Child and Adolescent Psychotherapy

Making the Conscious Unconscious

Peter Blake

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9780367741334
• eBook ISBN: 9781000363678
• Edition: 3
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In this new edition Blake gives a personal account of his professional experience of working with children and adolescents over the last 45 years. Providing a wonderful integration of the conceptual and the practical, this book clarifies complex theory while giving practical advice for clinicians through a nuts and bolts description of how to interview parents, emotionally assess a child and adolescent, set up a consulting room and conduct a therapy session. The addition of chapter summaries, questions and suggested further readings provides a valuable structure to those in child and adolescent training programmes.

The author's experience, gained from public and private work, is vividly described with the use of clinical examples to illustrate his thinking and way of working. This third edition highlights his evolution from a more traditional epistemological (knowing) approach, with its emphasis on interpretation and insight, to a more ontological (being) framework. He explores a more intuitive and unconscious way of working and argues this is more developmentally appropriate to children and adolescents. His accessible writing style transports the reader into his clinical world: a world full of fascinating stories of children talking through their play; of adolescents exploring who they are through their discussions about music, films, sport and computer games; of helping parents to understand and thoughtfully manage their child's emotional struggles.

This new edition, an amalgam of theoretical orientations (Kleinian, Bionian, Winnicottian, relational, non-linear and neurological), draws from recent developments, both in theory and technique. It will be of immense value to psychotherapists, psychoanalysts and all those involved in the treatment of children's mental health.

Chapter 1
The analytic legacy

Why history?

Rosa, a 17-year-old girl, has just thrown a brick through the window of a church. This is next to the clinic she attends for weekly psychotherapy.

Anne, her therapist, hears the breaking glass and rushes out of the clinic to see Rosa and a small group of girls running away. In this scene it is hard to see how Anne knowing about the history of psychoanalytic work with children could be of any relevance to helping her work with Rosa, yet it is. Anne must recover from the shock of this incident and begin to think about why Rosa is doing this. This thinking is crucial in determining what she will do. But she is not alone in this process. She has the benefit of over 100 years of thinking and clinical experience of great minds to help her understand what may be going on for Rosa. The conceptual and technical tools used by current child therapists are the legacy of previous generations of therapists, who have shared their thoughts in publications and supervision. To understand, and more importantly, to challenge these historical wisdoms, it is imperative to know how they evolved and in what context they were formed.

Knowing about the lives of Anna Freud and Melanie Klein may seem irrelevant. Such knowledge can be dismissed as attempted sanctification of previous analytic gurus. But Anne’s knowledge that Anna Freud’s background was in teaching, and that her early clinical work was with displaced and disabled children, allows her to understand why Anna Freud may see Rosa’s behaviour as being determined by environmental forces, rather than the result of some intrapsychic explosion. Of course Anne will have to decide for herself what Rosa’s behaviour means, and what she should do about it, but knowing what previous therapists have thought and why they had such thoughts allows her work to be placed into a collective wisdom that can only enhance her understanding.

The Freudian legacy

As with most things psychoanalytic, work with children begins with Freud. While he never saw a child clinically, his thinking about the meaning of behaviour led him to the belief that children have a rich and powerful phantasy life that not only affects them in childhood but in later life. This thinking arose from his work as a neurologist in late nineteenth-century Vienna. His hypothesis arose when he realised that if he allowed his patients to speak freely they would recount stories that involved some incident of a highly distressing nature. He discovered that these stories always involved some sexual incident, either sexual abuse or at least a sexual incident they found disturbing (Freud & Breuer, 1895). This led him to the ‘seduction’ theory. He believed the hysteria was caused by the young women being seduced. He postulated that the distress from this was so powerful that it had to be cut off from conscious awareness. This trapped the emotional turmoil within the body, resulting in the hysterical symptom.

In 1897, however, the seduction theory collapsed as Freud struggled to accept that all these women had been sexually assaulted. He began to believe these stories were not accounts of actual events but phantasies of sexual longing or frustration. He wondered whether all the patients he was seeing, male and female, had these sexual phantasies, and whether they went back as far as early childhood. This led him to explore the nature and development of sexual feelings in the child.

While Freud was hearing about this early sexuality from his patients, he believed it was not the sexual phantasies as such that were the problem, but the repression of such feelings that lead to neurotic symptoms. Such thinking implied that all human beings have sexual feelings in childhood. To explore this view, Freud observed his own children, and asked colleagues and friends to observe their children, to see if any signs of childhood sexuality could be discerned. These observations, along with his clinical material, led to the publication of The Three Essays on the Theory of Sexuality (Freud, 1905a), in which Freud put forward his ideas about the nature of childhood sexuality, and proposed the various stages and vicissitudes of these instinctual drives.

To accompany this theoretical paper, and to support his claims about childhood sexuality, Freud presented another paper that told the story of a 5-year-old boy, ‘little Hans’, and his struggle with his developing sexuality (Freud, 1909 b). Although Hans was never a patient of Freud (Freud only met him on one occasion), it is the first example of applying analytic thinking to the behaviour of a child. Hans’s father, a friend of Freud, told Freud about his son’s fear of horses. Freud asked the father to observe his son’s behaviour and to report these observations to him. Freud then instructed the father what he should do and say to the boy. What is important in this case is the serious consideration given to the child’s behaviour. It is not thought to be naughty or silly. For Freud it had meaning, a meaning that confirmed his theory about child development and sexuality. Hans was struggling with sexual feelings towards his mother, and rivalrous feelings towards his father, but such feelings had to be repressed for fear of a retaliating castration from his father. This case also highlights Freud’s appreciation of the need for close and detailed observation. While one may now disagree with Freud’s interpretations, it is in this case that we can see the beginning of what would now be called a psychoanalytic attitude – that behaviour (even a child’s behaviour) has meaning and can be determined by unconscious factors.

Little Hans is not an example of child therapy, and Hans is not Freud’s patient. Indeed, at this stage Freud suggested that analytic therapy was not possible with children. He felt that Hans’s feelings and behaviour could only be explored within the intimacy and safety of his family. However, a few years later, Freud does present his clinical work with an adolescent, an 18-year-old called ‘Dora’ (Freud, 1905b). Freud directly applies his early analytic technique to this girl. While a therapeutic disaster, with the girl abruptly terminating the therapy, it alerts Freud to the power of the transference, and how it has to be carefully managed.

Although Dora was an adolescent, Freud treated her as an adult. She had to lie on the couch and verbalise her thoughts in an uncensored way. At this stage the problem of children being too young to freely verbalise their thoughts remained unresolved. However, what was becoming increasingly clear from his work with adults and older adolescents was that childhood experiences were important determinants for later behaviour. This suggested that the upbringing of children needed to be reconsidered in the light of this psychoanalytic knowledge.

The early pioneers

The next step in the history of psychoanalytic work with children was influencing their education, in the home and at school. Early pioneers in this area were Her-mine Hug-Hellmuth; Siegfried Bernfeld, who established Vienna’s Baumgarten Nursery, a Jewish community school based on analytic principles of education; Alice Balint, who applied analytic thinking to educational psychology; August Aichhorn (1925), who worked with disturbed adolescents using analytic understanding; and Berta Bornstein, a social worker who worked with small children from an analytic perspective.

The first child psychoanalyst

The earliest worker who applied analytic ideas to children’s education is Hermine Hug-Hellmuth (1921). There is some debate whether Hug-Hellmuth could rightly be called the first child analyst. Holder (2005) presents evidence from different authors, some suggesting she was the first to use play in an analytical clinical setting, while others believe she was principally an educator who applied analytic understanding to the educational needs of children.

Her most important work is On the Technique of Child Analysis (1921). This work has been dismissed as a pale preliminary to the papers of Anna Freud and Melanie Klein. Critics note that Hug-Hellmuth did not develop a technique for interpreting to children; she only addressed issues involving older children (seven to eight and older), and there was a heavy emphasis on ‘educative’ analysis (how understanding the child can be used in management strategies at home and at school). These criticisms fail to note the original and pioneering quality of her work. In this work she discusses issues such as working with parents, understanding the negative and positive transference, the possible resistances from both the child and the parents and so on (Geissmann & Geissmann, 1998). This paper introduced such issues that Anna Freud and Melanie Klein would consider and develop in their own way over the next 60 years.

Anna Freud and Melanie Klein

Any history of psychoanalytic psychotherapy with children and adolescents must include these two women. They are rightly acknowledged as the two most important figures in this field. Both produced large volumes of work, which represent the two major schools of thought in child psychoanalysis. Both evolved comprehensive theories about the psychoanalytic development of the child, and different therapeutic techniques for use when working with children and adolescents.

Both became interested in the application of analytic knowledge to children in the 1920s. From the beginnings of their analytic careers they battled, along with their followers, both in theory and technique. These differences are not just of historical interest. To the present day they continue to have an impact upon how child therapists work. To understand these differences, and how they affect the practice of a modern child therapist, it is necessary to note how Anna Freud and Melanie Klein arrived at their views of the child’s inner world.

Anna Freud

Anna Freud was born in Vienna in 1895. She was the youngest of Freud’s six children. She was a slight, shy child who was conscientious in her schoolwork. She trained as a teacher, and taught as a primary school teacher for five years. This period was important, for while she never had children of her own, it exposed her to many normal school-age children. Teacher training also instilled in her the importance of a scientific methodology: things needed to be studied in a careful, cautious and rigorous manner.

Melanie Klein

Melanie Klein was born in Vienna in 1882, 13 years earlier than Anna Freud. Like Anna Freud she was the youngest daughter. Her father, Moriz Reizes, was a doctor. Klein, who focused heavily on the infant’s depressive states of mind, had a life full of tragic deaths. Her sister died when she was 8 years old, her brother died when he was 25, and her son died at 27. She had an early unhappy marriage that ended in divorce, a difficult relationship with her dominant mother and public battles with her rebellious daughter, who was also an analyst. Given such events, it is not surprising that she ‘discovered’ the depressive position. As Grosskurth (1986) notes she had a dominant personality, probably the result of being an unwanted child and unfavourably compared to her siblings by her parents. This dominant or assertive quality is expressed in her interpretative style.

Klein had wanted to do medicine, as her father had done, but her marriage at the age of 21 disturbed such plans. She remained without any formal academic training throughout her life. Unlike Anna Freud, she was glamorous and very aware of her appearance. She struggled with depression throughout her life.

Klein found that the road to the child’s inner world was not the dream, as Freud had found for adults, but play. Her interest in the earliest stages of development led her to observations of very young children, children with very few or even no words. She built upon Hug-Hellmuth’s ideas of how play can symbolically represent the child’s thoughts and feelings. She also noted her own son’s play as he recounted his violent phantasies. From these experiences she began to evolve a technique that would revolutionise the understanding of children’s play. This enabled her to be the first to have a sustained view into the child’s inner world.

It is important to examine in detail the main theoretical and technical differences between Anna Freud and Melanie Klein, as these affect current analytic work. These differences can be categorised into four main areas: engagement with the child, differing views of transference, relationship with parents, and interpretation and play.

Engagement with the child

In their earliest writings, Klein and Anna Freud differed strongly on how to engage a child when offering therapy. Anna Freud initially felt it was important to have a preparatory or introductory period with the child. She was aware that children did not wish to engage with therapy; they did not want to know about their troubling feelings and behaviour. The parents normally felt this disturbance. Anna Freud felt that there was no motivation from the child, unlike the adult patient who actively seeks help.

To overcome this problem, she felt it was necessary to settle the child into feeling comfortable and positive with the therapist. Only with this trust could the disturbing work of analysis proceed. To be able to look at negative feelings about themselves, children had to feel positively about the analyst and themselves. Regrettably, this introductory phase is often presented as some sort of seduction, with Anna Freud winning the child over with bribes or false praise. Anna Freud was trying to establish rapport with the child, something Hug-Hellmuth strongly advised, but as Edgecombe notes, the methods she employed were not very different from those of modern child therapists (Edgecombe, 2000, pp. 58–62). She would show great interest in whatever the child spoke about. She would empathise with the child, letting the child know she understood events from his or her point of view. She would play with projections or displacements, personifying the child’s ‘badness’ by giving it a name. If the child were initially defensive, she felt it was imperative that the therapist establish some therapeutic alliance. Alvarez’s more recent emphasis on the ‘hearability’ (Alvarez, 1992; Blake, 2001) of an interpretation or comment is in line with this thinking.

Anna Freud did not consider this introductory period to be part of proper analytic work. It was merely preparing the ground for the work of interpretation that was to follow. She described such methods as ‘devious’ (Freud, 1927, pp. 11–13), echoing Hug-Hellmuth’s idea of a ‘ruse’. It is interesting to note that many current child therapists, working on a weekly basis, use these ruses or devious techniques all the time. Listening to and thinking about The Lord of the Rings, Star Wars, The Simpsons and so on are no longer seen as icebreakers. Rather, they are considered important communications about the child’s psychic world. Also, a growing number of analytic child therapists, myself included, would now question the need for such material to be interpreted.

Anna Freud saw this technique of engaging the child as a necessary modification of the classic technique used with adults. She did not believe you could immediately interpret to a child. This would be too disturbing. The child’s inability to process his or her ‘revealed’ feelings, and the inability to morally manage them (a weak superego), would be damaging to the child’s sense of self. Klein felt that not only could you interpret immediately, but it was absolutely necessary to do so if you were to engage the child’s cooperation and interest in the analytic work. In this sense Klein saw Anna Freud as deviating from her father’s work. She, on the other hand, was faithfully applying the analytic principles laid down by the father of psychoanalysis. The battle to be the rightful daughter was on!

Klein believed that you could only engage the child by immediately tuning into his or her anxiety and naming this. In her early papers, this meant talking to the child about his or her repressed sexual feelings and the anxiety that surrounded such feelings. This topographical approach – making the unconscious conscious – would release the child from the inhibition, thus relieving anxiety. She gave case examples of interpreting to young children directly and early about their unconscious feelings, and this made them less anxious. As Klein developed her theories about the importance of aggression, the sexual focus of her interpretations lessened, and was replaced by commentary on the child’s anxiety about his or her more sadistic feelings.

While Klein never really changed her thinking about engaging the child through interpret...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Introduction to third edition – a plea for playing: making the conscious unconscious
• 1 The analytic legacy
• 2 Conceptual framework
• 3 Psychoanalytic observation
• 4 Referral and initial interview
• 5 Individual assessment
• 6 Developmental considerations
• 7 Assessment for therapy
• 8 Working with parents
• 9 The setting, physical and mental, and limits
• 10 Interpretation: a case for the abolition of interpretation to children
• 11 The role of play
• 12 The challenges of play
• 13 Playing with transference and countertransference
• 14 Interpretation, play, and transference and countertransference in practice: Paul’s story
• 15 Adolescents
• 16 Endings
• 17 Conclusion
• References
• Index