Journal of Child Psychotherapy, 2017

Vol. 43, No. 3, 369–379, https://doi.org/10.1080/0075417X.2017.1368688

Discussing the therapeutic setting in child and adolescent

psychoanalytic psychotherapy
Lida Anagnostaki*, Alexandra Zaharia and Mata Matsouka

1 Lampsa Street, 115 24, Athens, Greece

The aim of this paper is to contribute to a debate on the particular characteristics of

the therapeutic setting in child and adolescent psychoanalytic psychotherapy and its
differences from the setting in adult therapy. In our opinion, there is a fundamental
difference between these two, as in child and adolescent psychotherapy two distinct
aspects co-exist and in some areas, overlap. In this paper, we attempt to delineate
these two aspects, following Green’s division of the analytical setting into the active
matrix and the casing. We propose that in child and adolescent psychotherapy the
therapeutic contract, the active matrix, concerning the necessary conditions for
making a therapy psychoanalytic – namely, the therapist’s free-floating attention and
the patient’s free associations – is agreed between the therapist and the child/
adolescent. We argue that in contrast, the contract regarding the casing – the timings
of sessions, the fees and so on – is agreed primarily with the parents or carers of
the child/adolescent. Ruptures and possible modifications in both the matrix and the
casing of the setting are discussed through the presentation of clinical material.
Keywords: therapeutic setting; active matrix; casing; modifications; ruptures in the
setting

Introduction
It was back in 1913 when Freud, in his essay ‘On beginning the treatment’, introduced
elements of the therapeutic setting (though without, at that time, using this term). Such
elements included the fundamental rule of free association, the analyst’s free-floating
attention, his/her position outside the patient’s visual field, the regularity and duration
of sessions, and the terms of payment (Freud, 1913). Later, Winnicott referred to the
setting as the therapeutic environment (‘milieu’) (1958, cited in Bleger, 1967), while
Marion Milner, replacing the term ‘milieu’ with the term ‘frame’, stressed that it is
precisely the frame that separates analytical sessions from the daily life of the patient
(Milner, 1952). Stone introduced the broader term ‘psychoanalytical situation’, at first
in his classic book The Psychoanalytical Situation (1961), elaborating later on the
concept in his further writings (see for instance Stone, 1984). The ‘psychoanalytical
situation’ comprises all the characteristics of the psychoanalytic environment, the
psychoanalytic process and the personal relationships involved, in their conscious and
unconscious functions.
Bleger suggested that the silence and stillness of the setting hold together the
psychotic elements of the psyche (Bleger, 1967). These primitive, undifferentiated
elements are only released in cases of ruptures in the setting, where the psychotic core

*Corresponding author. Email: lidaanagnostaki@hotmail.com

© 2017 Association of Child Psychotherapists

370 L. Anagnostaki et al.

– the ‘private madness’ – of the patient may emerge (Green, 1974). Green maintained
that the setting is a silent, ‘dumb’ background; a constant that allows the variables to
play their game. It is a ‘non-ego’ that reveals its existence only through absence, like
the silent healthy body.
Hartup, writing specifically about the setting in child and adolescent psychotherapy,
has commented that the detailed attention paid to this aspect of the treatment – the
consistent room and time, the specific toys, chosen with care and put away safely after
the end of each session and so on – is sometimes misunderstood as ‘an attempt to
provide children with some kind of ideal environment in which they will not have to
suffer the frustrations of the real world’ (Hartup, 1999: 103). He has pointed out that
avoiding frustration is not what the child psychotherapist has in mind.
The setting is a place for a meeting of minds. … Thus it provides conditions in which the
invisible inner world of the young patient can become visible to the psychotherapist, and
the child or adolescent can allow the psychotherapist into that world.
(Hartup, 1999: 103)
The setting’s function includes the containment and holding of the patient. It contains
the projections of the patient’s unconscious conflicts that cannot be adequately
symbolised and put into words. In essence, the patient’s deficits in symbolisation are
transferred within the setting and are typically manifested in the patient’s efforts for
changes in the setting. At the same time, the setting provides the patient with a sense
of security, ‘holding’, that helps him/her develop confidence over the course of
treatment. It provides a ‘good enough environment’, analogous to ‘good enough
mothering’ (Winnicott, 1953).
In addition, the setting can be understood as a third party in an otherwise
exclusively dyadic relationship, creating an Oedipal condition: a triad consisting of
patient/therapist/psychotherapeutic setting. Thus, the setting itself denotes that the
therapist is not in an exclusive, symbiotic relationship with the patient, but is a separate
object with his/her own interests and needs. The therapist seems, at the same time, to
represent two opposite object types: on the one hand, he or she invites the patient to
regress to a state of dependency, while, on the other hand, by employing the setting’s
particular boundaried characteristics, he or she prohibits the realisation of desires and
emotions, introducing negation and undertaking a paternal function. In this way, the
setting becomes an external representation of the Oedipus complex (Parsons, 2000).

Matrix and casing

In one of his last books, Key Ideas for a Contemporary Psychoanalysis, Green
identified that the setting is divided into two distinct parts (Green, 2005):

(1) The active matrix, which consists, on the one hand, of the patient’s free
associations, and on the other hand, of the therapist’s free-floating attention and
his/her listening to the patient’s material. These two elements form a
‘dialectical’ couple, in which the analysis takes root. It is this part of the setting
that defines a therapy as psychoanalytic.
(2) The casing, which includes issues of time (number of sessions, duration),
periodicity and fees.

Therefore, according to Green, the setting incorporates the minimum and sufficient
conditions required for the unfolding of analytic treatment, that is, the symbolic part
 Journal of Child Psychotherapy 371

that includes acceptance of the fundamental rule, and the concrete arrangements
between analyst and patient – methods of payment, holidays, time and duration of
sessions and so forth – agreed at the beginning of the treatment and constituting a
contract between the two parties.

The setting in child and adolescent psychoanalytic psychotherapy

The main aim of this paper is to initiate further discussion of the individualities of the
therapeutic setting in child and adolescent psychoanalytic psychotherapy, underlining
its differences from the setting in adult therapy. The challenges we discuss below arose
within a workshop that was conducted under the auspices of the Hellenic Association
of Child and Adolescent Psychoanalytic Psychotherapy, specifically convened to
examine issues regarding the setting in child and adolescent psychoanalytic
psychotherapy from both a theoretical and a clinical point of view. The clinical
vignettes we present for illustration were provided by members of this workshop who
all work privately. Most psychoanalytic psychotherapists in Greece work primarily in
private practice, since funding is very rarely covered by either the Greek National
Health Service or by private health insurance. The impetus for this workshop emerged
due to a shared sense that the variations to the setting which occur in our everyday
therapeutic work with children and adolescents are discussed mostly in private; to our
knowledge, such debates have seldom been reflected in the literature.
Perhaps through the introjection of a therapeutic superego in their own personal
analysis, in which the more traditional psychoanalytic neutrality was helpful and
necessary, child and adolescent psychotherapists are often concerned about their ability
to maintain the same kind of neutrality in their work with children and young people.
Some child therapists, however, find that they need to adopt a more active role in their
work with children and adolescents, for instance by speaking more than a
psychoanalytic therapist might when working with an adult, or – in the case of young
children – by engaging in some physical contact. This could be necessary during play,
or when, for example, a young child climbs onto the therapist’s lap, or needs help with
practical issues, such as putting their shoes on. As Lanyado and Horne have pointed
out, the therapeutic relationship with children and young people is, unavoidably, not
solely a transference relationship, but a ‘real’ one as well, and young patients’
developmental and practical needs should be acknowledged and thoughtfully responded
to (Lanyado and Horne, 2009).
We would like to define neutrality as meeting the patient, in this case the
adolescent or child, ‘without memory or desire’ (Bion, 1967), without criticism,
without goals or prejudices in regard to the clinical material (Lipshitz-Phillips, 2002),
and without personal revelations on the part of the therapist. We contend that the
psychotherapeutic procedure is not governed by dogmatic rules per se, but by wider
principles, and that it is the harmonious management of these that forms the setting,
allowing the development of the therapeutic relationship. Bearing this in mind allows
the therapist to deal with a child or teenager who may, on occasion, try to provoke,
undermine, diminish or seduce, who may sit on the floor or move around the room,
may ‘pop’ outside for a moment, may bring food or drinks to sessions, may bring his
guitar, his dog or a friend along, who may be constantly engrossed by his mobile
phone, who may leave his diary for the therapist to read, or bring a CD with his
musical compositions and so on.
372 L. Anagnostaki et al.

In our opinion, alongside these technical challenges, there is a fundamental

difference between the therapeutic setting in child and adolescent psychotherapy and
that in adult therapy, and this is intrinsic to both the nature and manifestation of the
technical challenges and the way they are managed in either treatment. In the case of
child and adolescent psychotherapy, two settings co-exist, and in some areas, overlap:
there is a setting that is negotiated and agreed with the child or adolescent’s parents or
carers, and then there is a setting that is set and agreed with the child or adolescent
themselves.
The delegation of certain functions of the ego and superego of children and
adolescents to their parents or carers makes this entwining of settings an inevitability.
Klein, in her classic paper ‘The Psycho-Analysis of Children’ (1932), delineates the
main parameters that constitute the therapeutic setting for children, and within this
discusses at some length ‘the problem’ of ‘the analyst’s dealings with the parents of his
patients’ (ibid.: 75). According to Klein, the therapist’s relation to the parents ‘entails
difficulties of a peculiar kind, since it touches closely upon their own [i.e. the parents’]
complexes’ (ibid.: 78). Still, ‘the child is dependent on them, and so they are included
in the field of the analysis’ (ibid.: 78), even though Klein did not ‘put much faith in
the possibility of affecting the child’s environment’ (ibid.: 78).
In what follows, and adopting Green’s distinction of the analytical setting into
active matrix and casing aspects, we delineate these two overlapping aspects of the
setting in the treatment of children and adolescents, thus:

(1) The therapeutic contract, concerning the necessary conditions to consider a

therapy psychoanalytic – that is the therapist’s free-floating attention and the
patient’s free associations, bearing in mind that children’s play and drawings
also stand for free associations (Klein, 1932) – is agreed between the therapist
and the child or adolescent. In Green’s terms, this contract corresponds to the
active matrix of the therapy.
(2) The contract regarding the casing (session duration, fees, and so on) is made
primarily, but not entirely, with the parents or carers of the child or adolescent.
The degree of the parents’ or carers’ involvement depends on the age of the
child or adolescent, the severity of their psychopathology, and the phase of
treatment.

The continuous influence of the parents or carers in the shaping and realisation of the
terms of the analytical setting should not be underestimated, as it represents an
encounter between two significant frameworks of the child or adolescent’s reality,
namely the framework of the family and that of the therapy. This encounter is made all
the more complex when taking into account the cross-projections and projective
identifications on the part of both the patient and the parents or carers, often expressed
as resistance to treatment. When Daws argued for the need for both parents or carers
and the child themself to give consent to the child’s therapy, the existence of two
intertwined settings was implied (Daws, 1986). The role of the parent worker – yet
another therapeutic matrix – is crucial here. The challenges faced during the important
parallel work with the parents have been discussed elsewhere (for instance, see Tsiantis
et al., 2000), and are outside the scope of this paper, yet it needs to be noted that this
frame also represents a setting to be made sense of by the child/adolescent and the
therapist.
 Journal of Child Psychotherapy 373

Ruptures in the active matrix: endangering the therapeutic work

Any rupture in the active matrix of a therapeutic contract, such as the therapist’s
inability to listen to a certain kind of clinical material, or the therapist’s disclosure of
personal details and so forth, may distort the unfolding of the therapeutic process and
endanger the psychoanalytic quality of the treatment.
A vignette from the treatment of a fifteen-year-old boy is presented below. In the
beginning of this very demanding treatment, the therapist seemed to struggle to hold on
to the active matrix of the psychotherapeutic relationship.
Bill was a fifteen-year-old teenager with intense narcissistic and sadistic personality traits.
He never closed the door of the therapy room when entering the toilet, which he visited
frequently during our sessions, creating a mess, making me hear and see what he
‘produced’, leaving me to clean up after the end of our sessions. In the therapy room, he
talked incessantly, in a very eloquent, and indeed impressive way, about the destruction
that ought to be brought upon his “shithead” classmates, his “enemies” that “do not
deserve to be alive”; the scenarios he came up with were full of imagination and sadistic
glee. In the countertransference, I felt like I was trapped; at times, I felt furious, wanting
to yell at him to stop this torture. But he kept on talking and talking, and I kept on
listening, not being able to say anything that interested him enough, or made sense to
him. I was desperate.
Presenting Bill’s case and thinking about him in a workshop on the setting in child
and adolescent psychotherapy, I was helped to realise that I was at the passive receiving
end of Bill’s anal sadism. This position rendered me unable to listen to the deeper, more
emotionally genuine material that his non-stop babbling masked. With the help of the
discussion at the workshop, I decided to talk to Bill more directly. My tone of voice
expressed my new-found calmness and interest in him: “I don’t want to keep on listening
to the same things over and over again. What I would be very interested in is listening to
the reason why you have to keep telling me how pleasant violence is.” In response to this,
Bill’s facial expression changed. He stopped playing with his mobile phone, put it down
and looked at me: “Because that’s the way I grew up … he used to hit me all the time,
with no reason at all … once, when I was six, I tried to run away.” This was a turning
point in his therapy, and from then on, we were able to think about and discuss his
traumatic history.
The therapist’s inability to listen to the patient’s more emotionally genuine material,
hidden underneath ‘his non-stop babbling’, can be understood as a rupture in the active
matrix of the psychotherapy. According to Akhtar (2011), the act of listening fulfils a
maternal function. One has to let go of one’s own preoccupations and worries,
allowing oneself to be open to the other person’s psychic contents, to receive and focus
on the other person’s expressed needs. The therapist’s preoccupation with the patient’s
violent expressions, verbal and non-verbal, was, in this exchange, distorting her
psychoanalytic, ‘listening’ stance. She was not always able to maintain her ‘free-
floating attention’ to the underlying dynamics, and this seemed to result in an
unconscious interplay with the patient’s narcissistic and sadomasochistic parts,
jeopardising the active matrix of this psychoanalytic treatment.
The containing function of the workshop enabled the therapist to acknowledge her
countertransferential feelings and to confront the patient’s resistance, in order to free up
the therapeutic process. As a result, she became able to intervene actively and
deliberately, essentially telling the young man what their work together should be, not
to ‘do’ the sadism, but to examine it together. In this instance, the workshop served as
a setting in itself, an external setting, which, similar to a fruitful supervision, can
facilitate the restoration of the thinking process (Manolopoulos, 2011).
374 L. Anagnostaki et al.

We would argue that adhering to the set of principles that constitute the active
matrix of a psychoanalytic treatment is the sine qua non, the essential precondition, for
psychoanalytic psychotherapists working with children and adolescents, in just the
same way as it is the necessary condition for psychoanalytic psychotherapists’ work
with adults. Ruptures in the active matrix may put the overall therapeutic work in
danger and need to be dealt with, sometimes with help from an experienced supervisor,
in order to put the therapy ‘back on track’. In contrast to modifications in the casing of
therapy, modifications in the active matrix pose a threat to the core of the
psychoanalytic work.

Ruptures in the casing: thinking about modifications

Arguably, any modifications in the casing – changes in the financial arrangements,
frequency, or timing of sessions – may be imposed by external realities; hopefully, if
discussed and considered with the child or adolescent, such modifications are less
likely to impair the unfolding of the psychoanalytic process. However, in many cases,
things are not so clear; changes in the casing may reflect or indeed impose changes in
the active matrix of the therapeutic relationship. In some cases, we propose that the
shaping and handling of the setting’s casing may have a function analogous to
interpretations.
A vignette from the treatment of a young teenager, where an intervention to the
temporal frame enabled the psychotherapeutic work to finally deepen, illustrates
something of this kind:
Katia, 14 years old, was the youngest member of a family of four. Her birth had coincided
with the loss of the mother’s brother (Katia’s uncle); as a consequence, Katia’s mother
had suffered from a bout of depression and maternal care had been inadequate for the
first two years of Katia’s life. In entering puberty, Katia seemed to change altogether; she
became gloomy, adopted the ‘emo’ youth culture, started hiding her eyes behind a thick
curtain of black hair, kept clashing violently with her parents regarding boundaries, and
began to self-harm. In a joint meeting with Katia and her parents, before embarking on
our psychotherapeutic work, we agreed on a frequency of two sessions per week.
During the first year of therapy, the sessions were taken up with wordy, detailed
descriptions of events, alternating with totally silent times, filled with yawns. Katia talked
at length about how she would get her parents’ consent on bizarre hair dyeing, piercing,
tattooing … Between sessions, she often cut herself. However, when she came to my
consulting room, she hid her scars by wearing thick bracelets, putting me in an uneasy
position where I always had to wonder, trying to guess what was going on, worrying
about her, unable to express my thoughts and concerns openly. I felt as if my comments
and interpretations were falling on deaf ears and were rapidly and systematically covered
by words and yawns. Meanwhile, frequent telephone calls from her worried parents and
teacher, especially during the holiday breaks, violated the psychotherapeutic setting.
Approximately one year after the beginning of therapy, just before the Christmas
break, I received a phone call from her teacher, informing me that Katia had confided in
her that she was considering committing suicide and had already organised a plan. I
called Katia and offered her an extra session. During that session, I talked about her
difficulty in trusting me and so being able to speak frankly to me about her unbearable
feelings. She wanted me, however, to worry about her, especially when we were apart, and
that was why she was making sure that all this ‘dark and gloomy’ external information,
about her plan to commit suicide or about cutting herself, would eventually reach me.
Katia talked about the horror of the holiday break, her loneliness and her parents’
inability to understand her. She told me that she was afraid I might forget her. I suggested
to her an increase in the frequency of our sessions, to three sessions per week. Katia
 Journal of Child Psychotherapy 375

accepted my proposal, and so did her parents at a meeting I then arranged with them to
explain and agree the increase.
The change in my relationship with Katia, as well as in the quality of the clinical
material she provided, became apparent from the first week of our new arrangement.
Katia came with a smile on her face, asking for my permission to sit on the floor and then
asking me whether I wanted to listen to a song on her mobile phone. She said that grown-
ups usually don’t like the music she listens to. She played a noisy song, with ‘dirty’ lyrics.
She asked me whether I found the song disgusting. I told her that she was wondering
whether I could stand her music with the ‘dirty’ lyrics, but I thought that what she really
wanted to know was whether I could stand her, with her ‘dirty’ thoughts and feelings, or
whether I found her and her thoughts and feelings disgusting. Katia then rolled up her
sleeve, showed me the cuts on her wrist, and asked me anxiously: “Will you look at them,
or do you find them disgusting?”
During the first year of Katia’s treatment, the setting was violated, both in terms of the
active matrix by Katia acting in and out, often being unable to think, and also in terms
of the casing, as the setting was regularly permeated by information coming from the
‘outside’. The therapist responded to the crisis by increasing the frequency of the
sessions, that is by modifying the casing. It seems that this intervention functioned as
an effective ‘interpretation through action’ (Akhtar, 2011), a conscious intervention
made by the therapist emerging through the awareness of a particular dynamic between
patient and therapist, where words seem not to be enough. Therefore, in Katia’s case,
in response to her admission that she was afraid her therapist might forget her, the
therapist offered more time together, essentially validating and nurturing the part of the
patient that was seeking a closer, more intimate connection, rather than speaking
directly to her fear. As a result, the analytical encounter between therapist and patient
was significantly enriched.
The frequency of sessions and its importance in psychoanalytic work has long been
debated. Although clinicians who see their patients five times a week argue that this
frequency enables the unfolding and working through of the transference (Thomä and
Kächele, 1987), not all psychoanalysts agree that the classic temporal framework of
four or five sessions per week is the optimum setting in every case (for instance, see
Jacobson, 1971; Kurtz, 1988).
We propose that, for Katia, it was not the number of sessions per week that led to
the change in the quality of the clinical material she brought after the increased session
frequency, but the fact that the therapist had made a change in the temporal framework.
As Salo has pointed out, an intervention in the casing of the setting may help a patient
who has experienced an environmental failure in infancy to feel that they have been
heard (Salo, 2011). Interventions in the temporal framework, including, in some cases,
offering a phone call or the possibility of e-mail exchange during a long holiday, can
have significant transference–countertransference effects on the therapeutic relationship:
to the patient, it can feel as if these are individually tailored interventions, the therapist
thus demonstrating their willingness in an active and bespoke manner to become what
the patient needs.
In a similar vein, Ehrlich has argued that making the offer to increase the frequency
of sessions may instigate more engagement and hopefulness in patients, thus enabling
the work to deepen (Ehrlich, 2010). In Katia’s case, the offer to increase the number of
sessions came as a response, as an ‘interpretation through action’, to the unbearable
separation anxiety she was feeling in view of the forthcoming holidays. Hartocollis has
stressed that separation anxiety relates to the feeling of helplessness that the patient has
encountered in the past, in terms of the danger of losing an object of love, its
376 L. Anagnostaki et al.

prototype being the violent parting from the maternal breast that has been experienced
as castration (Hartocollis, 2003). We know from her early history that Katia had not
been adequately taken care of as an infant and toddler and that her dependency needs
had thus not been fully met, due to her mother’s depression. We maintain that the
change in the temporal framework allowed the analytic work to finally evolve and
deepen, because this offer on the part of the therapist seemed to fulfil Katia’s
unconscious request to receive tangible proof that she was wanted.
In Katia’s case, the interconnection of the two parts of the setting (the active matrix
and the casing) is evident: the modification of the casing directly affected the
therapeutic matrix. Similarly, there was an overlap of the two ‘negotiators’, regarding
the shaping of the casing: in this instance, the therapist needed to review the
therapeutic contract, both with the adolescent and with her parents. Fortunately, Katia’s
parents accepted and supported the change in the contract. Such negotiations can
become quite difficult of course when the parents or carers do not agree on proposed
arrangements or modifications in the casing, or when they try to forcefully impose their
own views and will in the shaping of the contract.

Ruptures in the casing: trying to disentangle the role of the parents

Disentangling the role of the parents, trying to understand and shed light on the latent
meaning underlying changes in the casing of a therapeutic contract when imposed from
the ‘outside’, is a difficult task, especially if ‘logistical’ explanations for the changes
are put forward. More importantly, this task is outside the therapist’s scope, since they
are not working therapeutically with the parents. Often the child and adolescent
therapist is obliged to comply with ‘necessary’ setting modifications imposed by the
parents, and is left with feelings of helplessness and frustration, possibly in
identification with their patient.
Details from a clinical case concerning thirteen-year-old Maria and the financial
negotiations that took place over the course of her treatment, shaping the tripartite
arrangement between therapist, adolescent, and parents, illustrate some difficulties of
this kind. The therapist, faced with the parents’ conscious and unconscious demand for
control over Maria and her therapy, came up with a solution that both allowed for
Maria to continue her therapy and for her parents to acknowledge her needs.
Maria started therapy due to depressive symptoms, phobias, psychosomatic
symptomatology and self-destructive behaviour. After two years of treatment, the family-
owned company went bankrupt and the parents announced that the therapy would be
immediately discontinued. Money became the key issue in the negotiation with Maria’s
parents for a possible new therapeutic contract, reflecting essentially unconscious aspects
of the relationship between Maria and her parents. In the meeting with the parents where
the therapy’s continuation was discussed, they said that Maria had already accomplished
a lot and did not need further help. In her next session, Maria said that she would never
be able to have enough good things, and would never find solutions to her problems.
The psychic ‘rescue’ of the internalised parental imagoes (but also the rescue of the
therapy) seemed necessary, and the therapist thought that this could be achieved through
a new therapeutic contract with Maria herself. The therapist and Maria therefore agreed
on a new therapeutic setting for a certain period of time (which was in fact until the end
of the school year), where Maria would take on the symbolic payment (a very small
‘pocket money’ fee) for her sessions. Her parents would only be responsible for bringing
Maria to therapy and picking her up. In fact, after the end of the specified period, Maria’s
parents agreed to the financial coverage of the sessions, recognising her progress and her
need to continue therapy.
 Journal of Child Psychotherapy 377

In this case, the parents declared they were no longer able to meet their financial
obligations regarding Maria’s therapy, due to the sudden change in their financial
circumstances, causing a serious rupture in the casing and putting the entire therapeutic
process at immediate risk. However, Maria seemed strongly committed to the active
matrix of the therapy. Consequently, a difficult technical and clinical issue emerged, as
the therapist was put in the position of deciding about the continuation or disruption of
the therapy, for reasons that had to do mainly with the parents’ particular way of
relating, rather than their actual financial difficulties. It is worth noting here that, even
though the family-owned company had gone bankrupt, it appeared to the therapist that
the parents were not in fact facing severe personal financial difficulties (for instance
they still went on long ski holidays abroad, bought a new car and so on).
Freud clearly stated that an analyst should refrain from offering treatment for free;
he argued that free treatment increases the patient’s resistance, removing the therapeutic
relationship from the real world, and thus depriving the patient of a powerful
motivation for bringing the treatment to an end (Freud, 1913). Following this line of
thinking, many therapists would agree to a low, token fee, when it comes to their
financially challenged patients, which is preferable to gratis treatment (Brenner, 2011).
According to Dolto, however, symbolic payment can at certain times in the
treatment represent a contract that restructures the psychotherapeutic setting, as it is
neither a gift nor a partial object; Dolto states that the treatment is in the service of the
person who suffers and is asking for help (Dolto, 1985). With symbolic payment, the
child or adolescent becomes responsible for their wish and is recognised as a subject –
without bypassing the relationship with their internal and external objects – even if
they are dependent, in other spheres of life, on the parents and the environment.
Maria thus readily undertook her therapy at a token fee, making a powerful claim
over her own mental care. In her case, the modified therapeutic setting protected her
from a traumatic repetition in her relationship with her parents, at both a symbolic and
an actual level. On their part, the parents seemed initially unable to wholeheartedly
consider Maria’s psychic difficulties and needs. Perhaps, by investing in her healthier
side, they might have been unconsciously trying to limit their full acknowledgment of
her vulnerability, proposing a restructuring of the setting that viewed the therapy as ‘no
longer really necessary’, ‘so much having been accomplished already’. Through the
restructuring by the therapist and Maria herself, who agreed to pay symbolically, a way
was found for her continued treatment under her own motivation, and as a result, these
same parents were eventually enabled to recognise Maria’s weaknesses, which made
the continuation of her therapy so imperative. Ultimately, they were able to re-commit
to their daughter’s needs, to the helpfulness of the psychoanalytic work and to Maria’s
progress within it, by agreeing to ‘contract’ back in and once more pay for her
treatment.

Conclusions
The setting, as a set of principles rather than a set of rules, links the therapeutic
relationship and the therapeutic technique, a third component containing the other two.
In the present paper, we have attempted to highlight a key parameter of the setting,
that is, the interdependence of the form (‘casing’) and the content (‘active matrix’), in
the bilateral relationship between therapist and patient. In the psychotherapy of children
and adolescents, however, the casing aspect of the setting may be subject to negotiation
378 L. Anagnostaki et al.

in the context of a tripartite relationship, due to the involvement of the parents or

carers.
The crucial challenge that is raised relates to the therapist’s ability to understand
and manage the setting’s complexity, particularly when confronted with issues of
breach or rupture. Parsons refers to the concept of the ‘internal analytical setting’,
placing the setting as a structure within the therapist’s psyche, describing it as a mental
arena, in which reality is defined by concepts such as symbolism, phantasy,
transference and unconscious meaning (Parsons, 2007). This inner setting is what helps
the therapist reach an internal listening that is truly free-floating. As the outer frame
defines and safeguards a space-time region, in which patient and therapist conduct the
analytic work, the inner setting defines and protects an area in the analyst’s psyche,
where anything that happens – including changes and modifications in the external
setting – can be understood in terms of unconscious symbolic meaning. The therapist’s
inner setting is formed by conscious, preconscious and unconscious choices that
include elements of the therapist’s personality, made up by the experience of their
personal analysis and supervision, the psychotherapeutic tradition to which they belong,
and the constitution of their therapeutic self, complete with ego, ideal ego and superego
elements. This is an internal process that continues years after the completion of the
therapist’s training, ideally throughout their professional life.
Following Parsons, we argue that the safeguarding of the therapeutic setting, both
in psychotherapeutic work with adults and in psychotherapeutic work with children and
adolescents, should not be associated with an obedience to rules, but with an
observance of principles. We assert that it is the therapist’s internal setting that
constitutes the indispensable guardian of these principles. Ultimately, it is this internal
setting that enables the therapist who is engaged in psychoanalytic work with children
and adolescents to manage a casing which is necessarily shared with their parents and
the challenges of the conflict that this can bring.

Acknowledgements
The workshop studying the setting in child and adolescent psychoanalytic psychotherapy was
coordinated by A. Zaharia, and M. Matsouka. The members of the workshop were: V.
Adamidou, L. Anagnostaki, S. Anasontzi, T. Kavalierou, A. Katsarou, M. Peppa, D. Savvoglou,
and E. Fatsea. The clinical material was provided by S. Anasontzi, A. Katsarou, and T.
Kavalierou.

References
AKHTAR, S. (2011) Unusual Interventions: Alterations of the Frame, Method, and Relationship in
Psychotherapy and Psychoanalysis. London: Karnac Books.
BION, W.R. (1967) ‘Notes on memory and desire’. Psychoanalytic Forum, 2: 279–81.
BLEGER, J. (1967) ‘Psycho-analysis of the psycho-analytic frame’. International Journal of
Psychoanalysis, 48: 511–19.
BRENNER, I. (2011) ‘Making extraordinary monetary arrangements’. In AKHTAR, S. (ed.) Unusual
Interventions. London: Karnac Books.
DAWS, D. (1986) ‘Consent in child psychotherapy: The conflicts for child patients, parents and
professionals’. Journal of Child Psychotherapy, 12 (1): 103–11.
DOLTO, F. (1985) Séminaire de Psychanalyse d’Enfants. Paris: Seuil.
EHRLICH, L.T. (2010) ‘The analyst’s ambivalence about continuing and deepening an analysis’.
Journal of the American Psychoanalytic Association, 58 (3): 515–32.
FREUD, S. (1913) ‘On beginning the treatment’. In SEULIN, C. and SARAGAGNO, G. (eds) On
Freud’s ‘On Beginning the Treatment’. London: Karnac Books.
 Journal of Child Psychotherapy 379

GREEN, Α. (1974) On Private Madness. London: Karnac Books.

GREEN, Α. (2005) Key Ideas for Contemporary Psychoanalysis: Misrecognition and Recognition
of the Unconscious. London: Routledge.
HARTOCOLLIS, P. (2003) ‘Time and the psychoanalytic situation’. Psychoanalytic Quarterly, 72 (4):
939–57.
HARTUP, T. (1999) ‘The therapeutic setting: The people and the place’. In LANYADO, M. and
HORNE, A. (eds) The Handbook of Child and Adolescent Psychotherapy, 1st ed. London:
Routledge.
JACOBSON, E. (1971) Depression. New York: International University Press.
KLEIN, M. (1932) The Psycho-Analysis of Children (1997). London: Vintage.
KURTZ, S.A. (1988) ‘The psychoanalysis of time’. Journal of the American Psychoanalytic
Association, 36 (4): 985–1004.
LANYADO, M. and HORNE, A. (2009) ‘The therapeutic setting and process’. In LANYADO, M. and
HORNE, A. (eds) The Handbook of Child and Adolescent Psychotherapy, 2nd ed. London:
Routledge.
LIPSHITZ-PHILLIPS, S. (2002) ‘Some thoughts on the use of the setting in psychoanalytic
psychotherapy’. In ALFILLE, H. and COOPER, J. (eds) Dilemmas in the Consulting Room.
London: Karnac Books.
MANOLOPOULOS, S. (2011) Psychikoi Desmoi, Koinwnikoi Desmoi. Athens: Gabrielides.
MILNER, M. (1952) ‘Aspects of symbolism and comprehension of the not-self’. International
Journal of Psychoanalysis, 33 (2): 181–5.
PARSONS, M. (2000) The Dove that Returns, the Dove that Vanishes: Paradox and Creativity in
Psychoanalysis. London: Routledge.
PARSONS, M. (2007) ‘Raiding the inarticulate: The internal analytic setting and listening beyond
countertransference’. International Journal of Psychoanalysis, 88 (6): 1441–56.
SALO, F. (2011) ‘Changing the frequency, length, and timing of sessions’. In AKHTAR, S. (ed.)
Unusual Interventions. London: Karnac Books.
STONE, L. (1961) The Psychoanalytic Situation: An Examination of its Development and Essential
Nature, 2nd ed. Oxford: International University Press.
STONE, L. (1984) Transference and its Context: Selected Papers on Psychoanalysis. New York:
Jason Aronson.
THOMÄ, H. and KÄCHELE, H. (1987) Psychoanalytic Practice: 1 - Principles. Berlin: Springer-
Verlag.
TSIANTIS, I., BOETHIOUS, S.B., HORNE, A. and HALLERFOURS, B. (2000) Work with Parents:
Psychoanalytic Psychotherapy with Children and Adolescents. London: Karnac Books.
WINNICOTT, D.W. (1953) ‘Transitional objects and transitional phenomena’. International Journal
of Psychoanalysis, 34: 89–97.
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