Editorial

We are at an important moment in the history of child psychotherapy, facing a number of challenges inside and outside the clinic as we find our place in the current world of services for children and young people. Some of the challenges of working as a child psychotherapist today are reflected upon in the papers in this volume, together with insights into organisational and clinical ways forward that integrate psychoanalytic thinking with that of other disciplines, for example contemporary development research.

In our opening paper, Jo Russell examines some gaps between psychoanalytic theory and clinical practice in relation to what she calls ‘a dissociative internal landscape’. For children and young people with such inner worlds, she found, Klein’s traditional analysis of the deepest anxiety through interpretations, examination of resistances and persistent tracing of the transference seemed to be inflammatory. One is reminded of Anne Alvarez’s patient, for whom ‘some of [her] interpretations seemed to make him more mad’ (1997, p. 762).

Russell traces the relational roots of such a presentation, weaving together development research, attachment theory and psychoanalytic thinking in a sensitive and illuminating account of the kind of psycho-biological history which establishes a dissociative inner landscape. She suggests that in these cases we need an approach which responds to the dysregulating bodily presence of relational trauma, while holding onto the crucial psychoanalytic tool of articulating the negative transference at a time and in a way that feels useful for the child in the room.

The paper contrasts the notion of reality and believability with the notion of truth, in the context of a child’s traumatic and chaotic relational world. The understanding is that for these children, the only way of communicating the truth of contradictory and mutually exclusive aspects of relational experience may be through enacting wildly different self states.

The containing work of searching for meaning, for relationship between contradictory states, has traditionally been part of the child psychotherapy offer in a multidisciplinary team. Andrew Briggs’ paper, given at the ACP conference in June 2017, explores the impact on our profession of the loss, as he sees it, of this containing role, in a world where: ‘Complexity is not recognised. The relationship context for patient symptoms and treatment is not recognised’. He suggests that there has been a loss of containment for us too, in the losing of what has been a favoured position, and he links this to the predicament of Milton’s Satan in Paradise Lost, and furthermore to the idea of Bion’s -K anti-meaning drive as the outcome of a fracture in the container-contained relationship.

The paper offers a powerful account of inter-relating levels of thinking about the organisation in terms of life and death instinct theory, and Teresa Bailey’s commentary is welcome in offering a rather different, and ultimately more optimistic, perspective on it. She focuses on the role of the senior child psychotherapist in offering containment and, potentially, a degree of mediation between the clinician and the organisation. She advocates playing by the rules, in a sense, and using them to our advantage; for example in the writing of job and care plans. Her argument is that the senior child psychotherapist, while standing clearly within the organisation, can robustly refute the imposition of a destructive culture, perhaps through drawing on internal resources, whether personal or collective.

The following paper offers a clinical parallel to some of these life and death instinct states of mind. Hillel Mirvis describes the re-presentation of an uncommunicable truth in relation to adolescent overdose, currently worryingly prevalent among young people being referred for help. Having thought about some of the possible reasons for this ‘overdose of overdoses’, and for its underrepresentation in the literature, Mirvis carefully follows the threads of meaning through two of his own cases and one from Anne Hurry, exploring the contradictions involved in communicating the presence of something destructive alongside the wish to take in something good and thereby establish some internal resources. He also illuminates the complications of the clinical response to these contradictory communications, and delineates some differing, possibly interweaving, ways of understanding overdose which are likely to be very useful for anyone working with this disturbing symptom.

Olympia Sklidi’s rich paper also follows an intuitive thread – the feeling of an unacknowledged and unknowable undercurrent of shame running beneath ruminative guilt. The paper makes a number of helpful links between psychoanalytic thinking, development research and neurobiology in this context, for example looking at Freud’s primitive psychotic anxieties in the light of the disorganised thought, emotional states and communication found in traumatised children by researchers such as Bruce Perry and Allan Schore. Having outlined the territory, Sklidi offers some clinical material involving work with an adolescent boy. Here too, a developmental perspective is taken, illuminating the challenges of adolescence in the context of seeing and being seen, using Winnicott’s thinking on the catastrophe of mother as a distorting mirror, and highlighting the intergenerational nature of this desperate situation. She ends with the hope that recognition of primitive shame woven into identity may inform therapeutic technique.

The next paper in this issue explores the contemporary phenomenon of technology through the countertransference. Sandra Carpi Lapi, Elisabetta Fattirolli and Maria Grazia Pini share their interesting journey from initial difficulties in understanding communications in and about the virtual world through to the possibility of giving these a shared meaning, in relation to three young people who brought their virtual worlds into therapy. Overlaps between internal and virtual worlds are thoughtfully explored. The paper raises a number of important and topical questions about the inter-relation of technology and the human body and mind, the potential impact of new technologies on the relationships of children growing up as ‘digital natives’ with their ‘digital immigrant’ parents, and the related issue of the effects of parents themselves being drawn into virtual relating on social networks.

In the following paper, Daniel Mercieca and Phil Jones explore the increasingly topical issue of the child’s voice, finding an absence of this in the literature, which is seen as a marginalisation in a process (in this case, therapy) that directly concerns them. They describe the involvement of children in a residential home who are or have been engaged in therapy as participant researchers in a reference group for a planned research project. Alongside the detailed data is a sensitive consideration of transference issues. The authors refer to the ‘tension between the risk of pathologising and the need to acknowledge vulnerability’, prompting them to keep in mind how the researchers’ own understanding of mental health influences encounters, and indeed the analysis of data. There is no such thing as a truly neutral response in this context, as this paper reminds us: in Midgley et al.’s (2014) exploration of adolescent hopes for therapy, even a ‘dunno’ is hugely open to interpretation. Despite acknowledged limitations, though, this study is an attempt to find ways of engaging children in research that gives them a chance to be properly heard.

The next paper also focuses on research: Joshua Holmes has undertaken a thoughtful and timely study of the aims of parent work, which he suggests may feed into developing more specialised training in parent work for our profession. The paper links approaches to parent work with Anne Alvarez’s (2012) thinking on levels of work with children. It suggests that the aims of parent work may need to be – and in fact are in practice – adapted to the psychological functioning and defensive structures of each parent. Four levels of work are described, from containment of the parent’s anxiety, through establishing a view of the child as a separate person with separate feelings, towards thinking about those feelings, and then finally, the sensitive work of beginning to make links with the child’s experience of their life history, and the role of the parent/s in that.

Our research digest on the theme of parenting follows, the first part of which focuses on research into a number of important links between parental factors and child development, and the second on research into parent interventions aimed at supporting child mental health. Finally in this issue, we are delighted to offer reviews of Judith Edwards’ recent book, Love the Wild Swan; Michael Rustin’s book, Class and Psychoanalysis: Landscapes of Inequality, Sue Sherwin-White’s Melanie Klein Revisited: Pioneer and Revolutionary in the Psychoanalysis of Young Children, and the Short-Term Psychoanalytic Psychotherapy treatment manual.