Introduction
This first section of papers concentrates on those of particular significance for their theoretical contribution, as opposed to those more immediately addressing clinical or technical issues. However, one of the most distinctive features of papers appearing in the Journal of Child Psychotherapy has always been the extent to which they have been firmly grounded in detailed clinical material, so that this kind of distinction is perhaps more than usually somewhat arbitrary. Nonetheless, with that caveat in mind, it remains the case that these articles focus primarily on explicating some key theoretical concepts.
It is, of course, impossible to divorce the developments that have taken place within the theoretical frame of reference of child psychotherapy from those that have occurred in the wider field of psychoanalysis. This introduction in no way sets out to provide an overview of those developments, either in relation to child or adult work, which is already available elsewhere (for one such review see Likierman and Urban, 1999; for a detailed account of developments within the Kleinian framework only see Spillius, 1994, and for a review from a Freudian perspective see Hurry, 1998). I shall therefore concentrate on highlighting a few points that seem to be of particular interest and relevance, as reflected in these articles, with some comment on subsequent developments to try to set them in context.
The role of transference
The transference has perhaps always been one of the most central concepts in psychoanalysis, and Rosenbluthâs paper gives an extremely clear account of the Kleinian approach to work in the transference with children. Whilst all schools of psychoanalytic thought would subscribe to its central importance, the details of how it is to be understood, in particular in relation to work with children, have provoked some of the most heated disagreements between Freudians and Kleinians. As Rosenbluth (1970, this volume) noted:
it was in child analysis in particular that different techniques were evolved by the two main pioneers in this field, Melanie Klein and Anna Freud.
There are two key points that Rosenbluth emphasises which, I believe, would still be seen as tenets of a more distinctively Kleinian approach. The first of these is the emphasis on the unique nature of the psychoanalytic relationship and the importance, in consequence, of ensuring that that uniqueness is preserved. Crucial to this is the focus on the transference:
There are many others in the childâs environment, parents, teachers, relations, who can reassure, give presents, educate, be kind or stern, but our role is fundamentally different from theirs. Children, just like adults, are in the end relieved if we do not allow ourselves to be sidetracked from our main goal, which for us is the interpretation of the transference.
This has obvious and major implications for how the child psychotherapist conducts himself or herself.
The second is the focus on the here-and-now experience (in contrast to something more by way of reconstruction):
The most important thing, it seems to me, is to stress in oneâs interpretations the current anxieties and conflicts in relation to the therapist; the link with the parents and with the past can often be implicit in oneâs wording.
The value of this kind of focus is thought to be two-fold. First, that in capturing the repetition of the past in the present in all the emotional intensity of the relationship currently being experienced it is both more convincing and therefore more effective therapeutically. Second, the focus on the transference relationship has the effect (almost by definition) of drawing the childâs conflicts into the transference thereby making it easier to address them in that context, and with the added bonus of freeing the childâs life outside from being the target of these conflicts:
If all transference feelings are consistently interpreted, more and more of the childâs unconscious phantasies and impulses gradually become centred around the treatment, and the baby relationship then becomes fully transferred to the therapist. This also means that the situation at home usually becomes relieved, as the baby relationship needs no longer to interfere so much with the present relationship between the child and his parents.
Debate over this position has continued and Alvarez notes in her paper (this volume) how the Kleinian position is sometimes (mis-)represented:
I think some critics of Kleinian work in the transference assume a very mechanical process of interpreting every tiny piece of material as referring directly to the person of the therapist. This would mean always interpreting the object to the neglect of the ego or the id. This type of âme-me-meâ interpretive work would be a bad mistake with any patient . . .
Since the publication of these papers the debate over the nature of the transference has continued. There has, for example, been an increasing emphasis on what Meltzer (1967) refers to as the âgathering of the transferenceâ. This involves more of an acknowledgement of the length of time that it takes to draw things in to the transference relationship and, closely linked to this, there has been much greater recognition of the value of containment, within the transference relationship, over time. Hopkinsâs postscript to her 1986 paper (this volume) makes this point explicit.
The debate about the nature of the transference is inextricably linked to another on-going issue, namely the question of what are the factors that effect change in this kind of work. Is it only mutative transference interpretations (Strachey, 1934) or are there other elements at work? It seems to me that it is in this arena that essentially the same debate is currently being pursued, as for example in relation to whether the therapist is to be seen only as a transference figure or whether s/he may also be seen as a new (developmental) object (see Hurry, 1998).
The clinical and technical implications of these differing theoretical positions are important and were further opened up in the discussions that took place at the Study Weekend of the Association of Child Psychotherapists in 1999 (see Lanyado, 2001 and related commentaries in the same number of the Journal of Child Psychotherapy). Whilst opinions remain divided, there would also seem to be some areas in which there is a certain coming together of these discrepant points of view, in particular perhaps in relation to work with new and particularly challenging groups of patients such as children with autism. For example, the emphasis in some of Alvarezâs later papers (see Alvarez, 1996) on the importance of being aware of the element of deficit in a childâs experience, and the possibility that the therapist may therefore need to be performing a new function for them (for example in relation to finding ways of making real emotional contact with the âun-drawnâ â as opposed to withdrawn â child), has parallels with the âdevelopmental therapyâ described by Hurry (1998).
There have also been related developments in the conceptualisation of what exactly constitutes an âinterpretationâ. Increasingly, there is a widely held view that it is not only verbal interpretations that are important but that interpretations may also be conveyed to the patient non-verbally or through the therapistâs more concrete actions, with whatever they might imply. Indeed, interpretations might remain formulated within the therapistâs mind but not be put into words if this would be felt to be premature. They would, nonetheless, influence the on-going transaction between therapist and patient. For example Reid writes of her work with a very young child:
Although I made few interpretations my actions were informed by my countertransference, checked against what I could observe of my patientâs behaviour and the atmosphere at the time. I think at this point my actions could be described as demonstrations of my understanding of what Georgie brought to the transference, via my countertransference responses.
(Reid, 1990: 37, emphasis added)
The role of the external object
Inherent to these debates is the question of the status of the external object. Developmentally there is the question of the role of actual experience, as against the infantâs own contribution (its interpretation of that experience in the light of its own phantasies), in the construction of the individualâs internal objects. Allied to this there is the question of the aims of the child psychotherapist and the extent to which their focus is, or should be, primarily on modifying the childâs internal objects through emphasising the childâs contribution to the state of those objects. Or, in other terms, stressing the need for them to assume responsibility for their psychic reality and to withdraw their projections.
This debate has tended to be rather polarised around the view that the Kleinian position has been overly preoccupied with the childâs internal reality to the neglect of real experiences, and the counter charge that the more Freudian view has overly emphasised external experience to the neglect of the childâs contribution.
Whatever the rights and wrongs of this debate historically, I think a reading of current contributions to the Journal of Child Psychotherapy would show that there has been a considerable coming together of views in this respect and that, for example, âKleinianâ papers would now take far greater explicit cognisance of a childâs history and real experiences. I suspect that the contributions of Bowlby and attachment theory have played an important role in this respect. At the same time, a careful reading of the present collection of papers would also show that this polarisation was always perhaps somewhat unjustified.
For example, the earliest of these papers from a Kleinian author (OâShaughnessy, 1964, this volume) already underlines the importance of the external object and shows why this matters:
her [the motherâs] external presence gives him [the infant] visible disproof of his internal state, and he can introject the external object to improve his internal object.
Almost 20 years later Alvarez (1983, this volume) makes a similar point:
The concept of the container is Bionâs (1962), and Spillius suggests that through this concept, Bion has made the external object an integral part of the system. She says his formulation shows not just that the environment is important but how it is important. I would say: one of the ways in which it is important . . .
Thus it has always been the case that, as in Kleinâs own formulations, external reality has been seen to have an important role to play. However, it is equally true that the emphasis has been on how it interacts with internal reality, by modifying or disconfirming it, rather than on how it might play a primary role in creating that reality.
It is a logical consequence that any psychotherapy conducted within this paradigm will privilege the modification of internal reality. As Rosenbluth (1970, this volume) puts it:
Certainly past external reality difficulties played a part in the origin of her conflicts, but we can do nothing about them any more. External reality should not be denied, but I do not think it is particularly helpful to interpret in such a way as to encourage the patient to fasten on to it to justify her own hostility.
This approach is also seen as having the advantage of reducing the risk of acting out. She goes on to say:
. . . this way of interpreting [putting the blame on to the mother] might encourage the child to act out her hostile baby transference at home in relation to the mother, whereas our aim should be not only to keep the baby transference in the treatment, but to focus it there increasingly.
As an aside, it is interesting to note that both OâShaughnessy and Hoxter nonetheless also refer to the important role that the external object might play through its active intervention to limit the activities of the more destructive aspects of the childâs personality. For example OâShaughnessy (1964, this volume) notes:
What may add further to [the childâs] distress is the absence of external control over bad parts of the self. Particularly if the ego is weak and destructive impulses are strong, is there need for external restraint.
Here of course the author has in mind what factors might have been important in the childâs development, rather than the role the therapist might take. By implication, however, it might be the case that, in the face of overwhelming id impulses, there is a need for the therapist to act as a kind of auxiliary ego. Henry would seem to be suggesting just this when she quotes Boston writing about the difficulties of working with very deprived children:
Understanding the hostility and phantasies may not be sufficient. The new object, the therapist has to prove that he can contain the violence and reduce its omnipotence by withstanding it and surviving as the original object in the patientâs phantasy did not.
(Boston, 1972)
Here too attention is drawn to the need for the child to have an experience of a new kind of object.
Projection/projective identification
The concept of projection, like the transference, also forms an integral part of psychoanalytic metapsychology. Whilst Kleinâs âextensionâ of this concept to include the mental mechanism that she termed âprojective identificationâ (Klein, 1946; 1955a) has proved immensely rich and fertile, it has also led to considerable confusion and lack of clarity because of the variety of different meanings that have subsequently accrued to it. Authors have all too often not been explicit in how they have been using and defining the term. Lubbe has given one account of the development of these differing usages of the concept in the Journal (see Lubbe, 1998) and it has also been extensively discussed by Sandler and others (Sandler, 1989).
Some of the differences in points of view clearly relate to the age at which it is believed certain mental processes are possible. Klein refers to projection (and introjection) as taking place in the first three or four months of life (see Klein, 1952). For Novick and Hurry (1969, this volume) this would simply not be possible since it requires an awareness of the separateness of the object, and the attribution of a mental and emotional life to that object, beyond the capacity of the ego at that stage:
Thus we would see the use of projection as becoming possible at a later stage than that of externalisation â at a stage, in fact, when the capacity to manipulate objects in fantasy has developed to the point where a drive-derivative originally directed at an object can be subjectively allocated to that object, while the self is experienced as the object of that drive-derivative.
In other words, the infant requires what we would now call a âtheory of mindâ.
Their point of view is based upon a very careful and precise dissection and definition of the terminology involved. Thus, they propose that it would be helpful to use âexternalisationâ as the more generic term for the processes under consideration:
We believe it would be helpful if the term âexternalisationâ were to be accepted as the general term under which would be subsumed all those processes which lead to the subjective allocation of inner phenomena to the outer world.
âExternalisationâ, however, is to be carefully distinguished from âgeneralisationâ which does not involve the allocation of inner phenomena, nor is it defensive in origin. For example:
Thus as the child becomes aware of his own wishes towards the object, for example the wish to devour, he naturally ascribes similar wishes to the object. This process is not projection proper; the conscious awareness of his own wish continues to exist. We would term this process âgeneralisationâ [original italics].
This seems an important distinction and not one, I think, that Klein would have made, in part precisely because her use of the term projection as applying to the youngest infant also predates any idea of the infant having a âconscious awareness of his own wishâ.
They then go on to tease out two specific meanings that are subsumed under the portmanteau term âexternalisationâ. In the one instance the process refers to the externalisation of a drive, in the other to the externalisation of a self-representation. They propose that the term âprojectionâ be reserved for the former:
we will focus in particular on the differentiation between those processes by which a drive is externalised and those by which an aspect of the self-representation is externalised. We would suggest that the term âprojectionâ be reserved for the former process â i.e. drive projection.
This is not a mere matter of semantics, and their paper makes clear the clinical relevance of these distinctions with particular reference to how certain material might be taken up with a child. It is particularly interesting to juxtapose this paper with that by Alvarez in this volume, which is similarly concerned with some of the fine differentiations that need to be made in considering what is being communicated in a session, if we are to be able to make the most helpful interpretation.
Alvarez draws particular attention to the need to distinguish between what is, in her terminology (or rather, as she says, Money-Kyrleâs), a desperate projective identification, and what is a destructive one. For example, she writes:
If what may be brought into the transference and put on to the person of the therapist are not only projections of parts of the patientâs self, but also the whole of his inner world, including his objects, split or in parts, past or current, how is one to make the correct choice? Suppose an adolescent patient says to us, âYou look tired todayâ, or a younger child holds up the mother doll and says, âShe just canât sit up todayâ. Is this a realistic perception achieved by a child who is learning to see what he sees â we do look tired â or is this a direct projection of an exhausted drained aspect of the patient himself? Or is this a consequence of the patientâs greedy demands on us earlier in the session? Or, alternatively, is this an attempt by him to elucidate and give form to a damaged drained internal object which is normally quite repressed?
In many ways her initial question highlights the difficulties that are raised by a rather more blanket and undifferentiated use of the term âprojectionâ and the need to clarify precisely what it is that is being externalised. This, as Novick and Hurry spell out, will inform how we then interpret:
Once the differentiation has been made it follows that interpretation of externalisation of aspects of the self must focus upon the need to defend against narcissistic pain, whereas interpretations of projection must focus upon the need to defend against the anxiety related to drive expression.
There is, then, a common thread linking these papers albeit this finds expression in very different language, and that is the importance of the clinicianâs sensitivity to the precise nature of the childâs communication.
A note on language
Finally, a brief comment about the use of language in these papers. Many readers of Klein, and of other Kleinian authors, struggle with the partobject language that is sometimes used to patients (illustrated here in the 1964 paper by OâShaughnessy but also still used by other authors, particularly those more influenced by Meltzer). Such language does not feature in papers from colleagues of a more Freudian persuasion.
Kleinians themselves will, of course, differ in this respect. As Alvarez notes in this volume:
there are considerable differences among Kleinian analysts and Kleinian psychotherapists today in the manner and pace with which they would introduce part-object language into an analysis.
Spillius, more recently, similarly notes:
A number of analysts, perhaps especially Donald Meltzer, find it appropriate to interpret unconscious phantasy directly in part-object bodily language, but the general tendency now is to talk to the patient, especially the non psychotic patient, less in terms of anatomical structures (e.g., breast, penis) and more in terms of psychological functions (e.g., seeing, hearing, thinking, evacuating).
(Spillius, 1994: 351)
Despite this acknowledgement of a change in practice, I am not aware of any papers (either in the Journal of Child Psychotherapy or elsewhere) that really seek to grapple with the implications of this major shift. There appears to be, both in the literature and in the training schools, surprisingly little open debate about the pros and cons of such different approaches. Given the care and thought taken about what to interpret, and how and when, this seems p...