Int J Psychoanal 2005;86:17174

Child psychoanalysis: How we work

Clinical models in practice: Two clinical cases with detailed session material1
RENATE KELLETER, Reporter
Richard Wagner Weg 53, D-64287 Darmstadt, Germany RenateKelleter@aol.com

PETER BLOS JR., Moderator

111 S 4th Ave, Ann Arbor, MI 48104, USA pjblos@umich.edu

This half-day panel under the leadership of Christel Airas, Convener, and Peter Blos Jr., Chair, was devoted to the presentation and discussion of clinical session material from the analyses of two children; a boy and girl aged 10 and 6 years, respectively. The focus throughout was on the analytic process: how each presenting analyst worked; the multiple levels of communication; transferencecountertransference interchange; and the inuence of theory on the day-to-day conduct of treatment. The rst case, Ned, was presented by Elizabeth Tuters. Ned was referred to her by his previous therapist, whom he had seen once weekly for one year, when he was 8 years old. This was disrupted by the parents. Poor grades and irresponsible behavior two years later precipitated a school crisis and, in turn, the start of analysis three times weekly. Ned has a brother who is two years older, and it was reported that the parents abruptly moved both boys to a school in the private system because his brother was being bullied. Ned felt lost and lonely. In his previous therapy Ned had disclosed that he had been bullied by his brother when his parents were out. They seemed unaware of Neds poor visual-motor skills and perceived him as a passive aggressive character who refused to learn. The school attempted to structure the situation through a signed contract. The analysis began inauspiciously with Ned not arriving for his rst two sessions because he became disoriented and lost in the course of a half-block walk to the ofce. A Monday appointment in month 7 of analysis and week 4 of school opens with Neds announcement of fatigue and headache requiring that he recline on the couch. A brief interchange leads to Neds dening himself as a chicken-pecker with regard to his typing ability and stating that this has caused the headache. Avoiding further discussion he reports without affect that his older brothers bike had been stolen and was replaced by his parents the following day. Ned then complains, Why do I have to come here? which leads to a brief discussion of school realities. He falls asleep for ve minutes. On awaking, Ned reports he feels better, thanks his
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Panel held at the 43rd Congress of the International Psychoanalytical Association, New Orleans, USA, 13 March 2004, cosponsored by ACP. Panelists: Elizabeth Tuters (Toronto), Kari Hauge (Oslo); Discussants: Maren Ulriksen de Vinar (Montevideo), Antonino Ferro (Pavia), Roberto Basile (Milan).
2005 Institute of Psychoanalysis

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analyst and reveals manual difculties, such as in tying his tie and shoelaces, and that he did not learn to ride a bike until age 8. The following day he again announces his fatigue and goes on to report that he could do his homework the previous day because of the nap. Further complaints about school follow. Ned wonders about his analysts interest in school. He complains about learning French and would choose Latin because nobody speaks it. Ned then falls asleep but the analyst must wake him after 10 minutes because time is up. He thanks her and makes eye contact when saying goodbye. The analyst is left with the feeling that Ned feels safe and trusting enough to let himself relax completely in her presence. A month later Ned sent an email to the principal of the school without the analysts or his parents knowing, stating he wanted out of the contract. Ned decided to leave the school before Christmas. He has returned to his former school and is much happier, but still has difculties with the work and paying attention. Maren Ulriksen opened the discussion. She observed that Ned is in a paranoid position and litigates against the world which shows and conceals his learning difculty. The parents rverie function is assigned to the analyst as is Ned himself. Ulriksen observed that Ned either does not have a voice of his own or that it is not heard by anyone. This may be a starting point for the analysis. She worried that an analytic intervention may become confused with a pedagogic one and that the negative transference will not nd a space for expression. Ned despises himself, a masochistic position. In the analytic work he will have to express antithesissadism. Commenting from the oor, Agneta Sandell (Stockholm) observed the unusually complicated situation in which Neds analysis began, making the creation of a potential space with his analyst very difcult. Margaret Fitzpatrick-Hanly (Toronto) remarked that it was not Neds choice to leave his rst therapist or his rst school. This needs to be taken into account as does the sleep that tests the analyst. The second case, Eve, was presented by Kari Hauge. Eve has a history since age 2 of facial grimaces and twitching in both arms when playing, predominantly on the left. Neurological examination has revealed no pathology. Further background includes beginning kindergarten at age 15 months, the birth of a brother at 3 years 10 months, and changing school at 4 years 6 months. Temper tantrums and being extremely controlling at home are signicant parts of the history. A four-times weekly analysis began with Eve being eager to come. She was in good contact and drew many pictures very rapidly. The grimaces and twitching were obvious. In the rst analytic session Eve began a story with dolls that involved intense sex play and which, by the third session, ended in a loud quarrel with a baby being sent to America for ever. The dolls were then put in a box and not looked at for two months. Subsequently, when Eve became excited while playing she would masturbate anally, her bottom play. Several times she took her pants off to show her bottom. Later, Eve remarked, My head does not like it, but my bottom likes it. This sexual activity gradually subsided. Session 40 begins with a hide-and-seek game and Eve saying, I can feel, but I cannot see. She seeks and repeatedly nds the analyst but the analyst is never

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successful in nding Eve. The play shifts to opening a box of dolls, animals and fences. Eve puts up the fences so that the animals have separate rooms. Then two big pigs are put together with two piglets. There is some chasing of a girl by an ox. Then, abruptly, a mother doll hastily kisses the father doll followed by a quick change of scene to a mother doll who rocks and sings to a baby. Again abruptly Eve stops, lifts up the mother dolls skirt, looks intently at the dolls crotch and places the father dolls face in it. Then, with a change in voice, begins another nice domestic scene. A complicated and confusing scenario follows, which Eve directs, and the analyst is made the baby who has been thrown away to America where, it is noted, they speak another language. The analyst verbalizes the babys feelings of dismay, fear and confusion. The babys mistreatment and abuse in Eves story escalates. The analyst makes no interpretations but provides words for feelings and actions. She tells us that in the countertransference she experiences shock and exhaustion. As the session draws to a close Eve displays signs of separation anxiety. The analyst, recalling that Eve is to visit the kindergarten where children had mistreated her, asks, Are you going to do something afterwards? Eve ignores the question and returns to playing hide-and-seek using her outdoor clothing. She begins to sing a rhythmic song on which the analyst remarks appreciatively. Eve laughs happily. But the analyst is left feeling sad and sorry. Roberto Basile opened the discussion with the observation that the analyst made no attempts to give interpretations. This was important, he suggested, since they would only have stimulated persecutory anxieties or been evacuated. The analysts receptivity created an atmosphere of condence so that the highly charged and confused drama could be staged. The analyst can be the container of the created mental stage with its confusion and can assist by naming the different emotions. Eves emotional overow seeks various routes for evacuation such as tics, contractions and anal masturbation as antidote to separation anxiety. The analysts capacity for rverie enables her to support some story development as the confusing play unfolds; the story of a girl and her emotions that feel lost because they have no container, and do not nd a mother tongue. There is the alternating nding and transforming proto-emotions into thinkable thoughts and containable emotions. When the child becomes desperate about the end of the session, the analyst also seems to become confused when she introduces the theme of what will follow the session. Appreciation was expressed for the analysts handling of the situation with admirable receptivity and emotional closeness. The dynamics within the session become at times so congested that the function of rverie needs some support from the father. Blos opened the general discussion by pointing out that Eve could play and thereby bring her drama on stage while Ned could only act before thinking. He was in no way ready to think about what he was doing. He could send a secret email to the principal but he could not tell the plan before. When he begins to think about what he is doing, then he will be ready for interpretation. Kelleter reected on the dual role of the analyst as both transference and developmental object in childrens play. There was clearly a great interest in questions of technique mainly in giving interpretations or at least comments.

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Basile noted that both analysts avoided interpretations with Tuters offering space and allowing Ned to sleep. Subsequent discussion demonstrated varying ways in which transference interpretations are used in different analytic cultures. Marie-Christine Laznik (Paris) pointed out that the French school of Diatkin and Lebovici would deal with the transference in play. The British school, in contrast, would make transference interpretations from the beginning. Ulriksen and Sandell felt that in the case of Eve there was too much mirroring and echoing when more salient comments could be made. Others focused on too much repetition thus making the play mechanical. Zachrisson (Oslo) reected on the sado-masochistic quality of Eves grandiose defense against separation anxieties. Several comments from the oor noted the absence of the father in both cases. Airas had opened the panel reading an excerpt from St Exuprys The little prince which tells how the little prince meets the fox. Their mutual taming created mutual ties. In metaphor this accurately heralded the discussion of the unfolding relationship between the two respective patients, Ned and Eve, and their analysts. The panel ended with much interest in exploring differences and similarities in our various analytic cultures and the ways this is reected in how we work.