Early Encounters with Children and Adolescents

Beginning Psychodynamic Therapists’ First Cases

Steven Tuber

• Publisher: Routledge
• Year: 2015
• eBook ISBN: 9781317598527
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Early Encounters with Children and Adolescents is the first training guide to use the works of beginning therapists as its focus. Far too often, therapists in training are given the "classics" to read—case histories by the masters in the field, which can sometimes leave beginning therapists intimidated or even in despair as to whether they can ever reach that level of proficiency. This book is the first to remediate that situation by providing beginners with role models they can more easily internalize through realistic case histories that reveal the ins and outs of starting in a craft that is never fully mastered. Not only are the cases themselves fascinating, but the therapists also refer to the processes they struggled with while treating these patients. Readers will thus have a striking new counterweight to the classics they will still want to read as they progress in the field. Eight beginning clinicians discuss aspects of their clinical process, including: issues of transference and countertransference; the role of supervision; doing parent consultations, especially when one is not yet a parent; cultural/racial/socioeconomic differences between patient and therapist; and the vulnerability of not understanding for long moments in treatment. Psychodynamic beginners in every discipline will find these case histories compelling, heartfelt and inspiring.

1
An Introduction

Steven Tuber

This book emerges from the vantage point of having educated doctoral students in clinical psychology for over thirty years. A question that has taken up a great deal of my pedagogical time and thought has been: how best does a beginning child therapist learn to be a competent clinician? I think there are three sources of learning. First and foremost, clinicians at any level, but especially beginners, learn most from their patients; there is no substitute for actual clinical experience. Second, students learn from their supervisors; there is little that can match the role that modeling and insight play in developing a beginning therapist. Third, students learn from what they read. Reading in child/adolescent psychotherapy, moreover, has historically taken one of two forms. The first form is the paradigm whereby a master clinician writes a book that provides conceptual understanding of specific personality issues and/or adds clinical case vignettes to support her work. Classics in this genre by such authors as Anna Freud, Melanie Klein, Donald Winnicott, Virginia Axline and Clark Moustakas were read when I was a student in the 1970s and are still read today.

The second form such books take are “how to” books, guiding the neophyte step by step from the first phone call with the parents through the evaluation process and eventual treatment of the child, including practical information on how to set up a therapy room, set limits etc. This type of work, epitomized by the works of Lanyado, Brumfield and Blake, is also essential to the training of any good child psychotherapist.

There is something missing, however, from both of these forms of required reading for beginners. Both these types of books have been written by “experts” in the field, putting the beginner in an especially difficult quandary: how to bridge the gap between these “pearls of wisdom” and the present state of fragility and vulnerability that the new therapist commonly feels. I have often felt that a long-standing deficiency, particularly within the arena of the training of psychodynamically informed clinicians, has been the near exclusive reliance on conceptual and clinical writings from the “masters” within our field. This certainly makes sense regarding conceptual additions to our development. It does take years of clinical craftsmanship, observation and thinking across a wide variety of settings before nuanced contributions to the how and why of health and pathology can be added to the literature. But when it comes to clinical cases, I don’t think this is nearly as true. The gap between the typical, usually highly successful process and outcome of a case presented by a senior clinician and the day-to-day strivings of a novice therapist is cavernous. I argue that this “gap” can be closed somewhat by hearing directly from beginning therapists themselves. Having such beginners speak not only to the clinical content of their cases, but to add in their experience of the process of being a beginner can be an invaluable addition to their training. This gap, moreover, while certainly providing something for the beginner to strive toward closing, is equally likely to evoke feelings of inadequacy, if not self-castigation or even despair. Perhaps more deadly, it may evoke a false self persona in the budding therapist: a far too complete assimilation of what they think they are supposed to think, act and feel like when with a child patient, and a concomitant need to disown feelings of vulnerability. This not only runs the risk of interfering with their capacity to be with their patients in the consulting room, at its worst, it also initiates a false dialogue in the supervisory process, whereby a loss of authenticity to be dreaded by all in the field may ensue. This is especially true when process notes as opposed to verbatim recordings are used as the sole source of data in the supervisory process. Selective remembering of the treatment process, on both a conscious and unconscious level, can distort the training of the trainee and limit both their and their patient’s development.

While these phenomena are always at play in our training, they can be reduced by two major factors. One is of course the talent of the supervisor/teacher to create a milieu of trust and openness in the supervisory and academic settings respectively. This is indeed an absolute necessity for the optimal development of any clinician. But another important factor is the role peers play in providing an arena where the safe admission of ignorance, clumsiness and/or “blindness” can be tacitly relied upon. Hearing the “mistakes” of one’s peers emboldens a student therapist to admit their own foibles. Getting benign, constructive feedback from a supervisor in the presence of one’s peers, or perhaps equally useful feedback from the peers themselves, whether in the classroom, the group supervision or the student “lounge,” hastens the development of an ego-driven comfort with one’s presence with patients, as opposed to a superego-laden vision of what one is supposed to be like. The intrinsic abundance of anxiety that is inexorable in the first months and years with patients can and is mitigated by the knowledge that your peers are not much better off than you are. When this peer influence is combined with the help of seasoned supervisors, the growth curve is accelerated to the betterment of trainee, patient and supervisor.

This edited volume can therefore be seen as an extension of the role of peer contributions in one’s clinical training to the realm of the written word. Eight present or recently graduated students from a psychodynamically informed doctoral program in clinical psychology were invited to write up either their very first or one of their very first long-term child cases. They were asked to depict their work with an eye toward their own process of development as the case unfolded. Issues of transference and countertransference; cultural differences between patient and therapist; despair and frustration when changes were not forthcoming; vulnerability when the patient is not understood; inadequacies regarding dealing with parents, especially when one is not yet a parent; the vicissitudes of help or the lack thereof from supervisors: all these are courageously and honestly detailed.

It is especially notable that almost all of the cases described in this volume ended “prematurely.” That is, either the parent of the patient withdrew the child from treatment abruptly, often without notice (see Chapters 7, 8, 9 and 10); or the therapist terminated the case because their training at that particular institution had ended (see Chapters 3 and 4). This phenomenon occurs so regularly in the lives of clinicians at training clinics, and yet is so rarely discussed, that it takes on the quality of a “dirty little secret” that nearly all clinicians experience yet rarely, if ever, discuss in a public forum. This book bucks this trend by not only selecting cases that do end this way, but in its poignant discussion of what this feels like to the beginning therapist.

It is the fondest wish of the editor and contributors to this volume that the cases about to be described prove to be of much use to trainees and beginning clinicians across the disciplines of psychology, psychiatry and social work. We also hope that in addition to the benefits that trainees may derive from the book, their supervisors in these disciplines will also derive utility from hearing how trainees experience their first cases. Some of these case presentations were first published in slightly different form in the December 2013 issue of the Journal of Infant, Child and Adolescent Psychotherapy (JICAP). JICAP had generously allowed me to not only edit those original presentations for that “special issue,” but to provide a periodic, ongoing forum for such case presentations. It is hoped that with that forum, coupled with the present edited volume, we will be well on the way to providing a consistent third source of readings for beginning clinicians.

The eight cases to be presented are quite varied, both in terms of the child’s presenting problems and the particular patient-therapist process that transpired. The first case (Chapter 2) is entitled: “The Very First Patient: Becoming Real Together” and is written by Kira Boesch. Here Kira presents literally her first patient, indeed, as she puts it, for the first months of Evan’s treatment, he was her first and only patient. Evan’s play therapy is ongoing, with no upcoming termination issues to wrestle with for at least another year or two. Here the presentation focuses on the raw newness of the experience of being a therapist for the first time, and trying to find a language and way of being that works with her patient. The child’s almost immediate intense connection to the therapist, epitomized by his creation of a doll he calls “Kira,” stirred up very powerful issues in the therapist’s evolving comfort with being called a therapist and feeling authentic in that process. This chapter thus provides a compelling means of hearing how a new therapist negotiates what therapy can mean to a child. It also provides a window into the processes of symbolization in play vs. concrete and literal enactment and this shift in interaction is a constant theme of the treatment. How to handle the intense transference and countertransference aspects of this doll play makes this case especially evocative and useful.

Mougeh Yasai’s (Chapter 3) work with a 12 year-old girl and her 31 year-old mom provides a dyadic treatment format with which beginning child therapists often must wrestle. The chapter is entitled “How Do I Work With Parent and Child, Especially if I Am Not Yet a Parent?” One extremely common aspect of child/adolescent therapy that is rarely discussed is how a childless therapist can provide both parental guidance and astute child work when she or he has never been a parent. Yasai bravely confronts this issue head-on, tolerating her own anxieties and discomforts as she builds faith in her clinical prowess and process over a three-year long treatment. She is repeatedly courageous and clear in her depictions of her self-doubt and of the complex levels of interaction among patient, mother, therapist and supervisor as they struggle together with the difficult issues raised by the work. In particular, issues of differences in culture and social class between mother and therapist are described with subtlety and nuance.

Elizabeth Baumann (in Chapter 4) then writes her depiction of the case of William, a seven year-old boy with a chronic history of loss and neglect. Chapter 4 is entitled: “How Do I Work Long-Term With a Child When I Only Have a Year to Work With Him?” Through the use of a play therapy drawing technique, she finds a meaningful and poignant method of entering this child’s inner world. Given this boy’s history, a central aspect of the case is Liz’s knowing that she can only treat him until her one-year Internship ends. Literally every trainee across the psychiatric disciplines is faced with the crucial question Baumann poses. Training in our field inevitably involves an Internship or Practicum experience in which the child’s need for ongoing treatment is at odds with the limited amount of time the trainee is at a given institution. The feelings of loss and guilt that termination imposes when it is the therapist who has to leave first is poignantly described in this chapter and is certain to evoke powerful resonance with readers who are entering the field. This in and of itself is a prominent and often neglected aspect of the literature on training psychodynamically informed clinicians: the degree to which the termination process is determined not by the patient’s progress but by the time-limited nature of the therapist’s clinical setting. Liz speaks beautifully to the pain and poignancy of the termination process between herself and William, as well as the impact of various supervisory and academic experiences she had that influenced her work.

The book takes a slight shift at this point with the back-to-back chapters of a beginning therapist and her supervisor writing about an adolescent case. Monique Bowen (Chapter 5) presents her work with Aden, a 19 year-old college student. Chapter 5 is entitled: “Finding One’s Self: Developing a Therapeutic Identity as a Beginning Therapist Doing Long-Term Work.” This chapter amplifies the preceding chapters in its focus on monitoring the growth of the therapist over time in fostering a sense of personal authenticity while doing this work. It also is more specific in its brave focus on “mistakes” made by the therapist, mistakes which over time serve to aid in the development of both therapist and patient.

Three issues not previously focused upon in the three previous cases assume center stage here. First, the issue of the patient’s immigration to the US, its comparisons with the therapist’s father’s immigration experience and the countertransferential themes evoked by their similarities and differences are described. Racial and ethnic differences between patient and therapist also play a profound part of this treatment process and are described here. Of interest also is the third issue of the therapist’s open acknowledgement, first to her supervisor and then to us, of the role her reveries about her patient, both in and out of the session, play in the treatment process.

In the next chapter (6), Monique’s supervisor on the case, Jenny Kaufmann, provides a wonderful portrait of her experience with the case, granting us a window into the triad of patient-therapist-supervisor that we rarely see in print. Her chapter is entitled: “Modeling a Therapeutic Identity for a Beginning Therapist in Supervision.” Here the author revisits the supervisory relationship’s formative function in the professional development of the trainee. Of special emphasis are the roles culture, privilege and race play in the triad of patient-therapist-supervisor, as all three persons are of different racial, class and ethnic backgrounds.

Chapter 7, entitled: “Building Safety and Containment: Responding to Challenges to the Frame With Both Parent and Child” is written by Jane Caflisch. Here Jane describes her work with a boy who was dealing with severe separation issues, fomented in large part by an unspoken, significant, chronic medical illness of his mother, an illness whose multiple layers including a marked instability regarding the treatment appointments themselves. At many points in the treatment, the symptoms he presented and his erratic attendance forced Jane to face a challenge many other beginners have to face: how do you prioritize whether the parent or the child is most in need of treatment, especially when dyadic treatment is not accepted by the parent?

Chapter 8, called: “ ‘Following the Affect’: How My First Child Patient Helped Teach Me to Listen and See” is written by Jason Royal. Here the author takes on yet another formidable obstacle to beginning work with children, especially young children. The patient is a five year-old boy and his symbolic play is confusing and chaotic much of the time. How the therapist learns to follow the child’s feeling states despite and sometimes because of the chaos his play creates is thoughtfully depicted. Indeed, in my experience teaching therapy all these years, helping the beginner not get overwhelmed by the non-linear, sometimes nonsensical, mind of a young child is crucial to his or her becoming an effective clinician.

The last two cases to be presented provide a most unusual situation: two therapists describe their work with the same adolescent patient over the course of their successive Internship placements at the same site. Chapters 9 and 10 are thus entitled: “‘Psychic Twins’: a Psycho-dynamically Informed Treatment of a Selectively Mute Adolescent and Her Mother” and “Passing the Baton From One Beginning Therapist to the Next: an Adolescent Treated by Two Successive Interns” written by Zoë Berko and Lauren DeMille. These two chapters provide the reader with a most unusual phenomenon. Two therapists, each working in their Internship year, happen to be placed, one year after the other, in the same treatment center, where they are assigned the same treatment case. The patient, a selectively mute adolescent girl, thus provides us with a treatment from two vantage points. During the first year of her treatment, the issues explored in the previous chapters are again manifest. The second year of treatment, moreover, provides the reader with a paradigm that commonly occurs in the course of psychotherapy training; namely that of dealing with the complex issues involved in taking on a case transferred from a previous therapist. Issues of competition and comparison are difficult for any therapist to wrestle with, but are exceptionally germane to the trials and tribulations of being a beginning therapist.

Zoë Berko began the treatment of 18 year-old “J,” a selective mute and her “psychic twin” mother in a dyadic format. The unique vicissitudes of this remarkable symptom and its impact on her, her family and on the therapist are beautifully rendered. When Lauren DeMille, a colleague of Zoë’s from the same Doctoral Program in Clinical Psychology, takes over the case after a year of treatment by Zoë, we are given a chance to see the impact of termination in a different light. We are also provided a meaningful glimpse into the assets, doubts and vulnerabilities involved in taking over a case from a prior trainee. Lauren is able to take the gains made by J with Zoë and use them to expand the treatment to both individual and dyadic work, leading to the remarkable moment when J utters her first words outside the home in years.

Eight of these ten chapters have already been published in a modified version by Routledge in the December 2013 edition of the Journal of Infant, Child and Adolescent Psychotherapy (JICAP, Volume 12). I would like to thank Dr. Susan Warshaw, Editor in Chief of JICAP, for her kind permission to publish these slightly differing versions of these articles in book form. Wherever possible, the consent of the parents and assent of the child were garnered before publication. When this was not feasible, the demographic material for these families has been heavily disguised without misrepresenting the core work of each case.

2
The Very First Patient

Becoming Real Together

Kira Boesch

Evan was my first patient. He was turning eight when we began working together. He is now ten, and the treatment is ongoing.

Evan was raised by both of his parents until he was school-aged, at which point he revealed to a mandated reporter that his mother beat him. Child Protective Services was called, and that agency removed Evan from his family home a few days later. Evan spent the better part of a year with a distant family member before being returned to the custody of his father. He was allowed supervised visits with his mother.

Evan’s father sought treatment for his son because in the year prior to our beginning treatment Evan had been having “fits of anger.” In response to being teased, Evan would quickly become tremendously upset and begin hitting himself and screaming. Sometimes he would express suicidal ideas. On two occasions when this happened at school, it landed him in the psychiatric Emergency Room. Evan’s father also sought treatment for Evan because of his understanding of the likely depth of the repercussions resulting from Evan’s early and extended trauma.

When I met Evan for the first time, his anxiety and fear were palpable, as was his need to cover them with a forced confidence and illusion of control. Tuber (2008), in his discussion of Winnicott’s paper, “Communicating and Not Communicating Leading to a Study of Certain Opposites,” (1963), discusses Winnicott’s idea that in malignant rearing environments, the growing infant must show a false or compliant self to the other, fo...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• CONTENTS
• List of Contributors
• 1 An Introduction
• 2 The Very First Patient: Becoming Real Together
• 3 How Do I Work With Parent and Child, Especially if I Am Not Yet a Parent?
• 4 How Do I Work Long-Term With a Child When I Only Have a Year to Work With Him?: The Conflicts Inherent in Time-Limited Therapy while in Clinical Training
• 5 Finding One’s Self: Developing a Therapeutic Identity as a Beginning Therapist Doing Long-Term Work
• 6 Modeling a Therapeutic Identity for a Beginning Therapist in Supervision
• 7 Building Safety and Containment: Responding to Challenges to the Frame With Both Parent and Child
• 8 “Following the Affect”: How My First Child Patient Helped Teach Me to Listen and See
• 9 “Psychic Twins”: A Psycho-dynamically Informed Treatment of a Selectively Mute Adolescent and Her Mother
• 10 Passing the Baton From One Beginning Therapist to the Next: An Adolescent Treated by Two Successive Interns
• Index