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Extending Horizons

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Extending Horizons presents a wide-ranging collection of papers by leading practitioners in the field of analytic psychotherapy with children and young people, surveying recent developments in technique and theory; the application of the discipline to special areas of work; and its integration, in certain contexts, with other systems such as family and group psychotherapy.From its origins in the traditional 'one-to-one relationship' between therapist and patient, as exemplified in the pioneering work of Anna Freud, Melanie Klein and Margaret Lowenfeld, the contributors to this present volume demonstrate how child and adolescent psychotherapy has advanced its frontiers in recent years to deal with specific areas of concern, such as child sexual abuse and mental or physical disability, and adapted itself - sometimes, initially, as a result of pressures imposed by the lack of adequate resources - to applications in wider settings where multi-disciplinary factors are engaged and the 'one-to-one relationship' is waived in preference to parent/child, family or group modes of treatment.Further contributions touch on topics such as childhood illness and bereavement, the psychotherapy of infancy, work with suicidal adolescents, ethnic minorities, and problems related to adoption. A final section presents fresh thinking in terms of theoretical approaches and original designs for undertaking further research.

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1. Intensive child psychotherapy: working with Matthew towards understanding

ePub

Alan Shuttleworth

This opening chapter is an account of intensive long-term psychotherapy with a young child. In this sense it offers an example of the classical experience of psychoanalytic child psychotherapy from which so many of the developments described in later chapters have sprung. The boy, Matthew, referred to the clinic in his sixth year, was thus attending during the period of his latency years and was, in terms of age, therefore, representative of a major group of child referrals. (The children presented in the following chapters by Erna Furman and by Elizabeth Muir were also seen during different phases of latency development.)

Matthew was referred with severe learning difficulties, but eventually he did very well at school. Of special interest in this study are the theoretical and clinical issues that are explored as the therapist struggles to find a way to the child, and eventually to consider how far he had been failing to think ‘with’ the child and thinking ‘at* him instead.

 

2. Treatment-via-the-parent: a case of bereavement

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Erna Furman

In contrast to the direct intensive work described in chapter one, this account introduces us to a treatment procedure that enables the child’s mother to provide him with appropriate support and counselling during a period of particular stress. Both the general and the specific indications for this choice of treatment are outlined, together with a description of the child’s progress over a period of some three years.

STEVEN

In this chapter I portray three crucial years of Steven’s development, from the time of his father’s death—just prior to Steven’s third birthday—up to the beginnings of latency at age 6. I focus on tracing how aspects of the father’s illness, death, and the subsequent fatherless years affected Steven’s development. He was helped by his mother, with whom I worked throughout this period in a weekly treatment-via-the-parent, and by the teaching staff of the Hanna Perkins Therapeutic Nursery School and Kindergarten, which Steven had attended since he was 3 V2 years old (Furman & Katan, 1969). The therapeutic work was based on the mother’s and teachers’ observations, augmented by my own weekly visits at the school.

 

3. Exploration and therapy in family work

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Beta Copley

The role and influence of the family in relation to the difficulties being experienced by a child or an adolescent may vary widely and depend on many complex factors—both within the individual and within the family. In chapter two it was a member of the young child’s family, his mother, through whom the therapist felt the boy could be appropriately helped and supported. This chapter explores family work in terms both of its diagnostic and its therapeutic potential. The latter may emerge as being of particular relevance either to the individual or to the family as a group. A number of clinical examples illustrate these processes, and a number of approaches to family therapy are discussed.

[R.S.]

Families in distress can be bewildered in their search for help; services may need to ponder the best way to intervene. Initial explorations can be useful. These can take different forms and have varied outcomes. An initial contact with a family can range from a short consultation to a more dynamic brief intervention. It may or may not be an introduction to further work, either with the family as a whole or with individual members. The term ‘exploration’ seems preferable to that of ‘assessment’ because it has a more dynamic connotation, allowing for the possibility of something being accomplished within such a process itself. ‘Exploration’ also lends itself more readily to the idea of a two-way process. Feelings within a family about the nature of the service and the institution offering it may need to be thought about openly. ‘Assessment’ can carry both passive and persecutory connotations, with implications of being assessed ‘for’ something—and possibly found wanting. Here I first discuss some psychoanalytically informed exploratory work with families, followed by a longer-term intervention; with these in mind I outline underlying concepts and indications for this method of work. I then consider this approach in the context of other schools of family therapy.

 

4. Integrating individual and family therapy

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Elizabeth Muir

This chapter explores issues that may arise in situations where a child’s participation in family therapy may seem to present some risk to the need for a secure experience of confidentiality within the child’s individual psychotherapy. A fresh approach to these parallel processes is described and examined in terms of psychoanalytic theory and of outcome in the case history of a young girl.

[R.S.]

In establishing an integrated approach to individual and family therapy, we are thinking in terms of a partnership between two equally valid and complementary concepts. This would begin with an assessment of both the individual child as the referred patient, and of the family. The form of treatment approach would then be determined by the formulation reached and also by the family’s perception of the problem.

The outcome of an assessment frequently results in a child being taken into individual psychotherapy while the family is seen collaterally in family therapy. In practical terms, undertaking collateral work with an individual child and with the family might seem in itself to be using an integrated approach. However, in contrast to a tradition that approaches the two processes as separate though parallel, we have frequently found it most helpful to work towards an active integration of the two experiences. In order to do this it is necessary to focus on some of the elements that are common to both individual psychoana-lytically oriented psychotherapy and family group psychotherapy.

 

5. Brief therapeutic work with parents of infants

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Isca Salzberger Wittenberg

This section begins with the beginning of the life-cycle. The first encounters are with a young couple who are awaiting the birth of their first child but are burdened with many fears and anxieties. In a second case a mother is helped to find her way out of a state of severe post-natal depression. The third series of interviews is with a young family who are being torn apart as they struggle to cope with a tragic loss. Although in each of the cases no more than a few interviews were given, yet the therapist was able to interpret in some depth, and the changes that were revealed over the time were profound and moving.

[R.S.]

When a few years ago the Tavistock Clinic set up a Brief Counselling Service for parents of children under five, I was very interested to participate in this new venture. I particularly welcomed the opportunity of seeing parents during the pregnancy and in the first year of their baby’s life.

Previous experience of brief work had convinced me that at critical points of transition in a person’s life even a few interviews can be useful. The new situation often produces an inner turbulence and may drive the individual urgently to address previously undigested anxieties. To be able to talk about their worries and fears, to be listened to by someone who can bear to stay with psychic pain and help them to think about their feelings in depth, may give clients some understanding of the nature of their problem. In some cases this may lead to a realization that more ongoing help is required, but often the insight gained and the experience of being understood is enough to enable clients to manage their lives more constructively and in some instances even to undo a block in their development. This latter outcome is only likely to occur when the problem is limited to a specific area of personality and has come to the fore through some recently experienced stress.

 

6. Infants' sleep problems

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Dilys Daws

We move here into the area of a General Medical Practice, where the child psychotherapist joins in the work of the Baby Clinic in seeing families who bring worries other than purely medical ones about their children. It has proved possible to enable them to resolve these difficulties, often within the space of a few interviews, and the chapter examines the theories and the technique involved.

[R.S.]

Psychoanalytically based brief work

Sleep problems appear to loom large for many present-day parents. These problems are presented urgently and overwhelmingly. Families often negotiate a referral by representing themselves as being ‘at the end of their tether’.

I work one half-day a week in the Baby Clinic of a General Medical Practice and see families about problems of babies’ or small children’s development. The most pressing of these are often sleep problems, and these need to be seen quickly. I have found that as few as one or two consultations may allow a change in the parents’ approach to the baby, which breaks a deadlock between them. For me, as a psychoanalytically trained child psychotherapist, this work is a departure from longer-term intensive work, and I am here beginning to examine the principles underlying it.

 

7. Joint psychotherapy with mother and child

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Helene Dubinsky

In contrast to the two previous chapters, the two cases described here require longer-term intensive work. Both mother and child are seen jointly as patients, and the therapist finds a way of interpreting that enables each of them to hear something that can offer an insight into themselves. At the same time it is clear that they are also discovering new possibilities for understanding and for communicating with each other.

[R.S.]

Many parents of children who are referred for psychotherapy recount tales of misery or persecution that they experienced when the child was an infant. Frequently the mother had been depressed and felt unable to soothe the baby. One has a glimpse of the mother’s hurt and of how a sense of mutual rejection and disillusionment can set in between mother and baby.

A new mother beset by anxieties about whether she can keep her baby alive or can respond adequately to its needs easily loses touch with her identity as a coping adult. She herself may need mothering and holding to enable her to contain these overwhelming feelings.

 

8. Some reflections on body ego development through psychotherapeutic work with an infant

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Genevieve Haag

In this chapter the author observes and explores in depth the many links that may be discovered between developments in the emotional and psychic spheres and the way that these may be related to shifts in the development of mobility and physical functioning. The theme is illustrated and discussed in the description of an infant who, at the beginning of his second year, was observed to be seriously inhibited in mobility and responsiveness. Mme Haag began engaging the child at this time in a psychotherapeutic endeavour that proved rewarding in both aspects.

[R.S.]

In normally healthy babies the development of primary identifications and the genesis of primary love-objects will fit in so smoothly and naturally with the processes of their motor development, pre-conditioned by neurophysical maturation, that we may not take note of the essential articulations involved. Nevertheless, the use of the term ‘psycho-motor’ has now been established for some decades, and it is clear that we are currently aware of the links existing between these three processes. In cases that manifest serious pathology of personality development, especially when accompanied by tonic and motor disturbances, attention will naturally be focussed on exploring these articulations.

 

9. Thinking about adolescence

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Rolene Szur

In As You Like It, Shakespeare (1599) presents two young women who escape from an ‘imprisoning’ parental environment to find a world more to their own liking and discover independence and sexuality within the natural order of the Forest of Arden, with joy, uncertainty, and laughter.

In The Awkward Age, Henry James (1899) describes a nineteenth-century history of subtle parental exploitation and social pressures that gradually lead on to the ‘imprisonment’ of two sensitive and dependent young women within bleak and arid marriages.

Contemporary images of adolescents sometimes seem to be coloured with expectations not unlike those that accompanied the arrival of atomic energy. It is as if they represented an explosive force that, while it might generate some light and heat, was equally likely to shatter ‘the world as we know it’. This has stimulated a considerable psychoanalytic literature, some of which is explored in the following pages.

We may begin by noting the concept of developmental lines as defined by Anna Freud (1965) in terms of a progress from dependency to emotional self-reliance and adult object relationships. The first stage she saw as a ‘biological unity between the mother-infant couple, with the mother’s narcissism extending to the child, and the child including the mother in his internal narcissistic’ milieu (Hoffer, 1952).

 

10. Work with suicidal adolescents at a walk-in centre in Brent

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Rosalie Joffe

While this chapter explores further the issues surrounding the significance of the setting as a factor in supporting the therapist’s work and the patient’s sense of containment, it also brings one sharply in touch with the extremes of confusion and despair that can overtake young people as they struggle to find a way out of conflict and inner loneliness. Rosalie Joffe’s analysis of her work in this context provides many vital insights into the state of mind of these unhappy adolescents and helpful guidelines for those who hope to protect them while they are travelling on this dangerous road.

[R.S.]

This chapter is based on my own work at the Brent Consultation Centre and the freely drawn-upon rich collective fund of knowledge of my colleagues there. I propose,

The setting in which I work is an old house in Brent, with four interview rooms, a waiting room, and a staff meeting room, on two floors. The administrative staff are located on the third floor.

The Walk-In Service is funded by the Education Department of the London Borough of Brent, who also fund psychotherapy for adolescents in the borough. There are research projects as well, which are, in the main, privately funded. Young people between the ages of 14 and 23 are encouraged to walk in or to telephone for an appointment. There is no waiting list. It has been our experience that almost all the adolescents who refer themselves in this way are too disturbed to be helped in short-term intervention. We see the client weekly or fortnightly four to ten times. It is understood by the client from the beginning that the aim of the interviews is to explore together and understand the problem and then to decide what help would be most beneficial. Should this help turn out to be psychotherapy, the adolescent knows that the therapist will be someone other than the interviewer—either a Brent Consultation colleague, if the client lives in the Borough of Brent, or, if not, someone in an outside agency.

 

11. Work with ethnic minorities

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Gianna Williams

The theme of group identities and of intergroup differences and potential hostilities referred to in chapter nine here forms the focus for a study of these issues in individual relationships. Specifically, it explores within the context of a workshop how far and in what directions ethnic differences or similarities might be seen to affect the psychotherapeutic relationship. This exploratory small-scale research endeavour, focussed on a number of ‘self-referring’ teenagers, may not provide, nor claim to provide, universal answers. It does, however, offer some very rewarding, hopeful, and interesting developments.

[R.S.]

In recent years an Ethnic Minorities Workshop was set up in the Adolescent Department of the Tavistock Clinic, with a view to exploring the potential effects of ethnic and cultural differences as a factor in the psychotherapeutic dialogue. Some members of the workshop felt that such differences were of relevance only during the assessment phase or within brief interventions and suggested therefore that if we wished to focus on cultural differences, discussion be limited to the presentation of work of this kind alone. They considered that once a patient had become engaged in treatment of a long-term nature, and if the work was well held in the transference, then the cultural differences would have receded. Other members, however, considered that cultural factors could remain relevant through many years in treatment, quoting from examples of their own clinical experience.

 

12. The triple burden

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Francis Dale

This account of psychoanalytic psychotherapy with two children suffering from congenital physical handicaps reveals a number of emotional and psychosocial problems that may confront such children. It describes how they were able to be helped to overcome these ‘emotional disabilities’ and to develop healthier self-images that could meet the demands and challenges of the outside world.

[R.S.]

Children born with physical handicaps suffer a terrible burden. They are ‘different’—often noticeably so—from their peers, with consequent impairment to the establishment of a healthy self-image. Frequently less mobile and

The two children discussed in this chapter both suffered in all these ways. In addition, the mother of the younger boy— David—while suffering on her son’s behalf, had also to cope with being a single parent and having come from a very damaging family background of her own.

The story of these two boys is a painful and distressing one, but also hopeful because both children began therapy sufficiently early in their development to help repair some of the psychic damage incurred and to limit some of the more serious long-term consequences associated with their handicaps.

 

13. Psychoanalytical psychotherapy with the severely, profoundly, and multiply handicapped

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Valerie Sinason

An extension of a psychoanalytical psychotherapeutic approach to the field of mental and multiple handicap has begun to offer significant contributions in this area. The history of psychoanalytic involvement in work with mental disability is described, and the nature of ‘secondary handicap’ is examined, distinguishing between mild secondary handicap and what the author defines as ‘opportunist’ handicap. The understanding of the experiences of the children whose histories are revealed and the insight into their inner struggles, fears, and frustrations sheds new light on a dark area and raises new questions.

[R.S.]

Individual psychoanalytical psychotherapy with the mildly and severely handicapped (though not the profoundly multiply handicapped, to whom we have only recently started to offer help) has been a scarce but valuable treatment ever since psychoanalysis began. In 1901 Freud formulated the theory of secondary gain that could be derived from an illness, and which is the central factor in what is now referred to as secondary handicap (1901b). He later described ‘somatic compliance’—the way in which bodily ills with their organic base become fixed with a ‘psychical coating’, a particular emotional investment (1905e). Thirty years after Freud formulated the gains that could come from illness, L. Chidester and K. Menninger (1936), two psychiatrists/psychoanalysts, were trying to promote advances in this field by stating that ‘mental handicap has long been looked upon as an organic condition, therapeutically hopeless, and probably for this reason few psychoanalysts have attempted to apply their methods to the study of retarded children’. However, despite the interest of leading psychoanalysts, and psychiatrists, including Melanie Klein (1931) and Pierce Clark (1933), the conviction that emotional disturbance was caused by handicap was too widespread to alter.

 

14. What autism is and what autism is not Deprivation and damage

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Frances Tustin

The title of this chapter brings a hopeful note of clarity into a situation which, as the author comments, is one that has been overshadowed with confusion and doubts—about definitions, diagnosis, methods of treatment, and potentialities for change. In exploring and comparing a number of approaches and in tracing the history of Mrs Tustin’s own discoveries and insights, this study contributes a new breadth and illumination into the nature of the condition.

[R.S.]

The author’s experience with autism

Mrs Tustin has worked intensively with autistic children for thirty years. After qualifying as a Child Psychotherapist at the Tavistock Clinic, she worked for one year in the Putnam Children’s Center in the United States. At that time, the Center was a research and treatment unit for what they called ‘atypical children’. Here, she looked after autistic children in their own homes, as well as working as a psychotherapist in the unit. She was also generously allowed to read the full notes of all the children who had been seen at the Centre since its inception ten years earlier. On her return to England, she treated autistic children in private practice who were referred to her by Dr Mildred Creak. Later, she went to work with Dr Creak at Great Ormond Street Children’s Hospital, where she treated only autistic children. For ten years she was also closely associated with the Institute of Childhood Neuropsychiatry of Rome University, which had a research and treatment psychotherapy unit devoted to the care and treatment of psychotic children under 5 years of age. On retirement, she has supervised the psychotherapeutic treatment of autistic patients with visitors from England and abroad.

 

15. An account of the psychotherapy of a sexually abused boy

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Jonathan Bradley

In the psychotherapy of this victim of sexual abuse the young boy was able to express extremes of sado-masochistic and gender confusions—to a degree, however, that made the most severe attacks on the capacity for containment and for preservation of the setting. Eventually the child was able to find his way to some positive internal strength with which to support the therapeutic alliance. Although the sexual abuse of girls is more frequently reported, it has been emerging that victimization of young boys is far more common than is generally assumed to be the case.

[R.S.]

Background

Chris was referred to a Child Guidance Unit at the age of 4. At the time, his parents were concerned because he was about to start school and yet was living so much in a world of his own that he seemed oblivious to danger. This was not their only worry: for some time Chris had been pushing pieces of plastic and cylindrical wooden bricks into his bottom in a compulsive manner. They had found that smacking him severely had not had much effect, except to make him more secretive. In spite of punishments, when given the opportunity, Chris would try to assault his baby brother (6 months old at the time of referral) in the same way that he assaulted himself.

 

16. Psychotherapy with two children in local authority care: Julia, a neglected child, and a 4-year-old's view of sexual abuse

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Margaret Hunter

The mental and emotional damage encountered in the two children about whom this chapter is written are painful examples of the kinds of harsh deprivation or mindless abuse that may bring children into care. Mrs Hunter’s account of the history of her work with each of these small girls provides a vivid portrayal of the nature of the damage effected by the experience of such relationships. It also discovers the strengths with which each eventually finds in herself trust, understanding, and real concern.

[R.S.]

Breaking through to hope: Julia and Susie

The two children about whom this chapter is written are two of the many who are neglected and abused by their families to the point where law intervenes and the Local Authority assumes parental rights over them. They become children ‘in care’ of the Local Authority. As workers in this field become more able to recognize and intervene in family situations of sexual abuse and extreme neglect, there is a growing need to address and help to mend the inner turmoil of these child victims. For we all now recognize that removing a 3-year-old from her father’s prostitution of her, removing a starved 18-month-old from her parents’ neglect, is only a first step towards safety and healing for these children. It is difficult but sometimes possible to support and guide abusing parents to better care for their children. Failing this, it is difficult but often possible to find new homes and better parents for these children. As workers in this field have long recognized, however, the children themselves often continue to have difficulty adapting to their happier circumstances, and too many of them will compulsively provoke in their new circumstances the rejection and the abuse of their early lives.

 

17. The splitting image: a research perspective

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Mary Boston

There has long been a split between academic and clinical psychology and between cognitive and affective aspects of development. However, some exciting recent research on infant development offers the prospect of healing the breach between these fields of study. These research findings, reviewed below, challenge some of the traditional theories and emphasize the need for openness to new ideas and theoretical formulations. Detailed observations made with video and film are found to link very closely with the infant observation studies designed by Esther Bick. (These are described in the Introduction to part two, ‘The Psychotherapy of Infancy’, and referred to by Genevieve Haag in chapter eight.) The author suggests that an emphasis in some recent child development research on the use of the imagination and of subjective experience, with more meaningful observational studies, could therefore offer possible models for developing new methods of research within the field of psychoanalytic psychotherapy.

 

18. The role of psychotherapy in the care of diabetes in childhood

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George Moran and Peter Fonagy

The outcome investigation described here is, as far as we know, the first controlled study of the effectiveness of psycho-analytically based treatment modalities with child patients. The research model included an original design that combined complementary approaches. One of these consisted of the ‘blind’ monitoring of progress charts from a group of patients suffering from brittle diabetes in a hospital that included a Department of Child Psychotherapy. All received regular counselling and support. Their charts were compared also with developments in the case of one patient who was able to receive intensive psychoanalytical therapy and whose progress was monitored by a separate professional group. Cri-

[R.S.]

Criticisms of psychoanalytic work often include the assertion that its methods fall outside the sphere of accepted scientific investigation. It has been claimed, for example, that clinical evidence is contaminated by the effect of suggestion from the analyst on the patient under the influence of a strong positive transference (Grunbaum, 1984).

 

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