Six Children

The Spectrum of Child Psychopathology and its Treatment

Ann G. Smolen

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429919275
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Theoretically anchored and historically informed, Six Children is a book about the nuances of child psychoanalysis as these unfold in the encounter with different forms of early life anguish. Addressing autistic, homeless, and despondent children on the one hand, and greedy, betrayed, and angry children on the other, the book attempts to integrate developmental deficits, intrapsychic conflicts, and constitutional givens in evolving a deeper understanding of both severe and milder psychopathology. Ample clinical illustrations are provided and technical interventions pertinent to each of these situations are carefully fleshed out. Equal attention is given to holding and interpretation, family intervention and individual focus, and affect management and mentalization. The fact that the six main chapters of the book are sandwiched between a careful review and update of the field of child analysis makes the book especially suited for being used as a teaching tool in didactic curricula. A comprehensive and carefully selected bibliography imparts the book a scholarly quality, which exists alongside the text's literary and humane cadence.

Chapter One

Child analysis—a brief historical review of its development

One of the earliest published papers about a child’s treatment was Analysis of a Phobia in a Five-Year-Old Boy (Freud, 1909b), often referred as Little Hans. Little Hans’s analysis holds a special place in the history of child psychoanalysis, as it was the first case study of an infantile neurosis; however, the material was not retrieved from a reconstruction of an adult analysis, but rather was a treatment conducted by the father through Sigmund Freud’s instructions. Little Hans’s castration anxiety (his presenting symptom) and his Oedipus complex were interpreted by Freud through his understanding of his work with adult patients. Because Freud conducted the whole treatment via the father, there was no real elaboration of child analytic technique, thus confusion developed as future child analysts attempted to differentiate child guidance/parent education from child analysis. It was felt, at that time, that a troubled child was helped through his parents. Child analysts did not have a child analytic technique or a well-defined method of treatment. They struggled with differentiating between parental education and parent guidance and what was deemed child analysis. To complicate matters, there was also confusion as to the differences between child psychotherapy and child analysis. For years to come, the case study of Little Hans was the first introduction to child analysis for child psychotherapy candidates (Young-Bruehl, 2007).

Anna Freud stated that the case of Little Hans “pointed toward a general theory of development” (Freud, 1980, p. 278), but did not contribute to child analytic technique. Anna Freud further clarified that her father “looked to Hans’s neurosis, his phobia, for confirmation of a hypothesis about how infantile sexuality components are the motive forces of all neurotic symptoms of later life” (Freud, 1980, p. 279). Anna Freud described her father’s hypothesis in The Infantile Neurosis when she wrote: “… conflict, followed by regression, regressive aims arousing anxiety; anxiety warded off by means of defense; conflict solution via compromise; symptoms” (Freud, 1970, p. 191). Young-Bruehl points out that Anna Freud summarizes in her book The Ego and Mechanisms of Defense when she describes what her father had noted. She writes:

In the case of Little Hans, it was the task of repression to remove the aggressive wishes (stemming from the anal-sadistic phase); it is the task of reaction formation to transform jealousy of siblings into love for them, exhibitionism into modesty, pleasure in soiling into disgust. Displacement from humans (father, mother) to animals (lions, giraffe, horse) is the order of the day, at the same time as attempts are made to divert threatening instinctual dangers from parental home to more distant parts of the external world. Identification with the aggressor determines the role play in which the child takes on the part of the dangerous, biting kicking horse. Projection externalizes his own bad impulses and makes him experience them as coming from his father. Denial in fantasy or in action serves to assuage the narcissistic injury sustained by the realization of the better physical equipment of the father and the child’s own inferiority in relation to the bigger, stronger, and perhaps omnipotent and omniscient man. (Freud in Young-Bruehl, 2007, p. 34)

x

The case of Little Hans was clearly the prototype for understanding conflict, defense, and symptomology in the child, and child analytic technique was based on this theory. However, Melanie Klein did not agree with Anna Freud (more on the Controversies later), and rejected the Little Hans prototype. Klein believed that all childhood problems, no matter the symptoms, were the result of trauma. For Klein, the weaning trauma, or paranoid-schizoid position, was what the Oedipus complex and castration anxiety was for Sigmund Freud, the basis for all neurosis and psychosis (Young-Bruehl, 2007).

Child pioneers: the early years

In the early 1900s, Sigmund Freud had serious misgivings that analysis of children was achievable. After Freud published The Three Essays on the Theory of Sexuality (1905d), Freud’s students were inspired to study and observe children. They “began to observe and record the behavior of their own children, with regard to infantile sexuality; the Oedipus complex, and castration anxiety” (Geissman & Geissman 1998, p. 95). In 1916 Sigmund Freud wrote about his observation of his own grandson as the 18-month old baby threw his wooden spool and retrieved by its rope over and over, working through his separation from his mother. Anna Freud stated: “he was the most observed infant” (Freud in Ginsburg, 2003, p. 265). Sigmund Freud’s students observed their children’s play, their games, and their overall general activities as a source of data gathering, which served as a foundation for exploring the inner world of the child. Carl Jung observed infants and trained women to treat children analytically. Jung felt that children under the age of eight-years old were not capable of understanding their thought processes and suggested that an indirect method of working with children was more desirable (Geissman & Geissman, 1998). In the 1920s this view began to change. Hermine Hug-Hellmuth is credited as the first to conduct a child analysis. She was the first to offer new ways of working with and thinking about children. In later years, her early initiatives were elaborated upon by other analysts and developed more fully into a child analytic technique and methodology (Holder, 2005). Freud chose Hug-Hellmuth to represent his work in the field of child analysis because she was totally devoted to his theories and would remain faithful to Freud’s doctrine. Hug-Hellmuth published numerous papers from 1911–1924, studying the child’s earliest memories. Freud held her work in high esteem and recommended that her theories be utilized, even within his own family. Hug-Hellmuth combined psychoanalysis and education in her treatment of children and in addition she believed that the parents should also obtain instruction and edification from the analyst (Geissman & Geissman, 1998).

Freud analyzed Mira Oberholzer in 1912 and several years later (1938) she emigrated to New York City where “she was considered one of the first child analysts” in the United States (Geissman & Geissman, 1998, p. 33). In Germany, Karl Abraham was treating children in analysis as early as 1916. Abraham “saw no theoretical or practical objection to treating children by analysis” (Geissman & Geissman, 1998, p. 36).

In the 1920s when Anna Freud joined the Vienna Psychoanalytical Society, she was not permitted to treat adults because only medical practitioners were allowed to treat adults in psychoanalysis; however, there was no such rule for treating children, so she became a child analyst. In Vienna, Anna Freud, following her father’s tutelage, began to devise theory and technique for child analysis. Simultaneously, in Berlin, Melanie Klein under the teachings of Karl Abraham developed her own theories and technique of child analysis. Both Anna Freud and Melanie Klein emigrated to London where each founded her own school of child analysis (Geissman & Geissman, 1998).

Anna Freud

Anna Freud’s first profession was as a teacher and she was involved with a group of socialist educators, including Siegfried Bernfeld, Willi Hoffer, and August Aichhorn. These men influenced her early child analytic theoretical formulations, stressing its educative potential (Schmidt, 2008). She originally began her analytic study of children by observing infants and toddlers at the Jackson Nursery in Vienna in 1924 and 1925, and then when she emigrated to London during the war she continued her observations at the Hampstead Nurseries. Because of World War II, it was not unusual for infants to enter the nursery as young as ten days old and remain until the end of the war. Some of the children were lucky enough to remain in contact with their mothers, but many were not as fortunate. These circumstances made it possible for Anna Freud and her followers to “observe the stages of libidinal and aggressive development, the process and the effects of weaning, and the education of the sphincters, the acquisition of language and the various functions of the ego” (Geissman & Geissman, 1998, p. 98). In addition, the different forms of separation anxiety were noticed for the first time. In 1945, at the end of the war, the Hampstead Nurseries closed, but evolved to become the Hampstead Clinic (and later the Anna Freud Centre) where Anna Freud continued her work and went on to develop the Hampstead Index, which aided her in creating her developmental lines, described in her book, Normality and Pathology in Childhood (1965).

Melanie Klein

Like Anna Freud, Melanie Klein was also a lay analyst. Just as Anna Freud was not allowed to treat adults because she was not a medical doctor, the same held true for Klein. Like Anna, she too became a child analyst. Unlike Sigmund Freud who studied the inner life of the child through his conversations with Little Hans’s father, and from reconstructions of his adult patient’s analytic material, Klein studied childhood conflicts and built her theories by directly working with the child (Geissman & Geissman, 1998). Abraham suggested that she become a child analyst. Klein began to see children in analytic treatment in 1921 and by the time she emigrated to London in 1926 she had already developed her analytic technique using play, which she felt was the child’s way of free associating and the ideal method of gaining access to the child’s unconscious (Holder, 2005). She felt that the child’s internal world is made up of “primitive imagoes, which must be differentiated from the images of reality, modified as they have been by the process of introjection” (Geissman & Geissman, 1998, p. 120). For Klein, the child’s mind is bursting with beasts and fiends. Where Anna Freud rejected the death instinct concept, Klein based her theories on it as she “describes an infant whose first movement is not a gesture of pure love towards its object, but a sadistic movement lined to the deflection of the death instinct” (Geissman & Geissman, 1998, p. 121).

The controversies (1924–1944)

Both Anna Freud and Klein presented their concepts and theories about child analysis as early as 1924. Klein presented her technique of child analysis at the Salzburg Conference, while Anna Freud was compiling data and building theory in Vienna where she presented lectures on child psychoanalysis (Freud, 1927), which became an ongoing seminar where child cases were presented and discussed. The child analysts who participated in these seminars were Berta Bornstein, Edith Sterba, Jenny Waelder-Hall, Erik Erikson, Anny Katan, Marianne Kris, Margaret Mahler, and Elisabeth Geleerd (Holder, 2005). When both women ended up in London during the war, the infamous Controversies began and a serious divide within the analytic community occurred. While these particular controversies officially ended in 1944 the child analytic community to this day still experiences the repercussions of this bitter disagreement. It is instructive to explore the differences that caused the split within the analytic community.

Anna Freud and Klein disagreed along several major theoretical and technical lines. As stated earlier in this chapter, Anna Freud discarded the death instinct concept, leaning toward Hartman’s theory of aggression as a reaction to frustration, while Klein remained steadfast to Sigmund Freud’s early conceptualization of the death instinct. Klein understood the death instinct as a clinical theory “regarding it as the main reason for anxieties in infants, who were afraid of destroying themselves and their objects” (Holder, 2005, p. 43). Another dispute was, while Anna Freud was interested in very young children and observed their behaviors, she believed that very young children were not analyzable, stressing that the ability to verbalize was necessary for secondary process thinking (Freud, 1965), which in turn made analysis possible. Klein did not rely on verbal abilities and analyzed very young children using play as a way of accessing the child’s unconscious. She demonstrated this by conducting an analysis and documenting it on her own five-year-old son. This important dissimilarity was thought to be the crux of the conflict between the two women, as Anna Freud held steadfast to the idea the “child analysis could only consist in the application of adult analysis” (Geissman & Geissman, 1998, p. 122).

Another important theoretical difference was their divergent conception of the infantile neurosis and how it came about. Anna Freud stated that the infantile neurosis was stimulated by the resolution of the Oedipus complex and castration anxiety. Klein, on the other hand, felt that it developed in the first year of life as a defense against psychotic anxiety. Stemming from these beliefs, Anna Freud thought that only neurotic children were suitable for an analytic treatment, while Klein’s work “opened the way for analysis of psychotics, who until then, had been considered to be irremediable because they were incapable of communicating in symbolic terms” (Geissman & Geissman, 1998, p. 126). Anna Freud demonstrated her technique in the case of nine-year-old Peter who lay on her couch and described his dreams, not unlike an adult. This case was conducted through words. Anna Freud stated: “we can apply unchanged to children what we have learned from our work with adults” (Freud, 1927, p. 24). She relied on interpretation and the acquisition of insight to ultimately bring repressed memories to consciousness. It was not until the 1950s that Anna Freud incorporated play materials into her technique. She explored the child’s unconscious but connected what was happening in the child’s environment to their unconscious conflicts. Anna Freud demonstrates in the case of Peter that she was “sensitive to the very real ongoing impact of the external world … and took steps to limit the damage being inflicted” (Midgley, 2012, p. 62). Anna Freud also felt that a full transference neurosis was not possible in child analysis because of the child’s ongoing dependent relationship with their parents. One of the most controversial concepts Anna Freud put forth was the idea that the analyst must, at times, serve as an auxiliary ego for the child (Midgley, 2012).

Klein, on the other hand focused completely on the child’s unconscious and with no interest in the child’s real objects, only his internalized objects were of interest to her. She felt, contrary to Anna Freud’s theory, that very young children were capable of developing a full transference neurosis. She described her analysis of Dick, a very young child who was probably autistic. She conducted this treatment well before Kanner (Kanner, 1943) described autism (Holder, 2005).

Another critical difference was Anna Freud remained loyal to her father’s theory that the superego developed as a direct result of the resolution of the Oedipus complex around age six, while Klein believed that the Oedipus complex was triggered by the weaning trauma, “so that it began under the predominance of hate. Klein later modified this view; although she placed the beginning of the Oedipus complex in the second oral phase, she now associated it with the depressive position and hence with a conflict between love and hate.” (Holder, 2005, p. 39)

The two women also devised different analytic techniques in their work with children. Anna Freud stayed true to Hag-Hellmuth’s vision that parental education is a vital component of child analytic work. In the early years, Anna Freud made use of a period of time at the beginning of treatment where she attempted to form a positive transference by feeding the child and gratifying other needs. As stated earlier, Anna Freud focused on the infantile neurosis. Melanie Klein did not work with the parents; she used play therapy and saw very young children with a focus on the earliest phases of development (Holder, 2005).

Lastly, Anna Freud and Klein had differing views of the role of the superego and its role in the analysis of a child. “For Klein, the great strength and severity of the early superego was the basis of childhood neuroses, and control of this punitive superego-that is, mitigation of its severity-was the aim of child analysis. Conversely, Anna Freud regarded a child’s superego as weak and immature and the child as still too dependent on his parents for a complete analysis of the parent-child relationship to be possible.” (Holder, 2005, p. 81)

To summarize: Anna Freud and her followers remained loyal to Sigmund Freud’s early theories, while Klein and those who followed her, made use of his later theoretical leanings. The Controversies officially ended in May of 1944 and in June 1946 the British Psychoanalytic Society officially named three distinct schools: the Kleinian school where young children were analyzed through the mechanism of play and psychotic children were treated by analysis; the Anna Freud group who studied normal childhood development and the complications that arise within normal development, focusing on neurotic children; and the Middle Group or Independents, led by Winnicott who felt badly that he and his followers were not accepted by either Freud or Klein (Geissman & Geissman, 1998).

Donald Winnicott: Middle Group or Independents

Winnicott trained as a pediatrician and was interested in infancy and the earliest infant/mother relationship. Anna Freud thought of him as leaning toward Kleinian theory and technique and turned her back to him, but the Kleinian group also rejected him. These rebuffs caused him much sadness and resentment, but he went on to be a major force in the Middle Group, also known as the Independents, who were opposed “to any extremist or totalitarian thinking” (Geissman & Geissman, 1998, p. 235). Winnicott placed significance on the influence of the external environment, “which he described as being an ally of the child’s ego in the maturational process” (Geissman & Geissman, 1998, p. 221). Winnicott was the first analyst to state that the ruptures between infant and primary caretaker are not of importance but rather it is the repair of such disruptions that are of importance. He focused on these ruptures as impingements to going on being, that if not repaired could lead to annihilation anxiety.

Independent of Margaret Mahler’s work on separation/individuation in the United States at around the same time, Winnicott wrote about the earliest mother/infant relationship, connecting maternal preoccupation with her infant to separation and independence. Winnicott spoke about the ability of the child to play alone in the presence of the mother and he defined “areas as being inner and outer, internal reality and external reality, transitional area, and cultural areas” (Geissman & Geissman, 1998, p. 220). Winnicott connected his theories of mother and infant to the relationship between the analyst and his patient and the importance of regression and dependency within the transference.

Winnicott contributed to the child analytic literature by developing several important concepts such as there is no such thing as a infant; primary maternal preoccupation, the good-enough mother, going on being; holding function; transitional space; and the transitional object to name just a few.

Primary maternal preoccupation (1956) is a state of mind of the mother where she becomes inwardly focused toward the end of pregnancy and remains in a state of heightened sensitivity during the first few months following the ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• CONTENTS
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• INTRODUCTION
• CHAPTER ONE Child analysis—a brief historical review of its development
• PART I: SEVERE PSYCHOPATHOLOGY
• PART II: MILDER PSYCHOPATHOLOGY
• EPILOGUE
• NOTE
• REFERENCES
• INDEX