A Question of Technique

Independent Psychoanalytic Approaches with Children and Adolescents

Monica Lanyado, Ann Horne, Monica Lanyado, Ann Horne

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781134181896
• Edition: 1
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

A Question of Technique focuses on what actually happens in the therapy room and on the technical decisions and pressures that are faced daily.

Coming from the Independent tradition in British psychoanalysis, the contributors, a range of experienced practitioners and teachers, describe how their technique has quietly changed and developed over the years, and put this process in its theoretical context.

This book will appeal to child and adolescent psychotherapists, analysts and counsellors who wish to explore more Winnicottian approaches to therapeutic work.

1
Introduction

Monica Lanyado and Ann Horne

1 The context

Coming together to compile this book, with its focus on the Independent tradition in British psychoanalysis and psychotherapy, we have had interesting discussions with our co-authors and between ourselves. In recent years—at least publicly since the 50th anniversary conference of the Association of Child Psychotherapists (ACP) in 1999—there has been said to have been much rapprochement between the different training and theoretical traditions. While we would agree with this—and indeed see the establishment of an Independent training in 1982 as pivotal in encouraging it—it is important to acknowledge that there are still important differences in approach amongst the training schools, approaches informed by theoretical divergence. Where we have moved on, we suspect, is in our capacity to tolerate and even enjoy discussion of these differences—an acceptance of diversity, and a new capacity to be curious about each other. This takes us a long way from the ‘collisions’ described by Rycroft (Pearson 2004—and see next chapter) as masquerading as ‘discussions’ in the Institute of Psychoanalysis in the 1950s.

However, we have not quite reached—as was hopefully proposed at a recent British Association of Psychotherapists (BAP) conference on ‘Diversity’—a position where what we all do in the consulting room is actually pretty well the same (Lemma 2005). There was much disagreement at the 1999 ACP conference about what was ‘correct’ and what was not. Indeed, part of the spur for compiling this book came from listening to talks at subsequent conferences of the ACP where very experienced members often rather diffidently proposed what to them felt like considerable variations in technique. We were struck by the on-going need for diffidence—perhaps stemming from a continuing counter-transference relationship to the mythical ‘correct’ approach—and by variation being perceived as radically different. Diverse applications of technique and method have been discussed amongst Independents since Winnicott, amongst Anna Freudians in-house over decades and available to the rest of us at least since Joe Sandler and his colleagues made Miss Freud’s thinking public (Sandler, Kennedy, and Tyson 1980), and amongst post-Kleinians at the latest since Psychotherapy with Severely Deprived Children appeared in 1983 (Boston and Szur 1983). Indeed, colleagues at the Institute of Psychoanalysis tell us that new findings from Mrs Klein’s as yet unpublished technical papers are also going to startle us about her capacity for flexibility and adaptation in the consulting room.

The 21st birthday, in 2003, of the child and adolescent psychotherapy training at the BAP—a training that locates itself in the Independent tradition of British psychoanalysis—also helped us feel it to be timely to collate a book that derived from that theoretical and technical position. This book thus seeks to address a gap in contemporary psychoanalytic writing about work with children and adolescents and is in major part a response to requests from trainees and colleagues.

We would wish therefore to engage in discussion about what actually happens in the consulting room, as opposed to what it is felt ‘ought’ to be happening. In this way, A Question of Technique describes and discusses contemporary practice and how it is evolving, the ‘what we do’ and the ‘how’ of psychoanalytically informed psychotherapy with children, young people, their families and the professional networks surrounding them. The authors of the chapters have tried to tease out these questions from their clinical work. Achieving the focus of this book has not proved easy—in part because different theoretical traditions mean different belief systems and moving from one theoretical position to another requires distancing oneself from what may well have been taught as fundamental and ‘right’. From our discussions and individual clinical and theoretical findings, there has emerged an interesting book that grapples with why we do what we do and makes it available to a wider readership.

The contributors come from a mixture of original training backgrounds—Independent, Kleinian and Anna Freudian—but would now identify their theoretical orientation as Independent, the majority position in the British School, the London-based British Psychoanalytic Society. In our deliberations and writing, it emerged that what linked us in a major way was our interest in building on Winnicott’s thinking, as well as drawing on the Kleinian and Anna Freudian traditions. It also became apparent that we were able to draw on Winnicottian thought and come to a range of conclusions. So in many ways this book represents a contemporary view of post-Winnicottian child psychotherapists at work. Some of the chapters reflect practice in individual work; others demonstrate the application of theory to parent work, families and networks while retaining in mind the primacy of the best interests of the child.

The content

We will give a brief tour around the contents of the book, anticipating that the reader will feel able to ‘dip in’ according to specific interests, as well as to read the text as a whole, to gain a comprehensive view of contemporary child psychotherapy from an Independent perspective. Our roots in the Independent Psychoanalytic tradition are reflected in Bernard Barnett’s ‘Foreword’ to the book. A senior member of the Independent group of British psychoanalysts, and a child analyst, with many links world-wide with those interested in Winnicott’s work, Barnett both reinforces and further elaborates the kind of mind-set that is thought of as ‘Independent’.

The running order of the book reflects the different areas of theory, practice and technique that we wished to encompass. The first section describes how contemporary Independent thought has developed within the psychoanalytic tradition. Continuing the theme of this introductory chapter, with its engaging interview of Anne Hurry by Maria Pozzi, we move to Ann Horne’s description of how the Independent group of child and adolescent psychotherapists came into being through the child and adolescent psychotherapy training founded at the British Association of Psychotherapists in 1982. From delineating the Independent identity in theoretical terms, she discusses the technical and clinical implications of these Independent views. She also describes the dangers of ‘pathological idealisation’ within psychoanalysis, institutionalised positions and assumptions that can stop the growth of new ideas if they seemingly contradict the views of psychoanalytic elders.

A more theoretical chapter by Janine Sternberg completes this section of the book, and takes the reader from the historical differences about technique, up to current-day live issues. Sternberg usefully reminds us of the key concerns that have influenced discussions about technique in the past, and in particular how different theoretical views lead to different ways of being and behaving in the consulting room. Importantly, she discusses the impact of contemporary research on our understanding of what takes place between therapist and patient, and the ways in which microanalysis of video material is shaping our view of how we respond in the present moment to our patients. The reader will find a masterly appraisal of a wide range of themes marking points where we have to reflect on how we intervene or respond to our patients. As an adult as well as child psychotherapist, Sternberg has very interesting contributions to make—quietly given, almost en passant—on commonalities and differences in working with these diverse groups. Her analysis of technique includes language, tone, intonation and silence; the use of transference and counter-transference; and a very interesting comment on ‘to play or not to play’, a matter taken up by Maria Pozzi and Anne Hurry in their conversation. The section on interpretations is particularly thought-provoking. In offering comment on the diverse technical practices found in our analytic work today, Sternberg opens up an extremely helpful context for the clinical material that follows in later chapters.

We decided to put most of the chapters in ‘developmental order’—parent-infant work, then work with latency and adolescent patients—partly because there are some important differences in technique according to the stage of development of the patient but also rather simply because keeping development in mind is important to an Independent. The second section of the book therefore centres on parent-infant work, a comparative newcomer to the repertoire of child and adolescent psychotherapists but now rapidly expanding.

Working directly with parents who have their babies with them in the room during the consultation, rather than talking to parents about their infants who are not present, came to prominence following Selma Fraiberg and her colleague’s groundbreaking book Clinical Studies in Infant Mental Health (Fraiberg and Fraiberg 1980). Pioneering this work in the UK was Dilys Daws whose highly readable Through the Night: Helping Parents and Sleepless Infants, published in 1989, has also become a classic—not only clinically, but directly for many parents desperate for a good night’s sleep (Daws 1989)! Juliet Hopkins has also played a very important part, through her clinical work and her writing, in laying the foundations in the UK of this increasingly recognised method of intervention (Hopkins 1992). Hopkins has long been very active in teaching at the BAP and was a member of the original Training Committee.

Deirdre Dowling’s chapter illustrates this influence in her work with families who have been admitted to a therapeutic community as a ‘last chance’ effort to avoid taking their babies into the care of the local authorities. This is harrowing and deeply compassionate work as the babies are at severe risk but the parents and professionals still hope that the parents can be helped to become more adequate—otherwise they would not have agreed to admission to the unit. Dowling’s opinion, as a psychotherapist, plays a crucial part in how the assessment of the parent’s ability to care for the baby is reached. Through her clinical examples, and her discussion of the theory and technique which form the framework for her work, Dowling shows how she struggles to hold the parents in mind in a way that, from experience, she knows may in turn enable them to hold their babies in mind in a more nurturing and developmentally enhancing way. This isn’t always possible, despite the best of efforts by all involved, including the parents. Central to her thinking is Winnicott’s concept of ‘the capacity to be alone’ (Winnicott 1958). She demonstrates how the application of this idea to parent-infant work is very fruitful in helping the therapist to have some clarity about what therapy might be able to achieve.

The next two chapters in this section are by Victoria Hamilton. The first of these is a paper she wrote in 1988, here republished, in which she uses clinical material from parent-infant consultations to illustrate her ideas about the importance of differentiating separateness from separation, as linked with the process of mourning, during infancy. Hamilton discusses the different meanings that the concept of ‘mourning’ has taken on, in its ordinary everyday usage, and in the psychoanalytic literature which usually focuses more upon the pains of separation and separateness than their more positive developmental functions. The clinical material shows how, for a mother who was in foster care from a very early age, ‘separateness’ as well as ‘separation’ from her baby is extremely distressing. The baby’s symptoms—a disturbing form of rocking—are understood as being this mother and baby’s ‘best way’ of coping with the pains of separation and separateness. Understanding the developmental gains of separateness and separation helped the symptoms to subside.

The second chapter by Hamilton is a fascinating reflection, in 2004, on the earlier paper. Now retired from clinical work, she reflects on the impact of painful losses and mourning in her own life and how this has affected the way she now thinks about separateness, separation and mourning, with particular reference to her patients in the 1988 paper. This frank account of her deepened understanding of the many different kinds of losses that people try to live with, shares with the reader something that we all know but don’t often write about so openly. Our own personal lives, and what we experience in them, are bound to affect our understanding of our work and our ways of being with our patients. It is unusual to have such a personal account of this experience and we are pleased to be able to include it in this volume.

The next section of the book explores technical issues when working with latency and adolescent patients. Iris Gibbs and Monica Lanyado in their chapters address the kinds of technical problems that are encountered in the therapy of looked-after and adopted children. These severely deprived, and often severely abused and traumatised, children and young people form a large proportion of the patients that are seen today by child and adolescent psychotherapists and other therapists and counsellors. Their complex therapeutic needs, together with their anarchic and often violent or aggressive behaviour in everyday life as well as in the consulting room, have raised many ‘questions of technique’.

Iris Gibbs, who came from a background of social work to child psychotherapy, is particularly well placed to think about the importance of working both directly with the child and with the carers and professional network around the looked-after child. She thinks of this in terms of finding an appropriate balance, for each child, between these two interdependent parts of the work. Her clinical illustrations describe some of the ideas she has found helpful in what can feel at times like ‘walking a tightrope’ when trying to work out boundaries of confidentiality for all concerned, in as wise a way as possible.

Often children come to therapy because their placements are at risk, and work with the foster carers becomes essential. There has been much debate about the wisdom of the child’s therapist also working therapeutically with the foster carers. Gibbs illustrates her view that working in this way can be very helpful in holding the whole placement together at times of crisis. She argues that by applying psychoanalytic understanding to the child’s internal world, whilst also working with the real relationships in his complicated external world, the therapist is in a uniquely effective position. Gibbs’s wide-ranging chapter illustrates the flexibility of the treatment models she uses, including inviting foster-carers into the therapy room for significant periods of the therapy, with the child’s consent, and working with foster carers in parallel with the child. She also describes the value of working with a child going through the process of moving from fostering to adoption.

Monica Lanyado’s chapter engages with the same kind of severely deprived patient, one who is further along the road to environmental and emotional recovery. Her patient, an early adolescent girl, had been adopted when she was nine and was reasonably settled in her adoptive placement when she came for therapy, but still had many painful issues around the severe rejection she had experienced earlier in her life. The feeling of rejection was compounded by the fact that she was a hearing child born to two profoundly deaf parents and there were significant communication problems between them. The patient covered her extreme vulnerability to feeling rejected with extreme defensiveness, which interfered with her ability to form new relationships.

Lanyado describes how important it became for the therapist to be ‘playfully present’ for this patient, in a way that echoed Winnicott’s statement that therapy occurs in the overlap of the ‘areas of play’ of the patient and the therapist (Winnicott 1971a). This implies a willingness from within the therapist to become playfully responsive to the patient. Lanyado suggests that the therapist’s playfulness can be a powerful ‘antidote’ to the rigid defences that such patients have erected. There are circumstances when not playing, because the therapist is uncertain about whether this kind of playfulness is technically ‘correct’ or not, can actually close down therapeutic possibilities. The value of humour in therapy is also discussed.

Ann Horne’s chapter ‘Brief communications from the edge: psychotherapy with challenging adolescents’ (Horne 2001) is republished here as it offers consideration of how one intervenes in a session with reference to one’s theoretical and developmental knowledge base. In this chapter, Horne—a self-confessed unreconstituted Winnicottian—explores the technical issues of working with severely ‘acting out’ and anxiety-provoking patients. She describes how the therapist as ‘developmental object’ (Hurry 1998) links with her way of enabling primitive anxieties and body-based defensive manoeuvres to be thought about and articulated before interpretation can become possible. A session is given, beginning with the classic Middle Group question: ‘Why is this patient saying this to me now?’ (as quoted by Anne Hurry, this volume, p. 12). The report allows the rise and fall of the work to be followed as the anxieties rise, gain words and then thought, and lessen—but the need to maintain some anxiety and leave the therapist concerned is noted! Salutary comment is made on the impact of the disturbed adolescent on his environment and the consequent tendency of the network around him to act out, reminiscent of Winnicott’s experience of his clinic’s refusing him permission to continue with his delinquent, first, child analytic training patient (Winnicott 1956).

There then follows a chapter describing Independent psychoanalytic technique in the more classical setting of three-times-weekly therapy with a severely narcissistic, late-adolescent patient who used the couch. Juliet Hopkins illustrates a Winnicottian way of working with this young woman, and the value of the positive regression that took place in the ‘transitional relationship’ that characterised the transference. The patient used illusion and merging as defences against deep ambivalence. Hopkins decided that rather than using more challenging interpretations of these anxieties and defences in a manner that would characterise a more Kleinian approach, she would follow a Winnicottian model in which the patient’s regression in therapy was understood as being an opportunity for a ‘second chance’ to make developmental progress.

Her patien...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contributors
• Foreword
• Acknowledgements
• A note on confidentiality
• 1: Introduction
• 2: The Independent position in psychoanalytic psychotherapy with children and adolescents: Roots and implications
• 3: Not simply ‘doing’: Thoughts from the literature on technique
• Part I: Parent–infant work
• Part II: Latency and adolescence
• Part III: Taking the broader view