Psychic Hooks and Bolts

Psychoanalytic Work with Children Under Five and their Families

Maria Pozzi Monzo

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781855759077
• eBook ISBN: 9780429917622
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

'In this book it is made plain that complex and powerful understanding can take place in brief work. The baby's development is carried forward, the family re-groups differently, and understanding brings a change in behaviour.'- Lisa Miller, from the Foreword. 'This book focuses on young children as old as five and the parents and siblings who live with them. It wants to explore deep, unconscious connections between children and parents, especially in those cases where symptomatic behaviours develop and turn a potentially pleasant and satisfying family life into hell.' -  This fascinating and comprehensive work is divided into two parts. The first gives the theoretical background to the subject, outlining the main theories of the pioneering Melanie Klein, Wilfred Bion and Donald Winnicott. The second part deals with the clinical cases that illustrate issues such as post-natal depression, separation difficulties, eating problems, bereavement and loss, learning disabilities and hyperactivity.

Part I

Theoretical Background

Introduction

In this book, I focus on young children up to the age of five and the parents and siblings with whom they live. My aim is to explore the deep, unconscious connections between children and parents, especially in those cases where symptomatic behaviour develops and turns a potentially pleasant and satisfying family life into hell.

When psychotherapists and psychoanalysts write about their work they are usually grateful to their patients and their families. This is particularly so in the case of child analysts, as children and their families constitute one of the essential ingredients of the work of writing. Through our therapeutic work and our relationships with patients, we continue to learn about human nature, suffering, and the functioning of the mind.

The word “patient” stems from the Latin “patior” which means to suffer. In the cases I describe in later chapters, the patient, or more often the patient’s family, are the sufferers. They come into treatment to find ways, with the help of the analyst, to reduce or to give up that suffering. The patients present themselves with emotional, neurotic or existential suffering. It can be a consequence of trauma, abuse or physical or mental illness, but is usually a lonely and meaningless type of suffering. It differs from the psychic pain that the patient will hopefully be able to experience and tolerate by the end of therapy. The Latin word subferre is the root of the verb to suffer and means to go below or under. The patient then, from being a sufferer, someone who bears the weight of life events and is a victim of this somewhat unhealthy state, becomes able to understand, to take charge and to turn that lonely suffering into the psychic pain that is part of the human condition. It is what Freud meant by his famous reply to a hypothetical patient questioning him about his imability to change the circumstances and events of the patient’s life. Freud replied: “But you will be able to convince yourself that much will be gained if we succeed in transforming your hysterical misery into common unhappiness” (Breuer & Freud, 1893–1895, p. 305).

The inspiration for the title of this book came from two families whose small children needed help. Four year old Claire and her mother had an idyllic relationship during the first two years of Claire’s life. The external world had been excluded, in some inexplicable way, from this tight dyad. However, when mother became pregnant with her second child and the “no” phase was ushered in, Claire became contrary, angry, and intolerable. She was no longer the delightful child she had been and clearly felt deeply betrayed and let down by her mother. She had not yet begun to master the presence of the “third person”, when the new baby arrived, despite father having been involved in her upbringing. Mother on her part felt guilty for giving her beloved “princess” such a harsh experience and was hurt by Claire’s reaction. She also felt hooked onto her daughter’s anger and disappointment and in the session she demonstrated this feeling by hooking her two index fingers together. This became a metaphor that we continued to use through the family sessions and I still use it, ten years later, in my current practice. It is the equivalent of the state of collusion where the child’s feelings and states of mind resonate and latch on to the parents’ feelings. The latter react in turn, without processing the events. The child and the parent, or both parents, are caught up with each other in a relationship that becomes like a tug-of-war, and is far from being the container–contained relationship described by Bion (1962a).

The concept of “psychic bolts” also emerged during family counselling with another four-year-old girl, Susan, who had not been able to sleep properly since she was an infant. The parents, the newborn baby, and Susan were distraught by lack of sleep and in a counselling session, the parents, out of exasperation, expressed the conflicted wish to put bolts on Susan’s bedroom door. “Psychic bolts could be enough,” I suggested. This metaphor stood for firm boundaries that could be opened and closed and it defined the separateness, which had never been properly achieved between Susan and her parents. It worked indeed, as we will see in the chapter on sleep. The term “psychic bolts” has also become part of my tool kit and has indeed alleviated the pain of many more unhappy families when too many “hooks” exist between children and parents and prevent the evolution of a containing relationship.

As often happens in psychoanalytic writing, this book is also inspired by my personal family history and vicissitudes. It focuses on the infant or small child’s world within the wider context of family relations and interactions. It is born out of my desire to continue thinking and to share with the reader the exciting work and achievements that can be obtained in psychodynamically-based work with small children, seen together with their parents, siblings, and occasionally also with the grandparents. It is a psychological work that aims to examine this young age within its family context, when so much can still be done to achieve relative stability and resolution of conflicts, even in just a few sessions. The widening of our knowledge and research about this early age and what affects it, have been confirmed by statistical evidence. In turn, this confirms the theories and ideas that have informed our work which, in the past, has also relied greatly on intuition, clinical judgement, and personal experience.

The first part of the book explores the theoretical thinking relevant to this work, as well as the method of psychoanalytic observation and enquiry that is applied, and the technical aspects and problems that are encountered. The second part consists mainly of the clinical work with families of young children and it is organized around some common difficulties and problems typical of this age group. The last two chapters demonstrate how this type of work can be applied more widely in a consultation to a nursery school and to a telephone advice line for parents of young children.

Phantasy is spelt in this way throughout the book, to refer to the psychoanalytic concept of an unconscious phantasy in contrast to fantasy, which is used to indicate a conscious process.

Names, locations, and other circumstances have been changed to preserve confidentiality as best as possible.

Chapter One

The importance of infant observation in under fives’ counselling

The infant observation method was first introduced by the Polish psychoanalyst Esther Bick in 1948. It consists of weekly observations of an infant and his or her mother within the home environment from birth to the end of the second year of life. It is now a well-established method by which we can learn about the development of the child’s mind, his emotional and cognitive life, his personality, and interactions (Bick, 1964; Lubbe, 1996; Magagna, 1987; Miller et al., 1989; Perez-Sanchez, 1968; Pontecorvo, 1986; Reid, 1997; Winnicott, 1941). Infant observation is an essential tool in training child and adult psychoanalysts and psychotherapists, as well as other professionals who are involved in human relationships. It studies the emergence of archaic and unconscious body and mind states, of feelings and emotions, and of needs and communication, at their very origins. It also opens the observer’s inner eye to his or her own emotional responses to what is being observed. The observer is in the active position of being emotionally receptive and tuned in to the actions, the atmosphere, and the feelings of the people observed. At the same time, the observer learns to refrain from action and to pose him or herself as a friendly and benevolent presence, ready to receive whatever the family offers, in terms of both verbal communication and the intimacy of family life that revolves around the infant. A space is created in the observer’s mind to give a home to the detailed scenario, with the baby and his surroundings at the centre. Meanings gradually emerge from the repeated patterns that are observed in the mother–infant interactions, as a result of some essential attitudes of the observer.

Firstly, there is the “negative capability”, as the Romantic poet Keats, in a letter to his brother, defined the attitude that bears uncertainties, not knowing, and the anxiety about new and unpredictable situations. In this frame of mind the observer does not act but witnesses events (Keats, 1952). Secondly, there is the capacity to identify with the many people who are present during the observations; for example, the hungry baby, the jealous sibling, the competitive father, the exhausted mother, the interfering grandparents, as well as the supportive figures in the family scenario.

This capacity for many and almost simultaneous identifications, is what Bion called “binocular vision” and “multiple vertices”. Meltzer clarified this concept as being “the natural mode of experience of an individual, who by contact with different parts of his personality, is able to identify with different roles in human interaction and perception” (Meltzer, 1978, p. 6). The capacity to be familiar with one’s own different aspects enables the observer to take up the different points of view of the characters in the observations. At the beginning of his observation, an observer developed a great capacity to identify with the infant, but failed to identify with the untidy mother, since he had declared himself to be a rather orderly person. As a result he lost the chance to observe that family. He unconsciously communicated his hostile and competitive feelings to the mother and this prompted her to stop the observation.

Observational skills and training are the foundations for working with families and small children. In the clinical part of the book, I will show that great fluidity in taking up different identifications is needed by the therapist.

An exciting aspect of the infant observation method is that the understanding of the developing emotional, mental, and interactive life of the infant, which is being inferred through pragmatic observations, is also being confirmed and corroborated by recent research and discoveries in neuroscience. Emotions and affects have important biological components, such as heart rate, blood pressure, respiratory rate, and glandular secretions, which can be observed and exist universally throughout human culture and even in preliterate cultures (Amini et al., 1996). According to Ekman and Izard, the perception and expression of affect are “innate capacities and part of the genetic endowment from our phylogenetic heritage” (ibid., pp. 214–215). This implies that feelings are not just subjective, internal experiences, but have complex, physiological processes rooted in the history of human evolution. Affects have a survival function of communication, as we can observe in babies within their families as well as in studies in the laboratory, through the analysis of mother–infant video recordings (Beebe, 1982; Stern, 1971). The intensity, subtlety, and effectiveness of the communication of a baby, who turns away from mother’s intrusive gaze, or screams to draw her attention to his needs, is as powerful as the lack of any emotional expression in the depressed or autistic infant, who is dead to the world of feelings.

A sharp observer can begin to weave the thread of a family story even from the first encounter with the family in the waiting room of the clinic. Worries and feelings about coming to the clinic with a problem child, the problem itself that has prompted the parents to seek help, and the main family dynamics are often displayed in the waiting room through facial expressions, body postures, general demeanour, and activities. The following vignette illustrates this idea and emphasizes the value of observation in work with the under fives.

The family had arrived a few minutes early for their first appointment. The therapist introduces herself in the waiting room and invites them to go with her. She notices that mother and father are sitting next to each other on armchairs. Father holds a baby in his arms while mother slouches passively and looks distant and withdrawn. The three-year-old boy, referred for his aggressive and unmanageable behaviour, sits at some distance on the floor by the toy cupboard and turns his back to his family and the room. It takes them a long time to gather themselves together. Father tries to convince the boy to put the toys away and talks patiently and firmly to him. Mother looks as if she has given up. The boy eventually complies and they all follow the therapist along the corridor to the therapy room, with the solemnity of a religious procession. The impression of a depressed mother, a very involved father, and an angry and stubborn toddler is what the therapist has gathered from a photographic view of this family in the waiting room. The impression gained through the initial observation of the family dynamics and behaviour in the waiting room is later confirmed in the course of the session.

Working with under fives, whether in the first or last session, relies greatly on the observation and understanding of the here and now. The therapist elicits an account of the problems, concerns, symptomatic behaviour, and the child’s early history as well as the parents’ own experiences in their families of origin. The therapist also sharpens his or her attention to and observation of the nuances of the child’s play and the interactions with the parents, the siblings and vice versa. As it appears appropriate, one can just listen silently, or offer a descriptive commentary of the emotions, fears, worries, and conflicts that are expressed by the family members, or can make links with what is being recounted.

Interest, curiosity and a capacity to observe are paramount in this work, as in all psychological work. The receptive and nonintervening role of the observer during the infant observation can influence the parents’ curiosity and interest in their own baby as well as lead to many other, useful realizations. For example, a couple who had been observed with their baby for two years by a Swiss psychologist, decided to pursue marital therapy as a result of the observation experience. The experience of observing, absorbing, and processing the family scenario, often has a greater therapeutic function than one may imagine, before one embarks on an infant observation.

Chapter Two

Outlines of psychodynamic under fives’ counselling and theoretical background

Introduction

The model I describe in this book is based on the Under Fives’ Counselling Service founded at the Tavistock Clinic in the eighties. It is rooted in the belief, the experience, and knowledge that early intervention has a curative, as well as a preventative, effect. The emotional difficulties of young children are expressed in physical and behavioural symptoms that are closely linked with the developmental phases of infancy and early childhood. Parents come to Child and Family Psychiatric Clinics or consult child psychotherapists privately with a variety of complaints. We encounter infants who do not feed, cry incessantly or never settle into a sleep pattern. We see children who do not learn to talk, cannot be toilet-trained, refuse to separate from their mother or do not settle at playgroup. We also see children who are hyperactive, violent, isolated or excessively shy.

The Under Fives’ Counselling Service offers up to five sessions to the parents and child, who can refer themselves to the clinic directly or be referred by their health visitors or doctors. Most of the families I discuss in the book have been seen in N.H.S. services or privately in England and abroad. The therapeutic model is also rather flexible (Miller, 1992), as it reflects and adapts to the needs of families of this age group. Flexibility and improvisation are often required by parents to deal with the intensity of passions and urgency of needs of their under fives. Similarly, although it is preferable to meet the whole family and work with both parents, the counselling accommodates individual needs of attendance and frequency. The gap between sessions also varies according to the needs of each family and such issues are carefully explored together with the therapist.

The symptomatology of infancy and early childhood usually has a particular poignancy and can cause great distress, anxiety, confusion, and discomfort to parents and carers. Infancy is a vulnerable age and small children, being malleable and open to the world without having strong defences, are easily affected by what happens to them. They are still not equipped to defend themselves and are totally reliant on those adults around them for appropriate protection and adequate parenting. Therefore a prompt intervention is required when this age group is in need. Early intervention, even in a few encounters, can resolve the presenting difficulties and unblock complex situations. It can prevent things from getting worse or becoming entrenched or, when necessary, it can open the situation up to other therapeutic interventions. To respond to parents in need, often at the end of their tethers, quickly mobilizes a therapeutic alliance. When motivation is high, emotional availability and openness are also at their utmost. It is heartening to see how many families can benefit from short counselling and can strive to keep to the number of sessions initially offered.

Theoretical influences on under fives’ counselling

In this section, I explore some of the theoretical ideas that have inspired my particular style of work and on which the model of under fives’ counselling is based.

Melanie Klein

Melanie Klein, together with Anna Freud and Donald Winnicott, was a pioneer in the psychoanalytic understanding and treatment of children. Her ideas were clearly influenced by Freud’s theory of childhood sexuality, which was confirmed in his treatment-by-proxy of Little Hans (Freud, 1909a). Klein traced the em...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Contents
• Acknowledgements
• Foreword
• Biographical Note
• Summary
• Part I Theoretical Background
• Part II Clinical Cases
• Concluding Remarks
• References
• Index