Abstract
Child analytic work is multi-faceted and intensely pragmatic. It involves many parties (parents, stepparents, siblings, teachers, schools, and government agencies) and many techniques. In addition to the use of transference, countertransference, dreams, and reconstruction, there is also developmental assistance and much use of displacement. The path toward insight may proceed via pretend play, drawings, and games and at times, scarcely symbolic nonverbal enactments, representing very early developmental levels.
I review these two volumes from the point of view of a child and adolescent analyst and as a student and teacher of psychoanalysis. Our field is broad, almost unfathomable, encompassing the past, the present, the anticipated future, and the moving target of development.
The two volumes Parent Work Casebook and Adolescent Casebook are structured similarly. Each chapter describes an assessment and a treatment, usually over several years’ time. The narrative of each child or adolescent’s treatment is followed by three discussions: two by commentators and one by the editors.
Reading these books is a veritable education in both development and analytic technique. The authors represent symptoms as they arise from phase-related conflicts and portray the effects of past traumas on current developmental challenges. The authors delineate how social and bodily developments initiate, interweave with, and sometimes inhibit psychic growth. There is careful and detailed reporting of how the analyst brings up the psychological aspects of bodily and interpersonal development with children and their parents.
I highly recommend Parent Work Casebook and Adolescent Casebook to all psychotherapists and psychoanalysts. To adult analysts and therapists, I remark that all patients have had parents, retaining the character resulting from those early and ongoing relationships. All adult patients, of course, were adolescents, and retain the solutions to the challenges of sexuality, identity, and adaptation to the wider world from that life stage. Child analysts will especially enjoy these collections. They may feel, as I did, vindicated that others have had the same thorny entanglements. They may be proud of our group, as we often take on difficult and complex patients, follow them for many years, and see them recover from severe symptoms and then sometimes even thrive and prosper.
In both volumes, some elements of the history are relatively neglected. The race and ethnicity of the patients and analysts are rarely specified, probably to ensure anonymity. Issues of class and socioeconomic status are only sometimes discussed. The negotiation of the fee is almost never included in this otherwise thorough explication of how the treatment is arranged with parents, children, and adolescents.
Parent Work Casebook is edited by Jack Novick and Kerry Kelly Novick, as well as Denia and Thomas Barrett. I found it interesting and poetic that two psychoanalytic couples collaborated to produce this volume on intervening with parents. Denia Barrett, the current coeditor of Psychoanalytic Study of the Child, has written about dreams, play, interpretation, and the variety of ways we consult to parents (Anzieu-Premmereur et. al., 2016; Barrett, 2012, 2022). Thomas Barrett’s (2008) paper on acting out, “Manic Defenses Against Loneliness in Adolescence,” is often included in the curriculum of work with troubled teenagers.
Jack and Kerry Novick have written extensively about psychoanalytic treatment of children and adolescents (Novick and Novick, 2006, 2007, 2010). Before the Novicks argued the case for continuing parent involvement (at least in my experience), child analysts tended to focus on in-depth treatment with the child, including only occasional meetings with parents. Parents understandably often felt mystified and excluded. This exclusion carried with it the implication that parents did not need to be engaged in understanding the child’s subjective experience. Lack of parent involvement in child treatment is likely to lead to splitting, with blaming of the parents by the analyst and/or dismissiveness and competitiveness of the parents toward the analyst. Because of the intense involvement between the analyst and child, the parents may fear that the analyst will make off with the child and the child’s allegiance (Frankiel 1985).
Anna Freud famously defined the goal of child analysis as enabling the child to return to his/her/their own path of development (Ablon 1988). The Novicks have added to this goal that the analysis should also restore the parent-child relationship to a positive path, so that it can be a “life-long resource for both parents and children.” Child clinicians know that if the parents are not supportive of treatment of their child, the treatment has little chance of being ongoing or succeeding. I find parents to be highly receptive to a statement that embodies the Novicks’ principles: We are meeting to find a way for your child to understand and overcome their symptoms, and to move forward in their life. During this process, we will work together to help understand and improve your relationship with each other, so that you can be an ongoing resource (and ideally a source of joy) for each other over the years.
This idea of mutually supportive and generative parent-child relationships has also informed the Novicks’ thinking about late adolescence and emerging adulthood. They emphasize the importance of evolving interdependence rather than stark and severe separation in late adolescence. Several years ago, at an American Psychoanalytic Association meeting, they commented that just as adolescents leave for college to confront the many difficult choices and experiences, including sexuality and use of substances, they are encouraged to separate and move far from home, thus being deprived of useful parental influence. The Novicks advocated for continuing support and engagement through this phase, which I found helpful in advising parents of troubled college-aged teenagers and young adults into their 20s. Several years ago, at the annual Association for Child Psychoanalysis meeting, there was a vote taken that resulted in extending the age of adolescence upward from 21 to the current limit of 26 years old. This may be seen as something of a land grab by the child psychoanalysts but does seem justified.
The Use of Case Studies
Case reports, especially those such as the ones in these two casebooks, benefit from being both holistic and longitudinal. A thorough psychoanalytic case report forms an integrated account of a person’s being. It is not only focused on symptoms and their genesis, but like the best literature, it includes the sociocultural circumstances, the multigenerational back story, and a specific developmental and characterological progression. The curtain rises on the consultation, with its specification of the emotional tenor of the session, the language used, the omissions and nonverbal enactments. The feelings and thoughts and sometimes a bit of the biography of the psychoanalyst-author of the report are glimpsed. Candidates these days quickly grasp the bidirectional elements of the encounter. One I worked with said, “It is always about ourselves, too, isn’t it?” Then, the written case report is distinct from the oral version, presented in a class or at a conference, which like a piece of music, comes out differently each time depending on the focus of the presenter at that time and the audience.
The study of individual treatments may be seen as part of the tradition of observational, natural history (Hinshelwood 2013). They proceed “inch by inch,” as in David Mallett’s 1975 children’s song “The Garden Song”: “Inch by inch and row by row, I’m going to make my garden grow.”
Or “bird by bird,” as a book about how to write about our world would have it (Lamott 2013).
The psychoanalytic case history presents a longitudinal study, a therapeutic relationship over time, one that is both similar to and different than the relationships of the patient’s past and present. The patient’s evolution and growth are described in the context of and alongside the therapeutic relationship. Sometimes, most fortunately, the span of time in which the patient’s life is depicted extends to years after the treatment has ended. The best case studies convey the incredible investment put into an analysis—the regularity, the persistence, and the strength to tolerate the pain and anxiety that must be acknowledged in most treatments.
Parent Work Casebook
The editors’ goal in this collection of clinical accounts of work with parents is to show actual work with parents with the difficulties and rewards that accompany this work. I will give an overview of the cases included and focus on one in depth.
Thirteen cases are included, spanning parenthood from preschool through emerging adulthood. Five of the cases are analyses, with four or five sessions a week for 1 to 3 years. Most of the patients in analysis continued afterward for psychotherapy once or twice a week. Five of the cases were seen in once-a-week psychotherapy with concurrent parent sessions. Two cases were consultations, and one was a preschool child treated via the parents.
The contributors nicely describe their flexibility: at times interspersing parent sessions in the child’s treatment, at times meeting with dyads, and at times conferring only with parents. I appreciated the description of the work with the frequent situation in which one parent refuses to be involved with the child’s therapist. One clinician managed to communicate to the missing/resistant parent by way of the parent who did attend. Another persisted in reaching out to an absent father, ultimately succeeding not only including him, but in helping him reconnect with his son. Is this psychoanalytic work or is it family therapy? The editors reply: It has been said that psychoanalysis happens when there is a psychoanalyst doing the work. . . . The analyst’s thinking includes consideration of the body and drives, attachment, and the reworking of oedipal relationships. Ideas about containment, dependency, transferences and providing what the patient needs are explicitly included as part of the technique in this model. (p. 238)
In another set of situations that creates role strain for the analyst, at times, children and adolescents present “a danger to themselves or others.” I put that in quotation marks, as it is the criteria in the emergency room for commitment, and in the practitioner’s office, it is the criteria for a duty to involve government agencies. One of the case studies recounts a consultation with an adolescent who says he is planning to murder his brother. The patient’s family insisted on minimizing the threat that the adolescent presented. The clinician made a report, thus losing his alliance with the patient and his family, though it was clear that there was no alternative. The strength of this particular case report is that the clinician describes his persistent attempts to negotiate with the teenager and his family, trying to find a way through the impasses that occurred.
One of the recommendations arising from these parent work cases is that we arrange for extended consultation with parents before making a treatment plan with a child. That offers the best chance for a positive parent-analyst alliance when frightening aspects of problems emerge. As seasoned child clinicians know, there is a bit of a catch-22 here, as the very parents whose children present a threat are often those who employ denial and projection as central defenses, and thus refuse to participate in an initial in-depth assessment.
Now, I will turn to the hopeful and deeply touching account of the psychotherapy and parent guidance of an 8-year-old named Marco. Marco and his parents had immigrated 2 years ago to the United States. Upon entering first grade, he was seen to have a language delay and symptoms of autism spectrum. Yet the accuracy of this diagnosis was confounded by the many moves the family had made and the difficulty with a new language. In his third play sessions, Marco shows his preoccupation with loss.
He noted out my window that darkness had fallen . . . he paused before muttering, “the day is gone.” I said, “yes,” he had come this week at a later time and so it was dark by the end of his visit. . . . He stood unmoving and seemed confused. Finally, he repeated “the day is gone.” Not knowing quite what to say I responded, “Yes, but tomorrow will be another day.” (p. 69)
This sensitive analyst infers that he is struggling with a great sense of loss—but why? His parents seem loving and attentive. In the next few parent meetings, she asks Marco’s parents to bring in photos from birth to the present. In infancy, Marco appeared secure and happy. But in toddlerhood, when he had begun attending a childcare center, he looked worried and tearful. His parents discovered, some time later, that Marco had been mistreated there, at times left alone in a dark room. Without the clinician’s curiosity and pursuit of a detailed history, this story may never have emerged, as the parents understandably had developed denial about the events and their effect upon Marco. The analyst helps the parents grieve and tolerate their remorse. Furthermore, she makes a photo narrative, of this sequence and uses it to help him understand the past that has led to his tendency to sadness. This method is particularly important for Marco, who because of his cognitive delays, has difficulty with memory. After this creative therapeutic effort, Marco becomes enlivened in sessions. He is talkative, participates in pretend play with dollhouse characters and makes colorful, artistic drawings. He makes a friend and regains his enjoyment in being with his parents.
As I review the cases in Parent Work Casebook, I realize that the problems reported truly represent almost all that arise in working with children: adoption, orphanhood, immature parents, absent fathers and mothers, abusive parents or siblings, toxic divorce, academic failure, anxiety, depression, substance abuse and eating disorders. These cases offer reassurance to the child clinician, who will think, upon reading the dilemmas presented and the feelings they evoke: “I am not alone! When confronted with these serious difficulties, other analysts also sometimes have feelings of inadequacy, uncertainty, and doubt.” Many of the cases illustrate moments of impasse and resistance, followed by persistence, curiosity, and ingenuity on the part of the clinician, who often, but not always, prevails in helping the patient to find a way forward. Many cases could readily be used in a class teaching psychodynamic work with children and families.
Though these many insights are impossible to summarize, the editors have offered some rules of thumb. They recommend resisting the pressure to offer quick solutions and formulations, instead initiating a process of inquiry into the symptoms and history of the child and family. Readers will become more aware of the role of internalized parents, internalized parenting functions and the real, contemporary relationships between children, parents and grandparents. We need not communicate only with our designated patient; we can helpfully include the family. We should maintain each person’s privacy, but not support harmful secrecy. It is vital to focus on the parental alliance early on and in an ongoing way, and to seek consultation when in stormy waters.
Adolescent Casebook
The editors, Jack and Kerry Kelly Novick, state that they wished to study whether adolescents are being treated in psychoanalysis and whether psychoanalytic treatment is effective for them. They also ask how analysts today conceptualize adolescent development and what techniques they use in treatment.
There are 19 adolescent case reports, each with two discussants and comments by the editors. The discussants highlight bright and blind spots and illuminate the process of the analyses. The cases and discussions are written by 40 contributors, 8 of them international, and the remaining 32 from across the United States.
In order to grasp the import of the case material, I wished for a table including age, presenting symptoms, psychiatric diagnosis, global assessment of functioning, important historical and developmental history, frequency and length of treatment, key interventions, use of dreams, involvement of family, and outcomes.
Fifteen of the 19 cases were seen three to five times a week, with most of those being seen four times a week; the others were seen twice a week. The analyses began when the patients were aged 9 to 20 years. Most patients continued for several years, thus traveling with the analyst through two or more developmental periods. All but two treatments involved significant amount of concurrent work with parents.
Like poems, none of these cases can be summarized in a satisfactory way, as paraphrasing and condensing the narratives and dialogues loses the feeling, momentum, and meaningful detail. A description of a good poem never matches the poem itself. That said, I will share some of the case material to give the reader a sense of two of the case histories.
Radhi, Ages 9 to 13
Radhi, age 9, was referred by her teacher because of failing grades and inappropriate sexual behavior in class. Radhi’s mother died when Radhi was 8 months old, and Radhi’s father, an alcoholic, was never involved with her.
Radhi was treated by an analyst who worked at her school in a program that provided treatment to indigent children. I was moved by the analyst’s account of work with Radhi, who had suffered tremendous adversity. Though the analyst’s presence and interest alone were therapeutic to Radhi, it was the therapist’s facilitation of Radhi’s understanding of her symptoms of seductiveness and self-destructiveness (failing grades) that led to Radhi’s dramatic progress.
During the first session, Radhi tells the analyst a recurring dream: “Mom, Dad and me are driving through a jungle and then suddenly the car breaks down . . . as they go in search for something, I am alone. I get very thirsty and there is no water. I am scared as it is very dark and I keep calling out their names but nobody replies . . .” The analyst says: “Radhi you are telling me you get some very scary dreams at night.” Radhi corrects her: “Miss! not some, SAME! I get this SAME dream every few days.” (p. 12)
Radhi wants to be sure that her analyst grasps the centrality of the dream content that is the same every night. This recurrent dream is posttraumatic, repeating the loss of her parents. It comes up immediately in the setting of meeting the analyst, a new object—in the transference, a replacement for the parents. As is the case with children who have terrible losses, Radhi is immediately afraid of the loss of her analyst. When the time comes to end the session, Radhi refuses to leave the room, saying she knows that the analyst won’t meet with her again. The analyst and Radhi understand Radhi’s fear of loss over the course of their work together, as well as Radhi’s turn toward premature sexuality and seduction to hold onto others.
One of the commentators helpfully explicates Radhi’s most prominent symptom, inappropriate seductiveness. S/he writes, [Radhi uses] . . . “seductiveness to defend herself against both the longing and rage toward the mother for leaving her.” Here is a quintessential way that children who fear being abandoned . . . at once protect themselves by not revealing their underlying authentic parts and over-exposing themselves, behaving in a seductive way toward, in Radhi’s case, both peers and therapist. (p. 25)
At the end of this case history, Radhi has understood her behavior, and is then able to establish sound therapeutic boundaries with her analyst and with her peers. She is thriving in her studies and engaged with friends. Radhi’s case history is instructive for analysts working with female preadolescents from deprived backgrounds who turn to seductiveness as a facade. The author has described a life-changing analysis for an orphan of little means, in a story that could be from Dickens.
Claude, Ages 16 to 19
Claude begins working with his analyst at age 16. In his first session, Claude enters the analyst’s office bent over, hidden in a hoodie, sobbing, and correcting himself so often that he cannot complete a sentence. His treatment, too, begins with the report of a dream.
There is a gym structure, like a tall jungle gym. I am climbing apart with my dad. . . . He goes to put his foot up and misses. . . . I think he is stable, but he falls. . . . I keep climbing up, but I fall back and presumably die also. (p. 251)
The analyst says it is a tragic dream. She is attuned to Claude’s identification with his father, who is not able to keep his balance. Again, as in the case of Radhi, the analyst understands the dream as possibly conveying an early transference—that the analyst may not provide stability. As Claude leaves, the analyst notes that he has left his phone on the couch. With a smile, the analyst gently says that Claude’s phone is “not ready to leave yet.” The analyst is alerted to themes of being forgotten or neglected. She makes an interpretation in the displacement; of course it is Claude who is not ready to leave yet. There is also an interpretation via the analyst’s action: she notices the phone (she does not neglect it) and returns it to her precariously adjusted patient.
Claude requests more frequency, five times a week. He is then able to discuss his sexual experiences and fantasies. The sexual transference is not interpreted, maybe being too hot to handle. Claude begins an intense relationship with a young woman at his college and precipitously leaves treatment, perhaps keeping himself separate from his female analyst.
The case histories in this collection are fascinating in themselves, but they are made immeasurably more informative by the commentaries following each case. As one example of an intriguing association to clinical material, the commentator on the case of Claude comments on technique in approaching adolescent sexuality and sexual and other fantasies. S/he notes that the analyst who works with adolescents must take care to respect the particular developmental adolescent need for isolation, privacy, and singularity. Adolescents find themselves experientially very much alone . . . for the first time in their lives—solitary both in their own bodily preoccupations and in the goings on in their minds. This sense of isolation can be seen to reside at the center of the separation/individuation process. . .[and] is further sharpened in the sheer force of narcissism in the experience of adolescents—that all-consuming fascination with their selves, their identities and their preservation. They say, in effect: “I am unique, different, not to be pigeonholed or overly defined.” . . . “Only me, not you, understands.” (p. 266)
Summary
These volumes offer the reader an education in contemporary psychoanalysis, demonstrating tactful, sensitive work with defenses, dreams, transference, reconstruction, and developmental support. Treatment of parent-child relationships is informed by understanding developmental stages and transgenerational themes. The authors are convincing that we can and should consider transference and countertransference with parents as well as children. The vagaries of adolescence are illuminated in analyses of many sorts of young patients. It is a privilege to read these two collections; they clearly support psychoanalysis as a life-changing treatment.