A Question of Technique: Independent Psychoanalytic Approaches with Children and Adolescents (Book Review)
Lanyado, Monica and Ann Horne
Reviewed By: Christopher Pagano, Volume XXIX, No. 4, Fall 2009, pp. 47-48
Important contributors to this edited collection, Lanyado and Horne have created a valuable and solid series of commentaries regarding the choice points that arise in child and adolescent psychotherapy rooted in the perspective of the still evolving Independent Tradition of British Psychoanalysis. Overall, the mix of theory and clinical technique is excellent, and is what makes this book captivating and useful. Perhaps the clearest articulation of what exactly is meant by the "Independent Tradition" is in chapter 2, where Ann Horne provides a good foundation for understanding the major tenets of this tradition (formerly know as the British "Middle Group" for their staking out a theoretical/clinical position between Anna Freud (ego psychology) and Melanie Klein). Despite the apparent location midway between these two theorists, it is clear to this reviewer that Anna Freud and more so, D. W Winnicott hold sway in the minds of the authors in this book. Despite the repeated references to the need to evaluate the choice that the child therapist faces between analyzing the transference and providing a Loewaldian "new object" experience in which development can get back on track, it is clear that Horne and Lanyado heavily favor Winnicott’s emphasis on freeing up the patient to find new paths of development as the solution to the repetition of maladaptive patterns. Thus, in an illuminating interview of Anne Hurry ("the prime mover in establishing the Independent child psychotherapy training at the British Association of Psychotherapists in 1982") in the Introduction, she states:
[W]hat you very often get is a patient who struggles to maintain a transference relation and avoid a developmental one . . . But if you can get through that, then you find the ability in the patient to use you in a different sort of way, to use you to develop rather than to stultify and distort his growth and confirm that all is useless. (p 13)
The remainder of the book is divided into parts, all of which contain actual clinical process, and these are titled "Parent-infant work," "Latency and Adolescence," and "Taking the broader view." While mixed in quality, most chapters within these sections provide ample clinical material and accompanying windows into the mind of the therapist, illuminating decisions, technique and choices.
The central tenets of the Independent theory and technique, and the associated theorists, include these: 1) People are driven primarily by their need for objects (Fairbairn and Winnicott); 2) Aggression is a reaction to trauma, loss or other environmental impingement on healthy development (Winnicott; Kohut); and 3) play as a goal in and of itself, developing the capacity to be creative and flexible (Winnicott). The authors tend to utilize Anna Freud’s technique of illuminating defenses by pointing to the need to have them in contrast to the Kleinian technique of interpreting "deep and underlying" motives, noting that in the Anna Freudian tradition it is crucial to "acknowledge the child’s desperate need to maintain the controlling defence, whilst also recognizing the intensity of the pain that necessitated such a severe and unrelenting defensive structure" (p 130).
The Independent approach is also guided by the belief that insight in the patient develops most fruitfully by the patient herself through the process of play and not through interpretations suggested by the therapist. The therapist prepares the ground for self-awareness by providing a "developmental object" appropriate to their developmental needs. The therapist’s authentic responsiveness within the play is primary. The analyst uses words to assist understanding only after a significant interaction has occurred within the transference. Several of the authors specifically cite Stern et al. (1998) and the experience and use of "moments of meeting," with the underlying tenet that the therapist always intervenes as a participant-observer (See p. 131-132.).
Affective attunement with the patient, and finding a way to show this attunement, is also central to this process. Clearly this approach to child therapy has deep roots in Anna Freud who advocated for the therapist to be more of a real person in order to address developmental deficits in child patients, and in Winnicott, who emphasized the need for the therapist to be able to play (an oft-quoted reference throughout this book). A subset of this call to well-timed spontaneity on the part of the therapist is the use of humor to highlight defenses. For example, when Horne tells her young patient of her approaching vacation:
[S]he shouted, "Good!" I smiled at her (she had expected something punitive from this outburst). "Well, you wouldn’t want to miss therapy too much!" She roared with laughter. (p. 227)
Lanyado gives a moving portrait of clinical work with a severely deprived and abused girl now in her adolescence. She shows how authentic engagement by the therapist, through her willingness to be playful and emotionally real, helps the girl melt away her desperately held defences. In an extended description of a particularly vivid play sequence, she relates how, the therapist (playing the headmistress in a boarding school) and the patient (playing a student) instructs her to accuse the student of being "bad" and having a "bad heart." Lanyado relates her internal process and actual response:
This play was so powerful that before I knew it, I had blurted out "But I couldn’t say that. You’ve got a good heart!" which is something I truly believe about her. I was really surprised by the spontaneous intensity of what I felt at this moment and they way that the words came out . . . . tears inadvertently sprang to my eyes, and I was touched by how deeply she was convinced that I would reject and discard her because I was so angry with her. (p. 143)
She concludes with a discussion of the importance of her willingness to play, something that enable them together to engage with a "powerful creative process," one that helped to "melt, dissolve, neutralize and effectively antidote the painfulness of the raw and undigested memories and feelings that she carried in her internal world" (p. 146). This is a moving example of the tension that the Independent tradition tries to hold and address, namely (in the slightly different language used by American relational theorists) the tension between allowing transference enactments to develop and creatively and genuinely struggling with the patient to find new ways of relating that can bring them new solutions to painful repetitions of past traumas.
Teresa Baily describes solo work with parents of troubled teenagers. The underlying thrust of the work is to help parents disentangle the feelings, desires and experiences of their own adolescence from those of their teenager in order to more effectively make contact with, contain and aid them. As she states "the therapist’s task is to help unpick tangles, make links, separate out adult and teenage emotions and desires that have become fused into a single mass" (p. 182). It is not entirely clear, however, how she succeeds in helping parents "name, understand and take back projections," and so on. The closest she comes to explaining this process is by showing how the therapist, by sitting with countertransference feelings of failure and the inability to provide a quick fix, is able to empathize with the reality of being a parent who wishes to control a teenager’s life. The therapist must have the ability to sit with the discomfort of not being able to control and fix and instead contain and reflect upon feelings. Communication and reflection upon feelings and dilemmas is more likely to help the adolescent navigate a secure path towards health.
Several additional chapters also focus on the importance of developing capacities in parents, efforts that in turn impact the child’s development. Dowling underlines the importance of developing a holding relationship with the parent, including with their own past, in order to build in them the capacity to be emotionally available to the child. Hamilton similarly focuses on the importance of eliciting the mother’s reflecting and transforming capacities by revealing the fullness of her own potential. Another aspect of the parenting work, this in Iris Gibbs’ chapter on "A question of balance," is work with parents to lessen their guilt by understanding the child’s need to project anger and rejection on to her objects. This enhanced awareness allows the parent to step back from retaliation (which can occur when they begin to experience their child as a persecutor) and avoids the dangerous and commonplace re-enactment of rejection. The work involves parent-infant psychotherapy in which the therapist helps the parents tolerate disturbing feelings and the demands of the baby, and also involves psychoanalytic psychotherapy and/or couples therapy for the parents.
In sum, this solid volume provides a lively series of discussions on the Independent tradition in British psychoanalysis, using ample clinical examples to give the reader a window into how the theory is lived out in technique. While Winnicott is clearly the father of this still emerging tradition, it is nonetheless a loose coalition with healthy debate still active. Sternberg nicely summarizes this tension when she notes that the Independent tradition is concerned about shame and humiliation and the vulnerability of the ego ideal, but this does not mean that the therapist should avoid anxiety or interpretation. It does mean using Anna Freud’s technique of interpreting in displacement (e.g., interpreting hidden feelings or motives of baby animals that the child has engaged in a play), as well as sensing when the timing for interpretation is right (when the patient is on the verge of or in the midst of self-awareness), all with the goal of leading the patient to self-understanding, greater internal flexibility and healthier ways of relating and self expression.
Christopher J. Pagano
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