Psychoanalysis In Childhood And Adolescence (Book Review)

Author:  Von Klitzing, Kai, Phyllis Tyson and Dieter Bürgin (Editors)
Publisher: Basel: S. Karger Publishing, 2000
Reviewed By: Gregg Johns, Winter 2003, pp. 38-40

Psychoanalysis in Childhood and Adolescence comprises a collection of manuscripts and commentaries by an international panel of noted child and adolescent clinicians and academicians who re-examine the current role of psychoanalysis for this population. The authors met in Basel, Switzerland, during January 1999, on the 60th anniversary of Dr. Dieter Bürgin’s birth. In addition, Dr. Bürgin serves as both an editor of this work and contributes a chapter on the role of pain in psychological functioning. Additional manuscript contributors include: Kai von Klitzing, Bertrand Cramer, Paulina Kernberg, Peter Blos, Phyllis Tyson, Jill Miller, Annette Streeck-Fischer, Marianne Leuzinger-Bohleber, and Peter Fonagy and Mary Target. Manuscript commentaries are provided by: Heidi Simoni, Paul Riedesser, Barbara Steck, Julia Pestalozzi, Heiner Meng, and Barbara Rost.

Although this text totals 156 pages in length, Psychoanalysis in Childhood and Adolescence provides a wealth of concise information spanning a broad range of topics. Research findings and clinical discussions explore issues in child development, play therapy assessment and techniques, feminine object relations and triadification, pre-verbal emotional development, the role of illness and medical interventions on child psychological development, inpatient treatment of traumatized children and adolescents, unresolved late adolescent concerns, mentalization in child psychoanalysis, and the role of compensation and pain in psychic development.

Kai von Klitzing’s chapter on Psychoanalysis and Development provides a thought-provoking discussion of the developmental underpinnings of transference and countertransference including narcissistic transference, splitting, and hysteric transference. Von Klitzing reminds the reader that the reality of analysis lies in observation and reconstruction of psychic development. This is akin to longitudinal research in that psychic developmental history is reconstructed through analyzing past correlates to dysfunction in the present. Clinical observations of the interactions of child behavior and those of the caregiver are emphasized to provide insights for reconstruction ofthis development. The hypothesis of Parallel Distributed Processing (PDP) is presented as evidence for the contributions of complex nonsymbolic computations to developmental cognitive processing. These nonsymbolic components underlie language and symbolism and are more intuitive and implicit in nature.

Von Klitzing builds a case for the PDP system in the developing child’s self-regulation of emotional states by reading those of the caregiver. This system becomes integrated with symbolic systems as development progresses. This integrates the growing body of developmental research and knowledge with that of current analytical research and practice. Emotion schemas are formed from early representations of self in relation to others. This phenomena is established through repetition of affective states consisting of sensory, visceral, and motoric elements and may occur in consciousness or within the unconscious. The analyst is encouraged to explore these pre-verbal and nonsymbolic elements in process of reconstructing development. Von Klitzing provides a compelling longitudinal case example, which follows the development of a boy from prenatal parental affective states and attitudes through pre-Oedipal and Oedipal triadification followed by attachment and separation issues.

In Can Therapists Learn from Psychotherapy Research? Bertrand Cramer recapitulates the importance of the often discounted “nonspecific agents” present in the therapeutic relationship. A study is described in which mothers, seeking consultation on behalf of their infants, are given an option of choosing either psychodynamic or interactional guidance treatment approaches. The mothers were provided with descriptions of each treatment modality and were referred for treatment based upon their preferences. Cramer presents data indicating discrepancies between patient perceptions and those of therapists regarding the process and outcome of therapy.

Paulina Kernberg’s chapter, The Forms of Play, provides an excellent overview of play therapy assessment and techniques. She provides descriptive thumbnail sketches of play behaviors characteristic of youngsters with autistic, psychotic, borderline, narcissistic, conduct, and trauma disorders. Kernberg also presents a compelling case study of a 4 year-old boy with separation anxiety through ten sessions of play therapy. This chapter provides an appealing read for the student and seasoned play therapist alike. It presents a modern perspective on the progression of play therapy in a style reminiscent of Winnicott (1971) and Axline (1969). On a personal note, I have assigned this chapter as required reading for my current class of pre-doctoral interns and highly recommend it to all engaged in play therapy.

Phyllis Tyson provides a compelling exploration of the unique developmental conflicts encountered in the mother-child relationship for females in Love and Hate and Growing Up Female. Emphasis is placed on the importance of the mother’s role in providing stability and balance in the development of the child’s emotional regulation through parental projections and conflict resolution. For girls, the mother serves as both primary object and a source of gender identification and self-regulation. Tyson describes the separation-individuation process for girls as having no clear metaphorical analogy as with the Oedipal complex in boys. The separation-individuation process is different for girls in that ambivalence is experienced with both the pursuit of intimacy with the mother and the need for establishment of autonomy. To quote Tyson,” (The) mother’s role is to provide a regulating balance. If she can absorb some of the ambivalence and rage and help the toddler find adaptive ways of expressing these affects as well as ways of complying with certain of her demands, she can maintain a sense of safety. Her timely intervention insures that affective storms do not reach proportions that undermine self-regulation and self-confidence, yet she conveys that angry feelings can be adaptively expressed” (p. 48).

The child wishes to be feminine like her mother, but also has needs to develop her own identity. Tyson further describes how pathological reaction formations and narcissistic entitlement can develop as defense mechanisms if the child fails to develop adaptive emotional regulation. These conflicts are resolved if the mother can help the young child negotiate her separation-individuation struggles through balancing of feelings of love with those of anger. Development of these skills is important for the child in resolving the later triangle shift associated with wishes to be the central object of the father’s affections while managing ambivalence about maternal needs.

In Psychic and Somatic Expressions of Preverbal Loss, Peter Blos presents a case example of a child adopted at thirteen months and referred for therapy at four and a half years of age. Loss of familiar persons, belongings or surroundings occurring before language is available, is expressed behaviorally and somatically in tension discharge. Blos describes how these conflicts can be manifested during toilet training, drive expression, fantasy and defenses. This unique case was further complicated by the adoptive mother’s projections after giving birth to a new baby. The birth of the sibling compromises the adopted child’s ego functioning and resurrects infantile modes of somatic and behavioral expression into play. This is truly a fascinating case!

Jill Miller contributes The Impact of Illness and Medical Intervention on a Child’s Inner World: A Psychoanalytic Viewpoint. A case study is presented which illustrates a five and a half year old child’s perception that doctors and her own body were attacking her while she was receiving multiple surgeries for shunt failures secondary to bilateral intraventricular hemorrhaging and hydrocephalus. Miller expands upon the developmental regressions and experience of handing over of one’s body to the care of others described by Anna Freud in physically ill children.Anna Freud outlined the process a child undergoes to make sense of the experience of his or her illness and develop adaptive coping mechanisms. Miller indicates that some children exhibit increased maturity following an illness while others return to a previously established level of functioning. However, for other children, prolonged illness may have a more dramatic impact on development and personality formation.

Annette Streeck-Fischer provides a discourse on psychoanalytically derived inpatient treatment strategies for children and adolescents. Developmental trauma involving abuse, neglect, maltreatment are discussed in terms of the impairments to self-regulation of psychic, neurological, and biological systems and corresponding behavioral problems. The special problems with concealment, dissociation, and blocking as defenses for managing trauma are addressed. These youngsters often experience difficulties with verbalizing or mentalizing their recall of the traumatic events which gives rise to heightened arousal, emotional states, and often dissociation. This chapter foreshadows the succeeding chapter on mentalization by Fonagy and Target, which provides a brilliant exposition of the theoretical and applied roles of these processes in therapy. Children require special assistance to successfully work through trauma issues. Providing a safe, supportive environment and assisting children in dealing with extreme emotions facilitates their ability to work through past traumatic experiences. This appears to be one of the most difficult concepts for inpatient clinicians to convey to direct care staff. These children’s maladaptive behaviors are often misinterpreted as volitional, noncompliant or disrespectful. This presents a special challenge for clinicians to in-service and educate staff about these children’s underlying emotional needs. Staff members often fail to consider the initial added trauma that admission to an inpatient unit contributes to the already traumatized child. These children are often in the custody of social services and are separated from familiar surroundings and persons. Streeck-Fischer’s chapter provides insightful commentary and case examples of the special considerations required for these children.

Marianne Leuzinger-Bohleber discusses a “third chance” for completing developmental conflicts left unresolved in adolescence. A case example is presented to illustrate how these conflicts can be revisited in adulthood. The analytic descriptions are rich with symbolic content of this young man’s transference and countertransference issues. This case illustrates how repeated traumas at multiple developmental stages further prevents the opportunity for resolution in adolescence. This case also provides for interesting dream work and an overview of extended family dynamics. This chapter provides a thought-provoking look at the reconstruction of development for the psychoanalyst and illustrated early on in the book by von Klitzing.

Bürgin concludes the book with a chapter examining the role of compensation and pain in the development of the psyche. Homeostatic correlates are presented for the child=s psychic adaptation to physical and emotional pain and stress as well as his or her perceived deficits in coping. Bürgin recaptitulates the infant’s need for external stabilization, namely by the primary caregiver, to facilitate adaptation to pain and stressors while fostering emotional stability.

Most of the topic manuscripts in Psychoanalysis in Childhood and Adolescence are followed by thoughtful and scholarly commentaries by additional noted psychoanalytic thinkers. These commentaries further support the contributions of the primary authors and provide additional case examples from the commentators emphasizing the relevance of topics to their practice and research.

I highly recommend Psychoanalysis in Childhood and Adolescence to all clinicians who engage in analytic, dynamic, object relations and play derived therapies. These current thoughts and research findings are important to adult as well as child/adolescent therapists in that they re-examine the developmental reconstructions of adult psychopathology. For the child therapist, this body of work provides a refined perspective on more age-appropriate developmental considerations for therapy and highlights the role of pre-verbal and somatic factors. This text is “jam-packed” with a wealth of succinct and diverse topics with little unnecessary filler material or discussion. For highlighting and underlining readers, you are forewarned that the myriad of useful comments, quotes and theoretical examples may deplete your ink!

References

Axline, V. M. (1969). Play therapy. New York: Ballantine Books.
Winnicott, D. W. (1971). Play in the analytic situation. In C. Winnicott, R. Shepherd & M. Davis
(Eds.), Psychoanalytic explorations - D. W. Winnicott (pp.28-30) Cambridge, Massachusetts: Harvard University Press.

Reviewer Note

Gregg A. Johns, Ph.D. is Internship Training Director of the Mississippi State Hospital’s APA-Accredited Pre-Doctoral Internship Program in Clinical Psychology. He is an experienced child and adolescent therapist and currently supervises psychological services for intermediate and chronic inpatient adult males.

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