Editorial

What belongs where?

Around a year ago, we put out a call for papers for this special issue by way of a question: ‘What belongs where?’ I think it is helpful to share here some of what we asked then:

As child psychotherapists we are familiar with thinking about the influence of environmental factors in our clinical work. But what do we mean when we refer to the ‘external environment’, are we referring to the maternal, paternal, or family environment? Or are we referring to broader aspects, such as culture, class, race, racism, inequality and poverty, the impact of Brexit and immigration controls, wars and the climate emergency? A common experience many of us as child psychotherapists have faced, when raising such issues, is to be told that our focus has strayed away to the external world, when our attention, as psychoanalytic practitioners, should be on the internal world … There is also a wider question we are curious about and want to explore further: is there any meaningful division between internal and external in psychoanalytic thinking? How do we think of this division? And if we believe – as we do in the JCP – that the external and the political should be at the centre of our thinking, rather than an occasional ‘add on’, how do we ensure this is the case? Frosh and Baraitser (2008) (cited in Morgan, 2021) claim that it is an important political act to challenge the theoretical division of what phenomenologically cannot be divided as ‘the warp and the weft’ (p. 383) of the fabric of being. However, Morgan also puts forward Hoggett’s (2008) challenge to this, which is that - ‘internal and external worlds, while overlapping and mutually constituting, are also irreducible to one another, each governed by its own rules of structure formation … the hyphen in psycho-social signifies a difference that cannot be dissolved’ (p. 383). Whatever each therapist’s position on this debate, all our work is inevitably done within the context of myriad psycho-social elements, coming from us, from our patients, and from the wider environments around us. We are keen to think both about why this is a challenging area, and how we can work towards improvements in our practice.

We were also interested to understand more about the omission of these factors in most of the papers submitted to the Journal, with important exceptions including Melzak (2013), Melzak and McClatchey (2018), Melzak et al. (2018), and Argent (2015). Then we only got one submission in response to this call for papers. Perhaps the regular omissions and this non-response are a form of answer, but how are we to interpret it? Is the message: ‘that doesn’t belong here’? I am encouraged to think not, as when we came to selecting papers for this issue, we realised that we did have quite a number of full-length papers thinking about the way our work is situated within the context of differences and inequalities across many dimensions, and the related theme of identity. Last year’s ACP conference was on the theme of identity, and the papers presented led to interesting discussions. Some members described feeling liberated by the theme to be more authentically themselves as delegates at that conference. Perhaps this liberated members to think more about how our own, and our patients’ identities, are inevitably in the work, whether we acknowledge this aspect or not? Or, perhaps these papers had been percolating for some time and the conference theme caught something that was in the air.

At the plenary of the conference, I had made a rather clumsy comment about an impulse to say something off key, as though I’d suddenly developed some kind of identity Tourette’s syndrome. My association had been to a TV programme about a young man with Tourette’s and his best friend. I’d been interested in the friend getting something from being around someone who couldn’t repress his misogynistic, racist and matricidal thoughts. His mother commented that the doctors told her he didn’t mean what he said, but she knew different. In an email exchange after the conference, Margaret Rustin asked me what I’d meant. I wasn’t all that sure, but she helped me to make sense of what I’d experienced.

I explained that I had welcomed the theme of the conference and enjoyed the sense of a pluralistic community embracing differences and tolerating tensions, but, just at the end, I started to feel some discomfort about how comfortable it all felt. It was refreshing to see our members bring more of themselves to the table, including their political selves, but I worried that we might forget that our conscious political positions are always undermined by our paranoid schizoid impulses. I was aware that, alongside my pleasure in the pluralistic party, there was the quiet background noise of my own prejudicial thoughts about my fellow delegates. These are not thoughts I want to give credence to, but I felt a little pulled to denying them in the very space where we should be able to ‘turn our good eye’ (Steiner, 1985). Then I felt annoyed and blurted out something a bit messy and unprocessed; it felt like an urge to upturn the plate of canapés at a too-polite party. Difference is hard because it stirs our narcissistic hate. That is, and should remain, uncomfortable. Margaret offered this response, which I share with her permission:

Alongside your concern about split off paranoid feelings must be the twin risk of idealisation, which I think is closely linked to some of the attraction to the politically correct. This seems to me a particular threat to psychoanalytic enquiry, as the grim story of the Tavistock’s relationship to its GIDS exemplifies. I agree that freedom to explore what our values and commitments are, is a welcome shift in the ACP, but it too has its dangers, in that self-revelation can easily become a narcissistic retreat from relating to the reality of the complexity of our world. (Personal communication, 2022)

I agree wholeheartedly that this is a risk. We need to be clear that we admit ourselves into the field of study so that we might see our patients and their experience more clearly, not less clearly. Our purpose is to scrutinise our own identities in order to understand how they fuel the irrational valencies in us that will become confounding variables, if they are not part of what we measure when we interrogate our countertransference responses. Some of this will have happened in our analyses, but we know that not all analysts are sufficiently curious about the ‘ghosts in society’ (Ghosh Ippen, 2019, in Biseo, 2023) to have helped us enough with this work.

The first paper in this issue is by Michela Biseo and, I believe, it serves as a model to all of us who want to be braver in working with race and racism in the consulting room. Describing a piece of work with a mother and infant during the pandemic, she is generous and courageous in showing us her own faltering first steps out of the comfort zone of only interpreting around ‘ghosts in the nursery’ (Fraiberg et al., 1975). In Biseo’s paper, there is no ‘narcissistic retreat from relating to the reality of the complexity of our world’. She tells us that:

The introduction of a ‘diversity port of entry’ to discuss race and racial abuse was cocreated, and had to be mirrored by my own self-analysis too; my own history includes parents and grandparents with strong direct links to colonial stories, refugees, persecution, unprocessed legacies of class and power, multiple cultures, different religious backgrounds, and my own mixed heritage.

There is no self-indulgent autobiographical revelation here. This is acknowledgement of a socio-political context that is always at play anyway and, as her clinical narrative shows us, needs to be explicitly brought into the therapist’s mind for that work to be potent. In showing humility around her own learning with her patient, Biseo does not seek to deny power dynamics by democratising the relationship. She does, however, demonstrate that it is when we can be in touch with, and tolerate our vulnerability, that we are most potent in our work.

The next two papers pick up on themes in the first paper. Helen Sussman’s paper is unusual. It is not a clinical paper, and might best be described as part literature review and part personal journal. She maps some of the issues that faced mothers and infants during the pandemic, spurred and informed by her personal experience of having a baby during the first lockdown. She gathers statistics and anecdotes, weaving them into something of a forecast about the kinds of early experiences that CAMHS clinicians might need to be listening out for in our clinics in the coming years. Like Biseo, she touches on the social inequalities that were exacerbated and underscored by how the impact of the pandemic was not felt equally by different ethnic and social groups.

Lucy Alexander, a child and adolescent psychotherapist working in a trauma informed project in Islington, has co-authored a paper with two clinical psychology colleagues from the project. Her arm of that project was based in a children’s centre, and her colleagues in a community youth centre and a school. She opens with the context of the project:

In 2016, four young people in Islington were killed by knife crime. In response, the council launched its youth crime plan, with the aim of tackling the causes and consequences of youth violence. Informing this plan was the idea that many young people become involved in offending ‘because of adverse childhood experiences, trauma, discrimination and exploitation’, and that the best way to address youth violence is to treat it as a public health issue rather than just about law and order. (Islington Youth Safety Strategy 2020–2025, p. 7)

There is something about the way that mental health professionals were brought in to help address the repetitions of intergenerational trauma, rather than to ‘fix’ a particular child, that shifts the emphasis here. This brought to mind Lowe’s (2014) paper about the 2011 riots, where he understands the riots as a symptom of a ‘sick’ society, likening it to the way that the child presenting in CAMHS, the ‘index patient,’ is often pointing to a sickness in the functioning of his family, unconsciously bringing them to get help. Alexander et al.’s paper also helps us think about some of the benefits and challenges when we step out beyond the consulting room, alongside our non-psychoanalytic colleagues, to work with the ‘village’ that raises the child. How do we venture out into those open waters, where our thinking is undoubtedly needed, and keep our psychoanalytic rudder steady? Without the usual ways of protecting the psychoanalytic frame, the regular room and time etc., this really is a challenge.

Using a composite case, Marcus Evans explores some of the dilemmas in his work with young people experiencing gender dysphoria. The paper focuses on technical challenges, some particular to working within the wider clinical context of the young people, including their relationship to other clinicians and services. We have two commentaries on this paper. The first by Anastassis Spiliadis is brief, but offers a systemic perspective, which is particularly helpful in this context. Tara Pepper-Goldsmith et al. offer an impressive exposition of some of the theoretically complex formulations that inform their work with similar patients.

The nature of sex and gender, specifically in relation to reproduction, is central to Andrew Briggs’s response piece to Judith Edwards' (2022) ‘The elusive pursuit of good enough fatherhood, and the single parent family as a modern phenomenon’ published in Issue 48.3 of this journal. He shares with Pepper-Goldsmith a belief in the essentially gendered and sexed nature of our phantasised biological parents, whether ‘known’ in external reality or purely as phantastical figures that we must create as part of our origin myth making. Briggs severs paternal and maternal function from gender on the grounds that we can all provide either function and goes on to delineate what is unique and important about the role of the biological father, whether physically present or not. My clinical experience supports the idea that not enough importance is given to the role of biological fathers in many families and many clinics. However, I suspect that the clinical population may skew the picture here. Where those raising a child are in productive, in the sense of being constructive, relationships to each other, and can offer maternal and paternal functions and triangulation, there is no reason that there would not also be space for the importance of the biological father in the mind of the child and the carers. I suspect that those that present in CAMHS clinics are those that are struggling with some, or all, of these aspects of parenting, just as families headed by heterosexual couples often do. The preoccupation with a rather reductionist sense of a reproductive parental relationship is less convincing to me. Where a child is raised by a same sex couple, for example, I would argue that their intercourse, while not concretely producing babies, is productive in the sense that its product is a loving union, cemented by the sexual relationship, which also serves to exclude the child in a developmentally important way.

I also don’t think that the fluidity of paternal and maternal function between different parental figures, in health, means that they are entirely ungendered phenomena. As, with gender itself, I find it more helpful to notice that the fact of the dusk and the dawn are important, because they locate us on a continuum, but they do not disprove the day and the night. These are, of course, just my views, and I am excited that a response piece has started a dialogue that I can join and hope you might too!

Our editors, Maria Papadima and Rachel Acheson, have collaborated on a paper that, again, uses a composite or fictional case to illustrate some of the technical challenges and techniques that they have developed in their work with a particular kind of presentation at the adolescent crisis service where they worked together. They formulate the problem as a difficulty in establishing identity, as one of the tasks of adolescence, and understand this difficulty as being constituted as much by societal changes, as by pathological individual development. Their treatment offer is focused on activating the network of family and school to support ordinary functioning, which may have become disabled by perceived risk around the adolescent’s behaviour. Much thought is given to the internal world of the patient but little of this is offered by way of interpretation. In fact, a rather affirming approach is taken in the service of fostering the healthy narcissism that is often absent. This deficiency, in turn, is seen to be hindering healthy individuation and separation for these young people. The authors describe their approach as both psychoanalytic and systemic, which is interesting in relation to the paper ‘Weaving between and beyond tribal states of mind – revisiting our identity as child psychotherapists’, a very welcome contribution by two child psychotherapists in training, Nikolaos Tzikas and Victoria Nicolodi. They speak to their experience as heirs to the Controversial Discussions, and draw on historians of the psychoanalytic tradition, neuroscience and group theory to make sense of it. I’m not sure that my experience of this inheritance has been quite so marked, but my early psychoanalytic education had an Independent leaning, and then I went on to do a Kleinian training, which may have softened the edges for me.

The final, short paper by Anna Navridi and Lida Anagnostaki is a helpful glimpse into the world of psychoanalytically informed qualitative research. The authors share some of the experience of drawing on transferential phenomena while preparing for and conducting data collection, through open ended interviews with clinicians working with refugees. They are exploring the clinician’s countertransference and secondary trauma. The paper helpfully summarises some of the theoretical underpinning of this approach, and its thinking is not dissimilar to the ideas discussed earlier in this editorial. Drawing on the material aroused through the transference supports the researchers to own their subjectivity and scrutinise it, to notice its warping effects, so that their lens can be calibrated, to some degree.

Rachel Acheson’s Research Digest looks at research into the mental health impact of climate change on children and young people. The various findings are interesting and, as we would expect from a relatively new field of enquiry, throw up more questions than answers. This is complemented by a book review of Sally Weintrobe’s ‘Psychological roots of the climate crisis: Neoliberal exceptionalism and the culture of uncare’ (2001), by Joan Herrmann. We can also look forward to papers from members of the ACP Climate Change Group, who presented at last year’s ACP conference, which are being prepared for publication in this Journal. There are two more book reviews in this issue – one by Kate Purdy, an enlivening account of her own experiences of feeling rejuvenated by Josh Cohen’s ‘How to live. What to do.’ (2021). The other is my own review of ‘Quietly Subversive’ by Dilys Daws (2022).