of being stared at, marked shyness—all these can be expressions of fears which relate primarily to the genitals and are frequently displaced to the face. Boys are thrown into confusion by the “mysterious”, invisible forces in their bodies, as Kestenberg says, speaking of spontaneous erection and ejaculation during puberty. She also refers to movements of the testicles. In a case vignette she describes a game of ball with a pre-adolescent boy, which primarily symbolized his need to gain control over his testicles, to contain his fears that they might get screwed in or climb upwards etc. It is to Kestenberg (1968) that we owe insights into the importance of unconscious and pre-conscious perceptions of the inside of the body and of body processes for the psychosexual development of boys and girls in adolescence. She does not link the importance of perceptions of the inner genital organs to one sex only but shows how the re-organisation of these body perceptions in puberty determines later sexual life.

A case of sado-masochistic perversion in adolescence Hansi Kennedy described a case of sado-masochistic perversion in adolescence (1989). The treatment of the 13-year-old Peter lasted through his entire adolescence. Kennedy described the boy’s masturbatory conflict which manifested in the sessions in excited play with a ruler. It was only in the course of the treatment that she was able to clarify the multiple determination of this game, the word ruler meaning both the object used to rule a line and the person ruling a country. It also represented a long shoe horn which belonged to his mother and with which he secretly played in his mother’s

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bedroom. The sado-masochistic aspect became clear above all in transference: The transference and the process of treatment themselves can be misused by the patient as sexual gratification instead of being used to further the analytical work. At the beginning of the treatment Peter suggested that I should put direct questions to him instead of waiting for him to speak freely, as he found this so difficult. It soon became apparent that he wanted a Gestapo-style interrogation in which he would be fettered and forced to confess his sins under torture. While such fantasies were sexually satisfying to Peter, the analytical work and the situation in general appeared highly dangerous and frightening … (Kennedy, 1989, p. 352, German version).

Kennedy writes that she did not interpret the Oedipal content of Peter’s fantasies at the outset of the treatment but concentrated on his defence, above all externalization and projection. Peter’s ambivalent feelings for Kennedy transformed themselves gradually into feelings of love and he said things like, “Tell me, do I love you or hate you?” or very seductively, “Darling—I’d like to murder you!” (ibid.). The patient’s sado-masochistic attitude also manifested outside the analysis, the bond with the mother still expressing itself in physical terms. At the age of three Peter had undergone an operation on his penis for a phimosis. His mother continued to take him to the doctor at the slightest sign of physical illness and demanded drastic measures. His mother intensified Peter’s fear of castration for instance in cutting his hair particularly short. Her preoccupation with his body aroused him sexually and fed his sexual fantasies. He experienced being alone with a woman in the room where the analysis was held as seductive and frightening. Despite this, when Peter had an attack of hay fever in a session and sadistically attacked his own nose with tissues, he managed to speak about the phimosis operation. Kennedy verbalized his pain urinating after the operation and the pain he suffered when his mother had to clean his penis at that time. He made fun of this interpretation, saying she saw sex in everything but he stopped attacking his nose! And the hay fever subsided!

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At the end of her description Kennedy emphasized that the affects had overwhelmed the ego functions and that it was only with psychoanalysis that they became amenable to being worked through. It was the analysis of the ego functions that first made the analysis of the transference fantasies possible, which could then lead to a resolution of the sado-masochistic position in the Oedipal conflict. The physical experience of his sexual excitation—also during sessions— could then become the object of interpretation.

Concluding remarks In girls the signs of sexual excitation are not outwardly visible but they can certainly perceive them as a body sensation. The blood flow and activity of mucous membranes are perceptible to girls and often accompanied by fears and a sense of shame—just as with boys. It may be that fear and dread of gynaecological examinations are connected to these feelings. The doctor might notice something that had up till then remained hidden from the girl’s environment; or her fantasies about the gynaecological examination or about the doctor might be linked directly to sexual arousal. The fear of sexual arousal in adolescence is grounded in feelings of guilt, which is, in its turn, associated with the defence against masturbation and with the fear of losing control over affects. These fears can be understood as the fear of losing control of the sphincters. They can be traced to deep-seated fears of falling apart as a personality, of total disintegration. Emotional breakdown in adolescence would represent disintegration. Temporary psychotic episodes in adolescents—not least after overwhelming sexual fantasies or experiences or after drug consumption—can be traced back to fears of this kind. Rising instinctual pressure, their desire for separation from parents, the pull of regression which holds them back and binds them, social pressure and demands from the peer group, desires both for autonomy and for tenderness—all create a storm of feelings that is often too much for the young person. In the treatment of adolescents one cannot stick rigidly to one particular technique: this roller-coaster of feelings must be taken into consideration. As in all psychoanalysis in which we struggle to find insight and reconstruction, it is a question in our technique of

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interpretation of moving from the upper to lower layers, from layers close to consciousness to find those hidden beneath. In doing so we must always bear in mind when offering interpretations that they have to be worked on in an ego-syntonic manner if they are to produce their synthetic function effectively. If the interpretation is experienced as alien to the ego it will at best be rejected. If the patient’s ego functions are unstable such interpretations will in adolescents lead to a destabilization which can have appalling consequences. The instability of the ego-functions in adolescents can often lead them to refuse to lie down on the couch. Alexander, the patient mentioned before, began his treatment sitting in a chair. He was 16 and the treatment was set up with several sessions in the week. After two years and a brief interruption of half a year he asked for a classical setting, lying on the couch, four times a week. I attributed this to a strengthening of the ego functions. These gave him the flexibility he needed to allow himself a temporary regression during analytical sessions. I have also seen adolescents who changed the setting during the session, wanting to sit or lie down according to what defence structure or transference situation was predominant. In Christine’s treatment the analyst came to be seen as an idealized, motherly object. This ultimately allowed Christine to find a new inner space in which sexual gratification did not have to be terrifying or bloodthirsty. The inner space finally gave her a feeling of autonomy: the ability to be independent of her mother and other maternal objects. The search for new identification objects in adolescents can be used for the purpose of defence but it is also an eminently normal process of development. To be on the safe side I have so far not discussed young patients who displayed a fundamental unwillingness and deep distrust of treatment from the start. If we can succeed in overcoming this distrust, which is characteristic of adolescence, a relationship of trust can often be established even if only after a long time. Anna Freud, however, also describes mysterious cases of children and adolescents who come to their sessions in which nothing seems to happen and yet their condition improves. “Simply through his or her presence as therapist and through his or her personal characteristics …” (Sandler et al., 1980, p. 75, German version) the psychoanalyst becomes a new object of therapeutic importance, a fact that we can often neither see nor recognize.

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“The body is clearly the arena of playing out fantasies and memories which are expressed as body sensations and even body imagery, rather than by thought imagery” (Greenacre, 1955, p. 64). Joyce McDougall (1989) refers to the body as a theatre. The pleasurable aspect, if it remains unnoticed in analyses, leads to acting out and defence. With adolescents there is always a danger that the pain which receiving interpretation involves will lead to the failure of the treatment. However if the transference relationship becomes stable enough the same pain can open up new perspectives of pleasurable experience: the chance to enjoy the developing body in all its functions and the chance in using the body finally to take possession of it.

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CHAPTER SEVEN

Rivals or partners? The role of parents in psychoanalytical work with children Kai von Klitzing

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orking with parents is still a neglected topic in the literature on child psychoanalysis although all child analysts are convinced of the necessity of involving the parents in their day-to-day analytical work. The first child analysis, the case of “Little Hans” (Sigmund Freud, 1909b), was even carried out indirectly via the regular reporting of the boy’s father and his supervision by Freud. Freud himself only had direct contact with the child once during the five months of his treatment. In the early years of child analysis the parents were perceived as a source of irritation or complication in the process. The child analysts were affected by their dependence on having the parents bring the child to analysis at all. There was often a complication in that parents would break off the childrens’ treatment prematurely. In her paper “Zur Technik der Kinderanalyse”, Hug-Hellmuth (1920)— one of the pioneers of child analysis—spoke of parental narcissism, which explains the “deep jealousy which wells up particularly in the mothers when they see their child rushing to attach itself to the person of the analyst” (p. 35). Despite these difficulties and indeed because of them she felt it was vital not to proceed without contact with the parents. Parents in her view were, above all, able to 111

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promote the analysis through the information they could give on symptoms and anamnestic details which the children preferred to keep to themselves. It was important to its pioneers to prove that child analysis followed the same principles as those of adult analysis. This made them tend to deny both the pathogenetic and the positive influence of the family. This is, above all, true of Melanie Klein whose theory and technique excluded the influences of the relational environment, presenting child analysis as in all aspects equivalent to adult analysis. The way in which Anna Freud in fact worked showed, however, that she engaged with the parents sensitively according to each individual case. It may well have been for “political” reasons that she wrote only very little on this subject. One way of working with the parents lay in sending them to their own analysis. Many parents of children in child analysis in the early days were themselves in analysis either with private analysts or in a polyclinic which offered psychoanalysis to both child and parents. This meant that the special nature of working with the parents within the framework of child analysis was hardly considered. In this context Kris (1981) discussed whether one should offer advice to patients if they were clearly making mistakes in the upbringing of their children. One problem in working with parents via the psychoanalysis of the parents themselves soon, however, made itself felt in that changes in the adult analysis emerged too slowly for them to be able to influence central developmental phases in their children. Parenthood is only one of several elements in the adult personality. Anna Freud commented on this problem in the following way: There is one point to which child analysts as a rule pay too little attention: analysts working with adult patients who have children see what a small part of the parental personality is preoccupied with the small child and what a large part of the personality has nothing to do with the child. When child analysts work with the parents of a child who is in analysis with them they address this (parental) element of inner experience that is concerned with the child. This is true for mother and also father. It is a mistake to believe that because a child is so intensely preoccupied with its parents that the parents for

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their part are equally preoccupied with their child (Sandler, Kennedy, & Tyson, 1980, p. 17 in the German translation).

Sigmund Freud (1916–1917) had already pointed to the closeness with which inherited and environmental factors are interwoven, and Anna Freud (Sandler et al., 1980) took up a similar position as regards child analysis: “It is for this reason that support is required in child analysis for both sides—internal support for the development of the child’s inner resources but also external aid to free the child from external pressures” (p. 268). She sees the most significant elements of pressure in the relational world of the child as represented by parental interventions in the child’s development and interference with the therapy. Furman (1957) took the discussion further, no longer seeing the parents, above all, as a source of interference with the therapy but describing the parent-child relationship as “a complex over-determined interaction in which two closely interconnected personalities complement each other along many, various and constantly changing unconscious paths.” The French child analysts, Soulé and Lebovici, also focused on interactive processes in the parent-child relationship with a particular interest in the level of unconscious images (Soulé, 1982, “The child in your head—the imagined child”, and Lebovici, 1988, “Phantasmatical interaction”). Novick and Novick (2001) see social-historical reasons for the neglect in child analysis literature of the topic of working with parents. They emphasize the role of women at the end of the 19th century and beginning of the 20th. “Women were idealised—yet at the same time robbed of all public power, including sexual power” (p. 55). They see signs of this tendency in Freud’s work too. In his writing on “Little Hans”(1909b), Freud had nothing but words of praise for the mother although he described her as a woman who had constantly threatened the boy with castration if he continued to masturbate. Yet the mother was not seen as a person who had great influence on the development of the child, apart of course from being the object of the boy’s desire and thus the trigger for the boy’s rivalry with the father. In this way it was, finally, the paternal threat conjoined with the developmental desires of the boy that led to the Freudian concept of the Oedipus complex. This appeared relatively late in the life of the child. The significance of the pre-Oedipal mother was denied.

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Through the supplanting of the theory of seduction in the Freudian theory of development, external reality and with it the influence of the real-life parents retreated into the background, bringing intrapsychic wishes and desires to the fore as the primary determinants of neurosis. This turning to the inner world was strengthened by the psychoanalytical theory of development which emphasized, above all, the way psychosexual phases developed endogenously. These phases were seen as relatively independent of outside influences. The almost complete denial of the influence of the parents based on this theoretical ground is mirrored in the clinical writings of child analysts. Berger (1991) conjectures that the marginal treatment of working with parents in child analysis literature “expresses a sublimated transference problem on the part of the child therapists in their relation to the parents”. The child therapists were basically denying the extent to which they depended on the parents, a dependence which represented a major loss of autonomy for themselves. Therapists working with children cannot regard them as their narcissistic possession—as therapists of adults can. As a result any excessive feelings of omnipotence are clearly limited but perhaps the price is a smouldering feeling of mortification, a slight that hurts particularly because and when parents question, sabotage, and (as it seems) even undo successful therapeutic work with the child (p. 176). A certain neglect of, and sometimes even a disparaging attitude to the parents and their influence has continued and is still apparent today in some child analysis literature. In a large number of interesting and theoretically valuable case studies in child analysis, therapy is terminated by the parents (Blos, P. Jr., 2000) or there are reports of negative influences of the parents on the child analysis process (Baruch, 2000). It is only the recent literature in developmental psychology on the connection between parent-representations, parent-child interactions and the psychical development of the child that has brought the necessity of involving the parents both in diagnostic and also therapeutic process more into the foreground. Prominent child analysts have for example incorporated the findings of attachment research into their theoretical thinking and indeed also into the way they work in child analysis. According to Fonagy and Target (2000), one of the central aims of child analysis today consists in setting in motion mentalization processes in the child in order to help move

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the child’s level of functioning from pure acting out or somatizing to one of symbolizing-mentalizing. The authors are convinced that forming the reflective function is largely dependent on the early mother-child bond (in Bowlby’s sense). A different position is taken up in work focused more on the father-mother-child triad and regarding the early triadification and triangulation processes as essential motors of psycho-emotional development. Von Klitzing et al., (1999) have introduced the triadic competence of parents as a central diagnostic characteristic in the evaluation of parent-child relationships. Triadic competence comprises aspects of the personality and partnership dynamics of the parents, their capacity for dialogue and triangulation, the flexibility of their representations, and also the continuity of their childhood history and trans-generational relationships. Essentially here it is a question of whether parents can be flexible enough in their concepts of the child (“the child in your mind”, Soulé), i.e., that they assume a certain age-related autonomy of the child which might differ from their own ideas. This dimension of flexibility is closely connected with the ability to accept a third person as relevant relational partner for the child without fearing the loss of the child’s love and their relationship with it. Such fears on the part of the parents—namely that a child, if it enters into an intensive transference relationship with an analyst, might no longer be able to love them—is often behind resistance to their child’s therapeutic process. In view of this, parents with a relatively low triadic competence are likely to be a burden on the analysis from the start or even make it impossible. Thus it is a task of clinical child analysis theory to work out ways of approaching the parents in such problematic situations. In this context Berger (1991) pointed out that in the treatment of children the child therapist too “is tested throughout and at all times as to his or her triadic abilities and competence in making room for third persons, in tolerating them and in being able to cooperate with them while simultaneously creating and maintaining a therapeutic space for the adolescent or child” (p. 176). In child analysis literature many case studies come across to a certain extent as an account of the failure in triadic ability on the part of the therapist. The central goal of child psychoanalysis as Anna Freud (1965) defined it was “leading the child back onto the path of development”. If one now pays greater attention to the significance of the

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parent-child relationship for the child’s development, then the removal of impediments to the individual’s development cannot be the sole goal of a child analysis. Leading the parent-child relationship back to regain its potential as a life-long positive resource for both parents and child is equally important. Seen against the background of such reformulated aims, working with the parents not only serves the purpose of enabling and fostering the child analysis process but itself becomes the agent of change in carrying forward the development of child analysis in general. Of course parental attitudes may form resistance to the setting-up and course of the child analysis process. Frequently—before the start of therapy already—the parents’ state of denial represents a defensive attitude so that often in collusion with pediatricians and teachers parents only look for help when the children fail dramatically at school or become impossible to manage in educational institutions on grounds of their behaviour. Further resistance on the part of the parents can be called forth by overpowering, almost traumatic feelings of guilt. Offering a child therapy could cause an exacerbation of guilt leading parents to avoid such difficult feelings. But beyond resistance and cooperation, there are further aspects of parental attitudes that are important for child analysis: these aspects have something to do with the fundamental motivation for parenthood and attitude to “being a parent”. Novick and Novick (2001) pointed out that parenthood takes a path from developing the desire to “carry” a child inside one to the desire to raise the child. Independently of cultural and psychological influences there seems to be a need in every individual to create something that goes beyond the self and care for it, i.e., to care for, protect, foster, and improve a new idea, a project, or a person. All of this is involved in being a psychological father or mother. Novick and Novick define the forming of a therapeutic alliance with the parents during the various phases of treatment as a divided stage on which the possibilities and impediments to aspects of psychological parenthood are played out and worked through. In analytical work alliances emerge with the child, with the parents, between the parents, and between parents and child (see diagram). The inextricably interconnected triads make very great demands on the triadic capacity of all involved but above all on the therapist.

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Therapist Mother

Child

Father Diagram 1. Triads and their interconnection in the psychoanalytic treatment of a child. Not only do therapists have to accept that outside the therapy there are parents to whom the child relates closely as real people and who shape the primary objects of the child’s inner world: they are also confronted with the partnership between the parents, i.e., with the parental primal scene, both challenging and hurtful to therapists’ feelings but which are in fact the prerequisite for therapists to receive “their” child. If therapists cannot be flexible enough to integrate the shifting object relations in themselves, serious relationship problems will be the consequence in the triads as they overlap. Therapists may feel they are the better mother or father for the child, the better partner for the mother or father, or may begin to feel persecuted by the threesome of the parents plus child. They may feel they have to protect the child against the parents or interpret mortifying standstills in therapy as failure on the part of the parents. All such transference and countertransference problems hinder the progress of a constructive working relationship between analyst and parents. Yet this relationship is an absolutely essential prerequisite for individual work with the child. Novick and Novick (2001) formulated the following three points as the aims of work with parents and the working alliance with

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parents in child analysis: that the parents should regain a feeling of competence; that guilt is transformed into useful concern; and that the parents develop the ability to perceive their child as separate from themselves. The parents’ feeling that they are competent as parents represents a kind of compensation for the narcissistic hurt implied in having their child enter into a relationship with other significant persons (among others with the therapist) and so increasingly become independent of them. Parents’ parental competence is linked to the internalization of parental functions, primarily in identification with their own parents and parental surrogates. Seeing one’s own child as part of one’s own self, so to speak as a narcissistic complement to a self with deficits, is most often a parental constellation that hinders the child’s development and therapy. It is a painful process to give up the illusion that the child could be a part of one’s self and so provide some kind of narcissistic extension of one’s own life into the future. If they set out on this path with the help of the therapist they benefit in that it lessens their feelings of guilt when faced with their child’s symptoms. It becomes possible for them to see their child as an increasingly autonomous object of their love and care and can concern themselves with its development: a concern which, if all goes well, they can share with the therapist and this makes parents and therapists partners in an alliance aiming for the most positive development possible for the child. Before or at the start of the treatment it is above all important to involve the parents fully in the diagnostic process. One question that needs to be clarified is whether the problems expressing themselves in the child’s symptoms are of an intrapsychic or interpersonal nature. If the second is the case, i.e., the child’s symptoms are predominantly an expression of current unsolved interpersonal conflicts in the family, then this is an indication first of all for working in a parent-child setting (cf. for instance the Muratori et al., concept, 2002). In the further course of treatment, beginning individual analysis requires a minimum of intact parental functioning. Frequently the parents suffer from feelings of guilt which make it hard for them to create an appropriate holding setting in their life with the children. These feelings of guilt should at least be brought up before individual sessions are set up. If the child’s symptoms primarily serve to maintain a fragile balance in the family relationships then an individual analytical

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treatment will necessarily meet with major resistance on the part of the child that cannot usually be overcome. A further counterindication for individual analytical treatment is the presence of extremely powerful taboos and secrets in the family. If for example a child’s origin is an adoptive family or the identity of its father has been kept a secret then the child will sense that it is forbidden to know essential truths about its own biography and that nobody speaks about such things. It would be asking too much of a child in such a situation that it should open up in an analytic treatment and be frank, associate freely, and explore inner truths. During the treatment of the child the parents’ narcissistic hurt on the one hand and that of the attending analyst in the countertransference on the other are often important themes. The parents’ feelings can be hurt that their child confides in another person. The analyst may be pained that this child is not his/her child but has a deep, even if sometimes pathological relationship with the parents. Such feelings can lead to rivalries. If they are not worked through this regularly leads to the parents breaking off the therapy. It often becomes clear that the parents themselves show a certain psychopathology and are in need of treatment. This can sometimes mean that a rivalry can emerge between parents and child over the therapist. Resistance in the psychoanalytic treatment can shift into the interpersonal field which leads to the parents being unable any longer to support the treatment. In working with parents during treatment such instances of resistance and such constellations must be openly addressed and worked on without this developing into a regular therapy for the parents. The end of the therapy presents a particular challenge for the alliance between parents, child, and therapist. The question after all is: “Who is going to decide when to end it?” In most cases it is the parents who decide and for us the end of the therapy sometimes feels wrong—like a breaking off of relations. We, as analysts, have to work on the “sting” that this represents, as we are forced to realize that it is the parents who have so much power. They are the child’s most significant others. It can also happen that fears arising in analysis and constellations not sufficiently worked through are “carried over” by the child to the parents and that they then react with interference in the therapy. After a long and intensive analysis with a child the pains of separation can be hard to bear for both child

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and analyst. For the analyst this can activate feelings of envy and rivalry and the pain is exacerbated by the knowledge that the child will continue to be with its parents. Finally, a fully acceptable ending from the analyst’s point of view can only be found if and when trust has been established and he or she has confidence in the parents’ ability to function appropriately. This is something the analyst will only achieve if he or she has established an intensive relationship to the parents and has genuinely engaged with them in such a way that both problems and resources in the parental function have been recognized and worked on.

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REFERENCES

Alvarez, A. (1980). Two regenerative situations in autism: reclamation and becoming vertebrate. Journal of Child Psychotherapy, 6: 69–80. Alvarez, A. (1992). Live Company: Psychoanalytic Psychotherapy with Autistic, Borderline, Deprived and Abused Children. London: Routledge. Alvarez, A. (2000). Moral imperatives in work with borderline children: the grammar of wishes and the grammar of needs. In: J. Symington (Ed.), Imprisoned Pain and its Transformation: A Festschrift for H. Sydney Klein. London: Karnac. Anzieu, D. (1989). The Skin Ego. New Haven, CT: Yale University Press. Baruch, G. (2000). Die Wirkung elterlicher Eingriffe auf die Analyse eines fünfjährigen Jungen. Kinderanalyse, 8: 61–82. Begoin-Guignard, F. (1987). Die Erfahrungen des Psychoanalytikers mit Kindern und Erwachsenen. EPF Europäische Psychoanalytische Föderation Bulletin, 29: 45–61. Berger, M. (1991). Zu den Erfahrungen von und mit Eltern während der psychoanalytischen Behandlung ihrer Kinder. Zeitschrift für Kinderund Jugendpsychiatrie, 19: 175–181. Bion, W.R. (1957). Differentiation of the psychotic from the nonpsychotic personalities. In: Second Thoughts, London: Heinemann Medical, 1967 [reprinted in paperback, Maresfield Library, London: Karnac, 1984, p. 57].

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INDEX

Aggression surge 91 Aggressive–destructive fantasies 9 Alexander analysis 91–92 “tissue nappy” 91 Amazon of pre-adolescence 77 Anzieu, Didier mantle of pain 100 Asperger’s syndrome 69–70 Autistic pathologies 21

Adolescence as phase of development 101–102 homosexual episodes in 103 sado-masochistic perversion in 106–108 Adolescent girl Christine’s case 99–100 identity and bisexuality 75–86 masturbation phantasy 77 particular role of skin 99 thoughts on technique from the analysis of 75 Adolescents analysis with Alexander 91–92 development of body image, body ego, and ego structures 89–110 psychoanalytical technique in treatment 89–110 Adult sexual body 76

Bion, Wilfred R. 18, 47, 58, 63 “catastrophic change” 20 formulations 20 models of reverie 20 sense “bizarre objects” 27 theories 47 thoughts 57 Bisexual identification 87 omnipotence 87

129

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130

INDEX

Bisexuality 75–88 in female adolescence 76–78 theme of 80 Body ego 90 development of 90 pleasure-physiologic 95–97 Body ego symptoms, significance of psychical processing 91 Borderline and narcissistic pathologies 21 children 61, 64 psychosis 64 Brainin, Elisabeth 89 Bridges: toys and stories 66–73 British Psychoanalytical Society 4 Britton 62 Central masturbation phantasy 77, 102 in adolescence 102 Child analysis 5, 12 analytical thinking 13 autistic spectrum 64 capacity for symbolization 61–62 child’s development 89 clinical and technical problems in 43–59 clinical vignettes 21–39 countertransference interpretations 72 establishing contact 66 grammatical and non-verbal aspects of interpretation 73–74 internalization of the analytical method 13 interpretation in 19–39 Jacob’s case 31–39 Jana case 37–39 “Little Hans” case 111 Mira’s case 19, 21–31

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Moustaki’s formulation 63 on play and playing 17–19 on the setting for 16 particular features of 14–16 psychoanalytical process 13 psychological problems 22 psychotic anxieties 64 social contacts, symbolize 61–74 technical modifications 61 therapist’s mirroring function 67 three levels of technique in 13–41 transferences of parents 15 Child and Adolescent Psychiatric Clinic 22 Child psychoanalysis 111, 115 Children mechanization of the technique 2 play 1 proper behaviour 1 psychoanalysis 1 Children and adolescents clinical and technical problems in 43–59 transference—interpretation— play 1–12 Child’s therapeutic process 115 Childhood history and transgenerational relationships 115 Chimney sweeping 94 Christie, Agatha 45 Christine’s case 99–100 genitals 99 pre-conscious desire 100 Collective stupidity 44 Countertransference 85, 93 interpretations 72 Damasio, Antonio 90, 99 Darix Togni 46

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INDEX

Death gap 64 Desexualized intention principle 88 Digesting-through-dreams 57 Dyslexia 49 Ego 90 development and structures 90 ego-functions 104 thoughts on technique 92–93 Ego structures, Freud’s concept of 90 Ego-syntonic manner 92 Egotism 94 Emotional turbulence 90 Emotions 44 alphabet of 50 Erotic exploitation 94 Erotization 72 Externalization of emotions 44 Externalizing 44 Father–mother–child triad 115 Female homosexuality 47 Female sexual functions 97 Feminine 86 Femininity of mother 85 Fenichel, Otto 89, 93 Ferro, Antonino 5, 43 bi-personal field 66 conceptualizations 20 “good enough mother” 20 “holding function” 20 projective identifications 20 Fliess, Robert 96 Fonagy, Peter 18 Forward-driving force 59 Fraiberg, Selma 14 Freud, Anna 2, 4, 7, 17, 62, 90, 92, 96, 112–113, 115 over child analysis 7 Freudian theory of development, external reality 114

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131

Freud/Klein controversies 4 London 6 Freud, Sigmund 113 Genital excitation 94 Gestalt 56 Ghost mother 23 Girls and women menstruation problems and pains 98 perception of the inner gentalia in 97–98 uterus and uterus contractions 98 Global sexual excitation 100 Godfrind, Jacqueline 85, 88 Günter, Michael 1, 62 squiggle game 62 Heterosexual 47 object finding 76 Homosexuality 47, 103 Houzel, Didier 66 Identity and bisexuality 75–88 Instincts and their Vicissitudes 89 Jack and the Beanstalk 68 Jacob’s case 31–39 aggressive phantasies 35 building blocks 34 Caesarean as a narcissistic wound 31 drawings 32–33 frustration 31 Jana case 37–39 first interview 37 Gymnasium 39 night-time fears and panics 37 omnipotent phantasy 38 parents’ separation 37

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132

INDEX

Kennedy, Hansi 106 boy’s masturbatory conflict 106 Kestenberg, Judith 98–99, 106 Khan, Ghengis 54 Khan, Masud 94 Klein, Melanie 1, 7, 16–17, 112 conviction 9 over child analysis 7 Klitzing, Kai von 111 Kremp-Ottenheym, Helga 75 Kris 112 Laufer, Egle 77, 87, 102 Laufer, Moses 77, 102 Libidinal cathexis 100 Libidinous cathexis 96 Lines of Advance in Psychoanalytic Therapy 4 Little Hans 13 “Living” the emotions 45 Luca’s inner turbulence 53–55 Luigi and reading 49–51 anxieties 49 characteristic tendency with 50 response 50 severe dyslexia 49 Male–female 85–87 Masculine 86 Masturbation equivalent 94 McDougall, Joyce 110 Mental functioning/ malfunctioning 59 Mentalization 18 Minotaur in petrified tree form 51–53 Mira’s case, child analysis 19, 21–31 affective-body states 25 early development 23 first interview with 23 further development 22

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psychotic depression 25 social contacts with adult 22 Mother–child bond 115 Mutism and inhibition 53 Narcissistic and bisexual positions 76 wound 31, 37, 104 Negative hallucinations 89 transference 9 Neuro-dermatitis 100 Neuropsychology 97, 99 Neurotic pathologies 21, 40 Nicolo’s case 51–53 Non-sexual relationships 85 Novick and Novick 116–117 Oedipal balance 63–64, 69 couple 63–64, 70, 72 conflict 108 drama 76 fantasies 79 father 78 pain 20 plane 38 Oedipus complex 13, 76, 113 Omnipotent phantasy 38 On Beginning the Treatment 2 Organ libidinization 95 Paranoid-schizoid 11 Parental personality 112 Parent–child interactions 114 relationship 113, 115–116 Pathogenic influences 15 Patient’s life-situation 81 personality problems 82 projective identifications 20 Payne, Sylvia 6

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INDEX

Personality and partnership dynamics 115 Phantasies and dreams, unconscious expression 90 Pleasure-physiologic body-ego 95–97 Postman Pat 68 Pre-genital infantile sexual strivings 104 Pre-Oedipal mother 77–78, 113 phallic mother 86 Projective identifications 51 Proto-emotional experience 18 Proto-emotions 44–45, 47 Proto-emotive states 44 PS<>D oscillations 21 Psychic component 105 disintegration 105 illness 13 process, unconscious 12 Psychical instances 91 pain 20 Psychoanalysis 1, 4, 81, 89, 92 fundamental suppositions 5 of parents 112 Psychoanalytic process 90, 94 technique 6 Psychoanalytical theory of development 114 Psychoanalytic treatment of adolescent 90 of children 9 of child triads and their interconnection 117 Psychoanalytical process 5, 8 theories 89

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133

therapy 2 thinking 5 Psychoanalytical work with children role of parents 111–120 Psycho-emotional development 115 Psychological tact 6 Psychosexual development outside and inside 98–99 Psychosexual phases 114 Psychotherapy, generic model of 6, 86 Psychotic depression 25 Raul’s incontinence 55–59 Reflections on the mind 46–48 Reverie and après coup 48–49 Reverie and projective identification 48 Rhode, Maria 61 Rivals or partners 111–120 Sado-masochistic elements 92 fantasies 93 perversion in adolescence 106–108 Schilder, Paul 96 Seductive sylph 103 Self-destruction 80 Self-medication 104 Self-punishment 80 Self-reflection—qualities 5 Self-reflectiveness 6 Sexual developments 103 encounter 81 excitation 91, 103, 108 fantasies, unconscious 98 gratification 107 identity 88 Sexuality 47

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134

INDEX

Sharp, Ella Freeman 4 Skin ego 100 Sphincter spasms 95 Spinning yarns 57 Spitz, René 100 Staehle, Angelika 9, 11, 13 Super-ego, technique-focused 10 Symbolization 18, 20 Symbolizing-mentalizing 115 The Ego and the Id 96 The Psychoanalysis of Children 1 The She-wolf 46 Theoretical backdrop 21 Timidity and persecution 45–46 “Tissue nappy” 91 Toddlers, phantasizing and thinking of 14 Transference 8, 61 fantasies 92–93 homosexual 103 interpretations of 102 neurosis 93 relationship 12, 97, 110

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resistance in the psychoanalytic process 94 sado-masochistic aspect 107 technical issues in the treatment 61–74 unhelpful transference interpretation 65–66 Transformations in hallucinosis 54 Tustin, Frances 64 child’s flapping hands 64 Unconscious identification 100 Unconsciousnesses 20 Williams, Donna 64 Winnicott, Donald W. 17 formulation 19 sense and of containment 29 thinking in Ferro’s conceptualizations 20 “true self and false self” 20 “truth and lies” 20 Young female patient 95

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