Editorial

This issue contains a range of papers of clinical and theoretical interest, reflecting both the breadth of work undertaken by child psychotherapists and the consolidation and development of research based on accumulated clinical experience. Taken together, we hope that they succeed in conveying something of the sense of interest and excitement with which these authors have approached challenging clinical situations – with the demands they make on practitioners to re-think technique, theory and approach – and the energy that has gone into research projects that demonstrate a practice fully alive, and relevant, to the challenges and opportunities facing us as a profession. We hope, too, that the overlap of clinical, research and theoretical interests between the authors, as well as their differences, makes for a rich and stimulating read.

The first two papers, by Maria Rhode and Andrew Briggs, converge in several ways. Both explore the frontier of body and psyche and consider the sorts of powerful responses that can make us feel deeply uncomfortable but also more in touch with our patients if we are able to recognise and understand them. Rhode’s lucid, thought-provoking article addresses difficulties in the therapist’s capacity to think and to recognise meaningful patterns in work with children on the autistic spectrum. The paper explores two of the countertransference pathways that can lead to this situation, focusing on the impact of projective and adhesive identification: the extent of bodily and emotional cohesion that a child has achieved, the author suggests, exerts an important influence on which pathway may predominate. Rhode’s paper is, like the other articles in this issue, rich in clinical detail that vividly conveys the challenges of understanding and working with such children. It is particularly interesting to be able to follow her detailed thinking about the extreme bodily anxieties that, for some autistic children, can accompany the awareness of being physically separate and the ways in which these may be forcefully experienced in the bodily countertransference.

Briggs’ paper, first presented at this year’s ACP conference, is also concerned with difficulties in the integration of bodily experiences within mental representations. Based on an account of the early stages of therapy with a severely sexually abused adolescent boy, the author focuses on the importance of therapeutic witnessing which, he argues, is an essential intervention in work with traumatised patients and one that must take place before interpretive work can proceed. The author provides a coherent examination of this concept in relation to core psychoanalytic theory. At the heart of the paper, however, is a harrowing description of Briggs’ own bodily experience following a particularly difficult session. The author exposes with great honesty and sensitivity the painful, violent nature of this episode which he comes to understand as his patient’s communication about anal penetration. By ‘witnessing’ the young man’s trauma in the bodily countertransference, Briggs is able to re-position himself in the work and thus begin to reduce the adolescent’s sense of isolation and to help him to restore his sense of self. The paper is a refreshing example of the work of a therapist who learns important lessons from his patient: his alterations in technique gradually enable the boy to become witness to his own trauma as it is registered in the therapeutic relationship and, in time, to begin to put his unarticulated story into words.

The theme of minds and bodies is present in different ways in the next paper by Paola Morra both in terms of how psychological conflict may get expressed in a bodily way, and with regard to the surprising and forceful impact this can have on the therapist’s countertransference. Here the somatisation is manifested in the severely restricted feeding habits of a five-year-old girl which are sufficient to result in concerning weight loss and a diagnosis of anorexia. The clinical account is of Morra’s initial encounters with the parents and the little girl, whose striking communications – through her drawings, her play and then also through what she is able to say – quickly bring the family’s unprocessed trauma right into the room. Morra’s discussion argues persuasively that a somewhat counter-intuitive connection is at work here in which the parents’ urgent attempts to avoid the realities of death give rise to a symptom in the child which unavoidably issues in a very real danger of death. Despite their best efforts, death is very much on little Giulia’s mind. Drawing on theoretical literature which speaks to these same correlations in the families of adolescent anorexic patients, Morra proposes that an inter-generational failure to manage the triangulation necessary for separation and individuation is also evident and that the two are intrinsically related in producing the daughter’s anorexia. Her explication of the healing value of a death phantasy by which children may begin to symbolise and so come to terms with the realities of loss and separation will surely be of interest to all of us working with patients who are struggling with these issues.

The next two papers by Tracy Prout and colleagues, and by Claire Whitefield and Nick Midgley, are highly relevant to the current drive for an evidence base and our on-going quest as psychoanalytic child psychotherapists to demonstrate, in robust and yet meaningful ways, what it is that we do as and how this makes for change. Both papers pull off the challenging feat of offering a valid research perspective on therapeutic interventions whilst remaining rich in the accessible narrative material that keeps us readily engaged as readers. The multi-authored piece by Prout and colleagues presents a psychodynamic treatment intervention for children from the US which is likely to be a fresh approach for most of us both in its brevity, at just 16 sessions, and its target client group of those with ‘externalising’ behavioural symptoms. Our CAMHS clinics may be overrun with such children yet a psychodynamic approach is often last on the list of treatments to be considered. Here is an intervention that explicitly declares the relationship between the disruptive behaviours and emotional defences and seeks to address the behavioural symptoms by improving implicit emotional literacy and emotional regulation. Yet this is not a cognitive treatment, but one we would recognise as essentially similar to psychoanalytic child psychotherapy, offering unstructured, play-based, ‘experience-near’ sessions within which transference and countertransference are the key tools.

Questions about the use of the transference and countertransference are also taken up in Whitefield and Midgley’s paper which investigates how therapists approach working with parents whose children are in parallel psychotherapy. Set within the context of the IMPACT–ME study (Midgley et al., 2014), their analysis draws on interviews with therapists offering parent work within the IMPACT trial (Goodyer et al., 2011) and seeks to discover if, when and how these therapists bring the parents’ own childhoods into their work together. This article will also be of great interest to any reader considering or engaged in child psychotherapy doctoral research as it illustrates how a systemised method can be applied to rich qualitative material to produce findings that are useful and stimulating without ‘dumbing down’ or diminishing the relational complexity of our work. We hear the therapists’ voices coming through loud and clear to elucidate how each understands their role and how they balance and tailor their approaches to parents in the service of the child.

We are very pleased to be able to include a Clinical Commentary once again in this issue: the clinical material concerns a young adult who comes to his intensive psychotherapy with previous experience of both serious mental health problems and helpful psychotherapy in the past. Is this child psychotherapy or adult psychotherapy and does this make a difference to how we should approach such young people? Our three commentators include practitioners who are qualified both as child and adult therapists/psychoanalysts – Inge Gregorius and Valli Kohon – and Peter Wilson whose extensive work at YoungMinds will be familiar to many of us. Their points of consensus and divergence make for interesting reading.

As so often, our Book Reviews section represents a range of issues that intrigue and interest child psychotherapists, highlighting some of our preoccupations, debates and controversies. These, together with the Research Digest, which helpfully brings together some pertinent studies on Reflective Function as a research method, provide an insight into the many diverse ideas that influence our daily practice.

Kate Stratton
Jo Russell