The Use of Psychoanalytic Concepts in Therapy with Families

For all Professionals Working with Families

Hilary A. Davies

• Publisher: Routledge
• Year: 2020
• Topic: Psychology
• eBook ISBN:
  9780429922657
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book begins with a readable practitioner's guide to psychoanalytic theory and concepts. It moves on to give a number of detailed practice-based examples of the application of this theoretical model in the therapy room with the families of children seeking help with a variety of difficulties. The ideas are presented as an enhancement, and not an alternative, to the different styles and schools of therapy with families, and aim at enriching and broadening both the therapist's thinking and practice skills. The examples include: children who have suffered emotional harm, young children whose behaviour can be violent, feeding difficulties, anorexia nervosa, somatic presentations, and children whose separated parents are in conflict. The author writes clearly and enthusiastically on the important possibilities that this way of thinking can bring to therapists' work with families.

CHAPTER ONE
Psychoanalysis

A brief synthesis of psychoanalytic thinking that spans well over half a century is presented. The main focus on four figures is not intended to minimize the important contributions of others, but does aim to track the progression of psychoanalytic thought from the consulting room of Sigmund Freud out into clinics, hospitals, and community settings from the middle of the twentieth century and on into the twenty-first century.

Sigmund Freud (1856–1939)

The theory and practice of psychoanalysis were first introduced by Sigmund Freud at the end of the nineteenth and the beginning of the twentieth centuries as a method of treating mental illness. He constructed his original theory of psychoanalysis from studying the hidden psychological origins of various somatic symptoms in his patients that were neither explained by physical medicine nor responded to the conventional medical treatments of the time. He developed the practice of psychoanalysis with individual patients, usually adult, and frequently women.

At that time, Freud and his followers were writing for the medical profession and not for therapists. Through his work, he came to understand that beyond a person’s observable behaviour, articulated thoughts, and expressed emotions lies something more complex and more profound. He sought to think about and to understand this internal self, and his work took him on from the study of the sick to an understanding of the wider meaning and implications of human behaviour, experience, and relationships. Specifically, he was interested in, and focused his thinking and writings on, that level of a person and personality that was not easily available to scrutiny. Freud called “the unconscious” these layers of a personality structure that exist below what is immediately and consciously experienced by an individual and readily observable by others.

In 1920, Freud presented one of his theories on the nature of the unconscious, that of the repetition compulsion. This theory proposed that, at a very primitive level of functioning, all experience that affects the developing personality tends to be repeated over and over, regardless of pleasure or pain, loss or gain, until there is resolution of the conflict or difficulty. In contemporary work with families, this process might be recognized as a repetition and searching for resolution which may continue over and over and down through several generations (Byng-Hall, 1995). (See Chapter Three, “Influence of early experience in relationships and effect on personality development and later relationships; patterns and myths in families”.)

In his patients, Freud observed that buried unwanted memories were often managed in ways that were dysfunctional in adult life, by means of defences: for example, against anxiety (attempts to fend off the memory or unmanageable conflict of feelings) or depression (withdrawal from what is unbearable). In clinical practice, we see children and young people also unconsciously employing dysfunctional mechanisms for coping with unwanted memories, distress, and psychic pain, such as attempting to bury, forget, or deny them. (See Chapter Three, “Defences used to protect the individual against intolerable anxiety or depression, including projection, projective identification, displacement, splitting, identification with the aggressor”.) This process can then lead to the symptoms, distress, and ill health that bring children for therapy. Freud came to believe that unearthing and reflecting on buried memories potentially had a healing effect, and this belief became the focus of psychoanalytic thinking and practice at the time.

Freud understood symptoms or dysfunction as developing not only from these defences employed by the immature personality to manage overwhelming anxiety about life events, but also as a failure to resolve early conflicts between different parts of the personality as it developed, with consequent implications for personality development and healthy functioning. In work with families, similarly, we find different family members holding different positions which might equate with different parts of an individual personality: one person being uncontrolled and acting impulsively, with another seeming to be exclusively controlling and repressive. As in therapy with an individual, work with a family moves towards each member managing an integration of the different positions.

Throughout most of his life, Freud’s work was directed at seeking to understand and treat what happened in the development of an individual that led to these symptoms causing dysfunction: for example, problems with physical health, emotional or psychological well-being, or within relationships. However, in his later work, he focused more on a theory of “normal” or functional development of the personality through the formation of the “ego” (the mature personality), with the integration of its component parts, the “id” (the uncontrolled and primitive impulses) and the “super-ego” (the controlling and repressive sense of what is good and expected behaviour) (Freud, 1923b).

Some writers have traced one of the earliest recorded practices of family work, maybe surprisingly, to Freud himself. In his work with Little Hans, Analysis of a Phobia in a Five-Year-Old Boy, the boy was treated for an apparent phobia of horses. Freud did not work directly with the child, but instead conducted the therapy with the boy through his father as “therapist”.

The case history is not, strictly speaking, derived from my own observation. It is true that I laid down the general lines of the treatment, and that on one single occasion, when I had a conversation with the boy, I took a direct share in it; but the treatment itself was carried out by the child’s father . . . No one else, in my opinion, could possibly have prevailed on the child to make any such avowals; the special knowledge by means of which he was able to interpret the remarks made by his five-year-old son was indispensable, and without it the technical difficulties in the way of conducting a psycho-analysis upon so young a child would have been insuperable. [Freud, 1909b, p. 5]

The therapy revealed the source of the child’s anxiety as dating to the time of his mother’s pregnancy and the birth of his little sister when Hans was three and a half years old. At this time, Hans felt the loss of his mother to the new baby and experienced rivalry for his mother with his father. He felt unmanageable fear and anxiety about the consequences of this competition. Hans’s fear was displaced on to the safer object of horses, which could be talked about, whereas rivalry with his father could not be clearly thought about, let alone spoken. He brought to his father descriptions of the feared animals and the circumstances of his fear, which Freud, with the father, understood as Hans’s anxiety in his relationships with his parents and about his rivalry with his new baby sister. Through a new understanding, Hans, in time, experienced relief.

In his work with Hans, Freud described his capacity as analyst to allow his own thoughts to follow the patient’s associations in order to make sense of the boy’s fear. In discussion, Freud writes that the analyst endeavours

. .. to enable the patient to obtain a conscious grasp of his unconscious wishes. And this we can achieve by working upon the basis of the hints he throws out, and so, with the help of our interpretative technique, presenting the unconscious complex to his consciousness in our own words. There will be a certain degree of similarity between that which he hears from us and that which he is looking for, and which, in spite of all resistances, is trying to force its way through to consciousness; and it is this similarity that will enable him to discover the unconscious material. [ibid., pp. 120–121]

Families may also give us hints or insights into unconscious unavailable material through “Freudian slips”. These can provide valuable information on the underlying nature of difficulties.

The analytic practice with Little Hans is different from contemporary therapy with families, where therapists work in a room together with family members. However, it is an early example of work with a child being carried out not by an analyst or therapist alone in the treatment room with the child, but by the child’s parent at home under the “supervision” of the analyst. It may also be understood as an equivalent to contemporary therapists working in the room with families and utilizing the experience and expertise of parents in order to treat the child.

Through his thinking on what he called the Oedipus complex, Freud presented young children’s strong feelings of possessiveness of parents and envy and rivalry with siblings as normal, expectable parts of growing up in a family. As with little Hans, he viewed a sibling relationship as part of the Oedipus complex, where the sibling rivalry is centred around competition for the attention of the parents. The rivalry is not limited to siblings where there is a blood tie, since it exists also in reconstituted families for the same reason of wishing to gain the attention of parents, and may be particularly apparent where one birth parent has been lost. The sibling bond is strong and complicated, and affected by birth order, closeness in age of siblings and gender, differential behaviour of parents towards siblings (actual or perceived), personality traits, and children’s life experiences. (See “Family examples”, below.) If sibling rivalry becomes extreme, or unacceptably aggressive or distressing, professional help is sometimes sought. (See Chapter Three, “Nature and appearance of unconscious processes, including transference and countertransference, the Oedipal stage, and free association”—”Oedipal stage”.)

Most often, Freud’s way of working with his patients was directly through the relationship developed intensely over time in the therapy room. Within the therapeutic relationship, the patient’s uninhibited expression of thoughts (through free associations and recounting dreams) was available to the analyst’s understanding (interpretation). The technique of interpretation as a therapeutic tool was one of Freud’s earliest contributions. (See Chapter Three, “Importance of interpretation and containment”.)

Importantly, also, patients developed a dependence on the analyst that allowed the analyst to understand aspects of the patients’ relationships with their parents or primary care-givers in infancy from the nature of the patients’ relationships to the analyst in therapy (transference). The analyst’s own personal response to this transferred material (countertransference) was also included in the interpretations back to the patient. This way of working, through the therapeutic relationship with patients’ unconscious material and past experience as manifest in present relationships and current defences, is a distinguishing feature of psychoanalysis and psychoanalytic psychotherapy. (See Chapter Three, “Nature and appearance of unconscious processes, including transference and countertransference, the Oedipal stage, and free association”.)

Freud’s work was influential in moving professional thinking from a focus on symptoms to an emphasis on the central importance of primary family relationships and, in analysis, on the relationship between analyst and patient. He worked with his adult patients through their formative relationships being “transferred” on to the relationship between analyst and patient in the consulting room. Now, therapists with families are working in the therapy room directly with young people and their families and their current relationships, which include also internalized models from past relationships.

Melanie Klein (1882–1960)

Following Sigmund Freud, Melanie Klein began her work in 1919 and developed further Freud’s ideas on the workings of the inner world. She was particularly interested in the idea of innate aggression, developing this from Freud’s theory of the death instinct (Freud, 1920g). Alongside this, she presented her idea of the centrality of love as a basis of life. She came to focus on the conflict between love and the more destructive feelings of hate, guilt, and aggression, and saw the resolution of this conflict as crucial in the development of the functioning personality (Klein, 1937). In Freudian terms, Klein thus considered the childhood struggle between the superego (what the child believed he or she should do or feel) and the id (the child’s natural desires or impulses), with attendant anxiety in the formation of the functioning ego (the integrated personality). The analysis or therapy worked to provide the safe therapeutic space and relationship that offered sufficient containment and understanding for the conflict of feelings to be recognized and thought about, and for defences to be no longer required.

Melanie Klein applied Freud’s theory of psychoanalysis to the practice of child analysis. She recognized the role of play in the analysis of children, where play in a child may be thought of as the communication equivalent of free association in an adult. She also saw play in itself as being therapeutic for a child, who could play out over and over again current inner unconscious conflict until some relief was experienced. For example, loving mummy and daddy, but feeling murderous hatred when they are together and the child is excluded. Though the play itself was felt to be therapeutic, the analyst might also offer interpretation or understanding of the unconscious feelings, fears, conflicts, and defences expressed in play by the child. In this way, the child experienced that overwhelming anxiety or conflict could become both bearable and available to being thought about and understood, with the aim of providing relief. Similarly, in family meetings, with the contribution of the therapists’ understanding and containment of feelings, the families’ facilitated conversations can in themselves be therapeutic. (See Chapter Three, “Importance of interpretation and containment”.)

In her development of play technique with children, one of Klein’s basic beliefs was that all play has symbolic significance. She realized the importance both of having a clinical space separate from the child’s own home for the conducting of the analysis, and of each child having his or her own individual box of toys which was used only for the treatment with that particular child and which was left closed in the therapy room after each session, ready for the next. In this way, the child experienced security and containment of conflicts and anxieties with the therapist and within the therapeutic setting.

Klein contributed ideas on “splitting”, which many therapists with families will recognize. For example, a father may be marginalized and reported as being “useless” and “never there”, with mother taking all responsibility, or the child who is the identified patient may be described as “the whole problem”, with other children in the family being presented as having no difficulties at all.

Splitting is recognized as a part of usual development. Infants hold on to and benefit from the “good” experiences (those that feel positive and manageable) and initially project the difficult or “bad” experiences into parents for them to process and manage for them. A young infant will enjoy and grow from the pleasure and comfort of the mother’s presence. However, initially, the infant will experience unmanageable rage and distress at the mother’s absence. At first when this occurs, the infant needs to split off the scary angry feelings into another person who provides containment through comfort, holding, and reassurance, and who bears and processes the feelings so that they are not overwhelming. For example, the infant screams in panic when mother is not there, mother arrives and holds, talks to, and reassures the infant, the infant quiets. Without the presence of the containing other person, the infant is likely to become swamped as the panic takes over. In time, from a repeated experience of the “bad” projected feelings being held and made bearable, the infant is able to internalize the good holding experience and manage the difficult feelings him- or herself.

Therapy with families where splits are presented would work both towards recognizing and acknowledging the function and dysfunction of the splits and towards integration of the “good” and the “bad”: for example, bringing together and recognizing both the positive contributions and difficulties of mother and father, and of all the children in a family. This can be achieved within a family structure where all family members can, for example, express their aggression and more “negative” feelings, such as rivalry and envy, as well as the “good” and acceptable ones. (See Chapter Three, “Defences used to protect the individual against intolerable anxiety or depression, including projection, projective identification, displacement, splitting, identification with the aggressor”––“Splitting”.)

Anna Freud (1895–1982)

At about the same time as Melanie Klein, Freud’s daughter, Anna Freud, began her work in developing the ideas of her father for the analysis of children. In 1927, she published her first writing “Introduction to the technique of child analysis”. She paid tribute to her father as the source of her own ideas and work, and acknowledged that they felt they were the first to understand human behaviour and its difficulties as originating not in overt factors, but from the pressure of instinctual forces coming from the unconscious mind.

Just before the outbreak of the Second World War, the Freud family fled from Austria and settled in London in 1938. Sigmund Freud died soon after the war began. Following her father’s death, Anna Freud continued to explore in her work the effects of the war on children who had lost a parent through death or separation, such as evacuation away from home. In London, she founded the Hampstead War Nurseries, which provided care for children of single parents. The children were encouraged to develop attachments through continuity in their substitute care, and by parents visiting as often as possible. With Dorothy Burlingham, Anna Freud published her studies of these children during wartime: Infants without Families (1944) and Young Children in War-Time (1942). Before her move to London, in a nursery set up for the poor of Vienna in 1937, Anna Freud, together with her colleague Dorothy Burlingham, had begun observations of infant behaviour. Following the move to the UK, Anna Freud continued this work, first at the Hampstead War Nurseries and then at Bulldogs Bank, a home for orphans. She believed that, as much as possible, the parents should be involved with their children, and her observations included interactions of child...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• ACKNOWLEDGEMENTS
• Dedication
• ABOUT THE AUTHOR
• INTRODUCTION
• CHAPTER ONE Psychoanalysis
• CHAPTER TWO Therapy with families and family therapy
• CHAPTER THREE Psychoanalytic theory concepts, and practice with families
• CHAPTER FOUR Young children with feeding difficulties
• CHAPTER FIVE Children and adolescents with anorexia nervosa
• CHAPTER SIX Children who have experienced emotional harm
• CHAPTER SEVEN Young children whose behaviour can be violent
• CHAPTER EIGHT Adolescents whose bodies bear the emotional hurt
• CHAPTER NINE Children whose parents are "at war"
• CHAPTER TEN Perspectives and practice
• REFERENCES
• INDEX