Relational Child Psychotherapy (Book Review)

Author:  Altman, Neil, Richard Briggs, Jay Frankel, Daniel Gensler, and Pasqual Pantone
Publisher: New York: Other Press, 2002
Reviewed By: Barbara Eisold, Winter 2004, pp. 27-29

This book is the collaborative creation of five male analysts, two (Neil Altman and Jay Frankel) graduates and faculty members of the NYU Postdoctoral Program and three (Richard Briggs, Daniel Gensler, Pasqual (Pat) Pantone) of the William Alanson White Institute. In the introduction (p. xiii), they tell us that it grew out of a peer reading/supervision group in which the participants agreed that “modern never became postmodern in the child literature” (p. xii). Thus they decided to examine “what we were already doing with our child patients [up to age 12] that could better be conceptualized in relational (and also presumably post modern) terms” (p. xii). The book was created “with many types of reader in mind,” as an attempt at synthesis and integration, especially of the new infant research (of both Daniel Stern and his followers and attachment theorists), object relations theory (Klein and Winnicott especially), and finally of systems theory. This enormous undertaking was divided into five sections, each of which was written by a different author and then reviewed by the others and revised (Altman, personal communication). In spite of the fact that the authors did not always agree with one another about individual section contents (p. xiv), they left their respective contributions unsigned. Thus the “surface,” of the book, as they acknowledge, is rough and, as such, is supposed to represent the variety of approaches that they say, characterizes relational child psychotherapy. But, in fact, the authors’ repeated use of the phrases “the relational child therapist,” “the relational interpersonal child therapist,” and the pronoun “we” to introduce material, leaves the reader with the sense that the ideas presented in the body of the book actually do belong to all five men. Their differences, which might have been of considerable interest, have thus been obscured.

What is the point of view of “the relational interpersonal child therapist,” as presented here? According to these authors, this person is open-minded, and does not think there is any one way to “do” child therapy. He or she is, however, always very conscious of projection, on the one hand, and countertransference on the other, and makes good use of both; (s)he also understands that developmental concepts are culture bound. Most of all perhaps, the relational child therapist is always thinking about the system or systems (family, school, welfare, foster care, medical, etc) in which the child is living and in which the therapy, therefore, is taking place. Unlike a more classically organized, child-focused clinician (e.g., Morton Chethic [2002]), the relational child therapist relies on “. . . a field-relational model that goes beyond the dyad” (p. 11) in which, through the use of play, it also may become “. . . possible to think of the therapist as a ‘new’ object for the child . . . as a person who may have a transformative impact on the child’s internal object representations” (p. 10).

In addition, the relational child therapist works hard to understand the representational world of all the participants in the child’s life. “Lest the reader immediately feel overwhelmed. . . given the complexity we are describing,” the authors reassure us by saying, “we hasten to point out that most child therapists juggle these various balls intuitively and quite effectively much of the time” (p. 15).

The first of the book’s five sections, called “Child and Parent Development from a Relational Viewpoint,” is a review of psychoanalytic developmental theory from the Freuds through Daniel Stern, with a heavy emphasis on the part played in a child’s development by both his/her parents and the culture in which (s)he is raised. Each of the four remaining sections is titled, respectively: “Psychopathology from a Relational Viewpoint,” “Conceiving of Treatment,” “Child and Therapist in the Treatment Room,” and The Context of Child Psychotherapy.” Since, by design, each section is supposed to stand alone (p. xiv), there is some repetition of subject matter from section to section; work with parents, for example, is a theme throughout, presented a bit differently by each author. As a consequence (and as the authors intend), different chapters will appeal to different readers, depending on each reader’s particular interests and needs.

As a person looking both to expand my own skills and to have as useful teaching articles, I will mention here some of the chapters that were highlights for me. There is a good chapter completely devoted to work with parents (Chapter 14, “Including Parents in the Psychotherapy”), in which routes to the development of a positive therapist–parent alliance, in a host of different circumstances, is described in some detail. Included is a discussion of building an alliance with parents who may or may not be available/cooperative/interested in their child’s treatment, who may have positive or negative identifications with their child, who may have therapists of their own, who may need/want to work on their own (couple) relationship, who may (or may not) be getting divorced, etc.

Another good chapter (Chapter 15), called “The Therapist in the Child’s Larger World,” includes discussion of the therapist’s role in communication with other professionals, (other therapists, school personnel, child welfare personnel, managed care companies, psychopharmacologists, etc.)—some, if not all, of whom will inevitably be involved with any given child-family system.

There is a fine chapter called “Launching the Therapy with the Child,” which includes a discussion of each of the following: the beginning sessions, the role of child (and parent) anxiety in directing the work, communication with parents, rules in regard to privacy, session structure, the use of play materials, and (finally) enactments—including those in which there is physical contact.

Most useful to me as a clinician was a chapter called “Assessment and Treatment Planning.” Before I read it, I had thought of myself as someone who works at length with parents. But the author of this chapter appears to have an exceptional degree of patience with parents, or, in some cases, with parents and child, and is willing to work with them to contend with his/their questions vis-à-vis the referring “problem” (the problem periodically seems to get resolved in this way). His wariness about “assuming excessive responsibility” (p. 173) himself for the outcome of any case, followed by his examples, has been useful to me in thinking about my own work.

My greatest reservation about this book is the somewhat polemical way in which the authors present their “relational” point of view. As already noted, the term “the relational therapist” (alternating with “the relational interpersonal therapist” or “we”) appears again and again, in what seemed to me to be definitive terms. Some examples are as follows: “…the relational therapist does not begin with an already developed idea about whom he is going to see” (p. 157); or, “The relational therapist does not view play in the narrow sense as an end in itself. Rather, she is concerned with how the child’s ability to participate in a relationship is a key factor in the child’s capacity for full and effective living” (p. 198); or, “Our relational perspective understands psychopathology as fundamentally interactional” (p.106); or, “We believe that there is no behavior that is a direct translation from the biological without being shaped . . . by a child’s experience.” (p. 106). These statements seem less representative of flexible, problem-focused thinking than of a kind of belief system or canon.

Whether or not this “canon” is, in fact, original to “relationality,” a question in its own right, is not my interest here. I am much more interested in the implications of the definitive tone, which to me imply a kind of defensiveness that detracts from the power of the content of the book, while at the same time covers up some difficulties. The most important of these “difficulties” it seems to me, is related to psychopathology and diagnosis. A second is related to therapist anxiety. A few words about each of these follow here.

Beginning with the first, (psychopathology/diagnosis), in Part 2: “Psychopathology from a Relational Point of View,” the authors tell us, they aim to “give the reader. . . a variety of . . . interconnected ways of thinking about children’s difficulties” rather than a “new relational taxonomy” (p.103)—a reasonable goal, it seems to me. But then it turns out that there are some real limits to the “variety of …ways” they approve of. In the two chapters of which this section consists, the author(s) take exception to some of the more conventional ways of viewing psychopathology. Although they acknowledge the existence of some biological disorders, they disapprove of diagnostic manuals, which they say “see people as passive, as victims of conditions” and assume that these exist beyond the influence of culture (p.148).

They do not want to “medicalize” their patients and they eschew the notion of developmental lines and pre-set stages in favor of more Thelenesque (Thelen and Smith, 1994) determinants, involving multiple emergent interactions, to which culture makes a critical contribution. In keeping with this “postmodern turn” (Eagle, 2003) even cognitive developmental norms (Piaget, for instance) are dismissed (see p. 54) because they tend to be based on invariant, one person progressions. They see diagnosis as “heuristic and multidimensional, a continuous process of constructing and revising a complex set of interrelated, evolving understandings about a child’s difficulties” (p. 130). When it comes to the evaluation of change, these authors eschew “the emphasis . . . on the resumption of . . . derailed developmental process” (the classical way of noting positive therapeutic change). Instead, in considering when to end treatment, they look at the child’s present life with questions such as: is the child receiving greater satisfaction in peer relations, is (s)he more interested in school/learning, has (s)he an increased ability to play and enjoy? (see pages 368-369). The child, in other words, is measured only against him/herself, at the moment.

There is no doubt that the subject of psychopathology and its implied opposite, developmental “normality,” are complex ones for clinicians, given our new understanding of how very unique development is for each individual. Often labeling and medication are overused; often environmental considerations are overlooked and developmental norms poorly applied. But, unlike adults, it is a fact that as children grow up, their brains and bodies change. They move from home to a presumably more uniform school culture. To contend with all this, they must learn some adaptation skills. Clinicians in turn must have some general, overarching (dare I say “normative”) ways of understanding and assessing how a child contends with these changes, in order to be fair, responsible, and realistic about the child’s own goals vis-à-vis the wider culture into which he or she will eventually want to move. A kinder, less proclamational, discussion of this dilemma (or dilemmas) as problematic would have been useful in this book, with some acknowledgement of the fact that most child clinicians carry in their heads some developmental norms (Piaget is the one I use most) and need to learn how to use them, in conjunction with wider considerations about their implications, if the child’s best interests are to be taken to heart.

Secondly (and far less important), it seems to me that the “this is how relationalists do it” message of the book, does not address the child-therapist’s potential anxieties at being asked to balance so many facets of a child’s life at once. Much of a child therapist’s willingness to “balance” may well depend on the need to contend with other professionals in the child’s life. A more thoughtful discussion of potential therapist anxiety in these various situations and of the range of feelings that some of these other people may have about therapy and the child therapist, might have been useful in encouraging clinicians to give up a more conventional, less multi-dimensional clinical endeavor, in favor of a wider, systems-based approach.

All in all, however, the book succeeds in compelling the reader to step back and take a wider, more inclusive look at the whole “relational” world of the child. As such, it is a positive contribution to the literature on child psychotherapy.

References

Chethik, M (2000). Techniques of Child Therapy: Psychodynamic Strategies. 2nd ed. New York: Guilford.
Eagle, M.N. (2003). The postmodern turn in psychoanalysis: A critique. Psychoanalytic Psychology. 20: 411-424.
Thelen, E. & Smith L. (1994) A Dynamic Systems Approach to the Development of Cognition and Action. Cambridge, MA: MIT Press.

Reviewer Note

Barbara Eisold is a Division 39 member in New York City and a faculty member of the Center for Social and Emotional Education.

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