Conducting Psychodynamic Therapy with Children and Youth: Some Thoughts for the Modern Clinician

Abstract

Clinicians working with children and adolescents must remain dynamic (“zestful, energetic, open to constant change”) while exploring the psychodynamics inherent within the patient-clinician dyad. Cultural climates and trends are constantly changing, and as communications improve in the digital era, the enormity of information makes it difficult to stay up to date. The author shares some opinions and observations he has learnt in his practice of psychopharmacology and psychotherapy with children and teenagers.

Introduction

In the world of psychoanalytic and psychodynamic psychotherapy, it is often said that Sigmund Freud studied the adult’s mind to learn about childhood, whereas it took several additional decades for his successors (Melanie Klien, Ana Freud, Erik Erikson, Harry Harlow just to name a few) to study a child’s mind to learn about adulthood. There is plenty of speculation, even controversy, about Sigmund Frued’s thoughts about child analysis, however, it cannot be denied that his supervision of the first recorded child psychotherapy case ¹ which was conducted by the patient’s analysand father, played a vital role in the genesis of youth psychotherapy in contemporary times. Later, his daughter, Anna, translated psychoanalytic principles and techniques to the mental and developmental world of children. With each decade that has followed since then, psychodynamic theory has continued to evolve, however, three fundamental principles of psychodynamic psychotherapy have stood the test of time—childhood matters; the unconscious exists and plays an important role in treatment, and transference (what the patient feels toward the clinician) and countertransference (what the clinician feels toward the patient) are ubiquitous in each treatment dyad.

I present here some basic tenets I have learnt in my child and adolescent practice, and I hope the reader finds them useful:

1. “Lean Back!”

During a visit to Costa Rica, my wife somehow convinced me to go rappelling down a series of waterfalls, even though I have a fear of heights and could not swim. I was only through the first one, when I started panicking. I kept looking down at how much farther I had to descend and kept slipping on the algae covered cliff, and bruising myself. The young instructor kept hollering, “Lean back!” He wanted me to be perpendicular to the cliff so that the soles of my feet could be in maximum contact with the rock, which would provide a better grip. I continued to ignore his advice until my chaffed knees could take it no more. I finally leaned back and planted my feet perpendicular to the vertical scarp. I was terrified—I could not see where I was headed, all I saw was the sky above. And then—it started working! I stopped slipping and placing one trembling foot behind the other, I started descending the waterfall. By the end of the seventh waterfall, I was having the time of my life.

Similarly, in one’s work with children and adolescents, a clinician must embrace their fears and their shortcomings for treatment to progress. Pediatric and adolescent patients have a much keener sense of the clinician’s feelings than adult patients do. If one does not “lean back” (even though doing so may be unchartered territory for the clinician) and instead insists on keeping their normal stance (as they would with an adult), the clinician will not get a sense of the child’s inner world, and risks bruising the relationship.

Here, I present a case example to illustrate this point further:

I was a second-year resident (PG) in my psychiatry training, and I had just met my first teenage patient. He had been referred to the psychotherapy clinic to address irritability and defiance toward his parents. My initial intake evaluation led me to believe that underneath the school refusal and the outbursts of yelling and screaming, there appeared to be a degree of anxiety and we began to explore and try to treat his anxiety. I proceeded to take a developmental history and tried to explore his dreams, his feelings and his transference toward me, as I would with an adult patient. However, my attempts at doing this were met with dismissive shrugs of the shoulder followed by “I don’t know….”

 “What does he like?” my supervisor asked me. I realized I had not asked that question. It was that day that my supervisor introduced me to Erik Erikson’s eight stages of psychosocial development ² and the primary developmental tasks facing the typical teenager ³ to construct their own unique sense of identity, ⁴ and find the social environment where they can belong to and create meaningful relationships with other people. ⁵ He explained that oftentimes, adolescents construct this identity by tethering themselves to an object (Abram ⁶ eloquently discusses this point and invites us to imbibe in “Winnicott’s late work on adolescence”).

For this young man, the main focus of his investment was his electric guitar. “Do you know anything about electric guitars?” asked my supervisor. I answered that I did not. “Good, start learning from him.” So, I started talking with my patient about his electric guitar. To my surprise, my teenage patient started talking! In fact, soon we were discussing all sorts of topics, not just guitars. It’s as if a whole new stream of consciousness had been let loose, and now that I had been empowered by my supervisor to “lean back,” I peered up into the vast skies of my patient’s inner world. “Look for openings, like children waiting to enter the circle of the moving rope, in a game of skip rope” my supervisor instructed. I waited patiently, and then I began to see the openings. The patient, completely engaged with me as he explained music terms, started using analogies from daily life so I could understand—so that I could understand him. I reflected the analogies to him, then added some of mine. Soon, we were playing—back and forth—until I started utilizing musical concepts to introduce analogies from the world of psychodynamic psychotherapy. Discordant chords became an analogy for strained triangulations within his nuclear family; plectrums became a metaphor for coping skills that allowed to survive anxiety provoking family events, and so on and so forth. Resultantly, over the next 2 years, we made significant gains in achieving his treatment goals.

In total, 20 years later, I still hold my supervisor’s counsel sacred. With each child, I start by asking “what do you like?” Then, I try and lean back, and wait for the play to unfold.

2. Embrace the failures along with the successes

In the 1957 masterpiece, Pyaasa, ⁷ Geeta Dutt oozes

Jaane kya tune kahi

Jaane kya maine suni

Baat kuch ban hi gai.

These three lines have come to symbolize psychodynamic psychotherapy. They might loosely translate to:

Who knows what I said!

Who knows what you heard!

Somehow, things got figured out.

Psychodynamic work with teenagers and children can be fraught with miscommunications, misunderstandings, and mistakes. For instance, toys and board games may set the stage for a flurry of psychodynamic activity at a speed that most adults cannot keep up with. Additionally, children between the ages of 7 and 12 tend to be what Piaget described as the stage of concrete operations, ⁸ and become enamored with “right and wrong,” scruples and norms. In this stage, they may be particularly vulnerable to perceiving that the therapist is not “playing by the rules,” since rupture is hard to predict since the “rules” tend to depend widely on the patient’s inner microculture.

In his seminal 1984 paper titled “How does analysis cure?”, ⁹ Kohut asserts that mistakes and empathic failures that are initiated by the therapist are not only inevitable but perhaps essential, setting the stage for the patient’s growth through what he labels optimal frustrations. Winnicott ¹⁰ takes it a step further, by insisting that we, as therapists “succeed by failing” as long as we “fail the patient’s way.” In other words, sometimes, while working with preteens and teens, it is less important to be “correct” or “successful,” and more important to be aligned with the patient, even if it comes at the cost of having “failed” as an adult in some way. When we fail, nowhere is it more important to own up to these errors than in working with children and adolescents. Not only do young humans tend to be more astute in catching such failings, but they are also generally better equipped to sew such ruptures into repairs, if provided with the opportunity.

Here is a case example to expand on what I mean:

When I first met “Samantha,” they were 12 years old and went by “Sam.” Sam was assigned female at birth (AFAB), however, during the initial consultation, Sam had requested meekly to be referred to as “they” instead of “he” or “she.”

This request confused me. I was relatively ignorant about transgenderism, and I suspected there were unchartered waters ahead for me. However, I also made a resolve that I would try my best to understand and help Sam.

Here, I present an excerpt from my work with Sam: ¹¹

T (therapist/me): Listen, before we start, I wanted to say something.

P (Patient): Sure.

T: Last session, I kept referring to you as “she,” and didn’t even realize it until after the session. I wanted to apologize for that. You see, this is new to me.

P: You mean the “they” pronouns? That’s alright, I mean, you’re human after all (scoffs). It’s actually kind of cool that you would admit that still you have stuff to learn and apologize. More people should be like that.

T (smile then say): You know what’s interesting? You were so quick to forgive me, yet it seems like you have a hard time showing yourself the same grace.

P (smiles sheepishly): Yeah, I’ve heard that before. My mom’s like that too. I guess we are kind of two peas in a pod….

Over the next several months, this brief dialogue which started with an apology and a forgiveness created an opening to analyze an over-identification between mother and child, which in turn led to an exploration with the patient’s mother about the profound sense of loss, grief, and mourning over the “daughter” she had raised with the love and intentions she never received herself from her mother. As we worked through the over identification that the mother had unconsciously collected over the years, it helped tremendously with her resistance in accepting my patient as her “son.” As mother made progress, the son shone.

Sam now goes by “Samuel” and feels comfortable and empowered enough to use the pronoun “he.” He is entering college at a prestigious university and is looking forward to life.

In the last few decades, there has been a steep growth in our understanding of gender diversity in our youth population, something that may not have been a part of the experience when psychodynamic psychotherapy was first developed. Add to this the increasing pace of migration across world populations, with its accompanying tasks of acculturation, assimilation, and adaptation. ¹² Together, this creates challenges as well as opportunities for the modern clinician.

3. The role of utilizing digital media and technology in conducting psychodynamic psychotherapy

If you wish to conduct psychodynamic psychotherapy in today’s day and age, I would like to recommend a good internet connection! Here, I enumerate some of the ways I have utilized digital media to deepen psychoanalytic and psychodynamic psychotherapy:

1. Initial phase of treatment:

Alliance building: Over the years, I have made it a habit to include, as part of my intake process, an enquiry about my patient’s hobbies, including pop culture and social media. I have found that oftentimes, I am unfamiliar with their favorite video games, music artists, or social media celebrities. Just like owning your mistakes, owning your ignorance may be of particular use when working with children and teenagers. Children in latency stages often tend to be self-centric, and often take great delight in “teaching” the therapist about their favorite action figures, dolls, cartoons, digital games, board games etc. This “teaching” activity often serves to foster trust in their “pupil” (the therapist) which may further strengthen alliance between patient and therapist.

When it comes to teenagers, I have found that being curious about their interests can help build alliance for additional reasons. First, teenagers often feel that the adults in their lives (e.g., parents) sometimes treat them like grownups and at other times, they treat them like children, based on whatever seems convenient to the adults. Amid this chaos and confusion (and for other important reasons), adolescents may create a distance between them and the adults in their lives. They crave this distance (since it may herald what Blos ¹³ has named the second individuation), however simultaneously mourn it. During this sensitive period, a psychotherapist can often help serve as a bridge between parent and child. On one hand, a therapist may be a “stand-in” for the original parents in some important and useful ways; on the other hand, because the therapist is not the parent, this may provide an optimal psychic distance, which may allow for useful therapeutic work. Second, I have found that when I profess ignorance about their individual microculture (e.g., when I simply confess that I feel awkward not know anything about a contemporary music artist), teenagers are often able to identify with my sense of vulnerability, awkwardness, and embarrassment, and often times abandon their (unhelpful) manic defenses to come to my rescue, to put me out of my misery. A simple query such as “Do you think we could watch a YouTube ¹ video about your favorite song together?” tends to go a long way in my experience.

Projection: One can only imagine what fertile grounds open up for access once you click on that YouTube video about the patient’s favorite song! I tend to play the lyrical version of the song, so that we may join together in understanding what the words of the song mean for the teenager. More often than not, this leads to an exploration of their inner psychological world. Furthermore, I have found that the ensuing discussions often create opportunities to explore transference and countertransference.

Here is a case example to illustrate these points:

I met “Mickey” when I worked at a residential treatment center for news with emotional and behavioral dysregulation. Mickey, now 15, had suffered harrowing neglect in the first few years of her life, followed by multiple bouts of sexual assault. Her disorganized attachment and severe trauma turned her into a “ferel” child—she did not bathe, she did not brush her teeth (in fact, she went to great lengths to distance herself from any semblance of being perceived as appealing or attractive, lest she be preyed on again), she stuffed her face with her hands when she ate (a manifestation of chronic emotional starvation at the crucial stage of basic trust versus mistrust), and she wore a constant eerie smile on her face, reminiscent of the “joker” character from the Batman series, or perhaps like one of Victor Hugo’s characters that Peterson describes in his paper. ¹⁴ To say that she was disengaged in treatment would be an understatement. Her hypervigilant, destroyed mind was so chaotic that it would seem impossible to garner any organization from her words or actions.

Mickey was obsessed with the pop star Justin Bieber and with one song in particular—“Baby.” ¹⁵ I had met with her on several occasions, and she would simply stay mute, with her guard all the way up. I had tried all of my usual techniques to try and build alliance and was at my wit’s end. Since everything else had failed, I asked her why she liked Justin Bieber so much. She did not respond. I asked her if she wanted to watch a music video with me together. Her eyes lit up, as she made eye contact with me for the first time. “Baby,” she muttered softly. So I uploaded this music video on my office computer, and we watched it together (she did not move closer to my screen, choosing to stay rooted to her seat the entire time).

T (therapist/me): Hmm…that was cool. He kind of looks like a baby himself.

M (snapping): No he doesn’t! He is a man, and he is the man of my dreams!

T (raising my hand in mock surrender, giving a reconciliatory smile) Okay! Okay! I’m sorry—he does not look like a baby…happy?

(Mickey stays silent)

T: So…why do you like this song so much?

(M stays silent for a long time. Usually, it is advisable to create space and wait for as much time as the child/teenager needs, however given her traumatic history, I reckon that too much silence might be overwhelming for her, so I start to pretend like I am guessing.)

T: Umm…let’s see…is it because you feel like you’re his baby, and he is crooning this out to you?

(silence)

T: No? …is it because it’s kind of a sad song and he is singing “I can’t believe I’m losing you…thought you would always be mine?” and you can relate to his sadness?

(she gives me a sharp glare)

T: No problem—moving on…hmm…maybe it’s because the guy and the girl end up together in the end, like he wins her back for a happy ending?

Mickey (Interrupting): It’s because Ludacris!

T: I’m sorry? Who?

M (still not making eye contact): Ludacris. It’s the rapper who sings in the song? Duh! (exasperated that I don’t even know who Ludacris is)

T: What about Ludacris?

M: Have you ever heard a Ludacris song? It’s always about money and whores and drugs, and treating women like shit!

T: Oh! I didn’t know that….

M: And have you listened to the rap in this song? (I realize that I had not paid attention to the rapping part) It’s so sweet—Justin Bieber gets Ludacris-Ludacris! —to talk about innocence and love instead of objectifying women. Any man who can do that is a man for me!

(we listen to the rap portion of the song together and it goes like this:)

When I was 13, I had my first love

There was nobody that compared to my baby

And nobody came between us, nor could ever come above

She had me goin’ crazy

Oh, I was starstruck

She woke me up daily

Don’t need no Starbucks

She made my heart pound

And skip a beat when I see her in the street and

At school on the playground

But I really wanna see her on the weekend

She knows she got me dazin’

‘Cause she was so amazin’

T: So then, if I understand your thoughts correctly, you feel Ludacris is someone who objectifies women, and Justin Bieber is someone who has been able to bring out the redeeming qualities within Ludacris.

M: Exactly!

T: Perhaps you are wondering, as your doctor, if I will turn out to be more like an immoral Ludacris, or a reformed Ludacris or if I might be more like Justin Bieber.

M: No one can be like Justin Bieber! But yes, something like that…

Through her projections, Mickey had revealed a deep capacity to feel, to think abstractly, and to assimilate, and this revelation left me, her therapist, shocked, in awe—starstruck. Things slowly began to turn after that session. Three years later, when Mickey finally graduated from the treatment center, she had made impressive progress and was on her way to a local technical college. At her graduation ceremony, we presented her with a poster of Mr Justin Beiber, and she squealed with glee, exactly the same way as she had the day she had entered our lives, but perhaps for entirely different reasons….

2. Middle phase of treatment

Reality testing: Once the therapist-patient dyad is past the initial phase, and the therapeutic alliance has strengthened, much can be accomplished during what is called the “middle phase” of treatment. This is when the psychotherapy has established a reliable rhythm, and the work is deepening. This may be the time that the therapist starts to shift slowly in the patient’s mind, from an overwhelmingly “good object” to a bit of a “bad object.” ¹⁶ As long as the therapeutic alliance is strong enough, the child or adolescent there is the capacity for affect tolerance come on and with some good luck, the splitting that creates in the child’s mind the presence of a “bad object therapist,” can be worked with, processed through, to foster psychic integration, which helps with consolidation and organization of the child’s mind. Once this starts to occur, if all goes well, the therapist and the patient can then work together to extrapolate what they have learned to the patients world outside the clinical space, which in turn may help with treatment goals and life goals.

Here is a concrete example where digital media was used to bolster the patient’s reality testing:

“Vang” was a 13-year-old precocious Hmong teenager who was referred to my clinic following concerns about promiscuous and impulsive behaviors at school. Her immigrant parents (both in their 70s) were aghast to find out that she had sent nude photos of herself to several boys at school and following an intervention with the school principal and a social worker had approached me to seek help. It was not easy to sit with VANG. She would enter the office, walk right up to me and announce. “Damn I smell good today—here, come take a big whiff!” As my supervisor said, she had no idea what to do with her budding sexuality. She was the youngest of 11 kids in her family, and had been shipped from one sibling to another, since no one knew what to do with her instances of acting out. She was now back living with her parents, and our sessions would often be spent in exploring her chronic sense of feeling “un-understood” by her family, especially by her mother and father.

V (patient): They have no idea what it’s like to be in middle school in America, my parents. They’re idiots. They don’t even speak the language. They want to raise me in this strict Hmong household, with all of their stupid traditions, and they want to make sure I am protected from the “big, bad, immoral world of the white people.” Well, then why did you move here in the first place, you dipshits?!

T (therapist/me): You feel like a foreigner in your own country, USA, being raised by foreigners.

V: Exactly! See—now why can’t they say stuff like that? You seem to understand me—and you’re not white!

T: It pains you that even though I am a foreigner just like your mother and father, somehow, I am able to understand you in ways that your own parents are unable to.

V: Something like that. They are so controlling—my brothers and sisters hate them too. They’ve all been forced to grow up in this oppressive bullshit Asian culture thing, just because my loser parents feel guilty about leaving their country. It’s disgusting!

T: Hmm…didn’t you say that one of your sisters married a Caucasian American?

P: Well yes,____(names her sister), but that was a shitshow! They forced their traditions on everything!

T: Are there pictures on Facebook? ²

P: Huh?

T: Your sister’s wedding, are there pictures on social media, that we could see together?

P: Sure….

As we browsed through the photo gallery together on her smartphone, I was struck by the elegant balance of Hmong traditions (the bride wore a traditional Laotian dress, certain Hmong rituals), Scottish American traditions (the groom wore a tuxedo with a kilt, there was a typical bridal party including groomsmen and bridesmaids who wore western attire), and also infusion of both traditions at important places (for instance, there were priests from both cultures performing rituals simultaneously, and even the dinner buffet was a mix of western food and Laotian delicacies!) I shared these observations with her, and she started noticing what I was seeing. This simple intervention set up the stage for the next phase of treatment, wherein she began using her mind to dig deeper, looking past her perceptions. Simultaneously, we made room for her perceptions (fantasies, wishes, fears—many of which were manifesting as projections), and eventually, the growth she had in treatment not only helped with her acting out (replaced by more mature defense mechanisms) but also helped improved her relationship with her parents, whom she began to see as imperfect but not broken or dangerous.

 Of course, in some other situations, it would have been preferable to keep her fantasies and projections intact, allowing her to expand on them or exploring them differently, without intervening with such reality testing; this is merely one example of a situation where the use of social media led to progress in psychodynamic psychotherapy.

Conclusion

As someone who was raised in New Delhi India and was given the opportunity to live in such vast cultures as Dhaka, Bangladesh (ages 2–4), London, England (ages 6–9), Moscow, Russia (15–17), and Kathmandu, Nepal (age 24, right before I moved to USA to pursue psychiatric training), I have arrived at a firm belief that we humans are more similar than different, irrespective of where we reside. Ultimately, we have similar sets of basic desires and fears, we have defense structures that are influenced by our unique cultures, yet contain some basic tenets and follow fundamentally familiar patterns. Based on my experience, I have found this to be true across age groups, including childhood and adolescence. I hope the reader may find these musings useful.