Introduction - In-Session Use of Digital Material in Child Psychoanalysis and Psychotherapy

ABSTRACT

This section on digital media in child psychoanalysis and psychotherapy is intended to help fill in a gap in the psychoanalytic literature where much more has been written about the cultural and developmental impact of the digital revolution compared to conceptualization and intervention in clinical work with children and adolescents who wish to access digital media within sessions. In this introductory article, I provide a preview of the section’s articles by four experienced psychoanalytic child clinicians. Each author-clinician offers multiple case illustrations and commentaries on the formulations that undergird their inventions with child and adolescent patients who sought to bring digital devices and media directly into treatment sessions. The hope is that this section will inspire other child analysts and therapists to write about their experiences on treatment’s digital frontier and thus expand our literature on this topic that is of vital importance in contemporary practice.

KEYWORDS:

• Digital media
• child and adolescent
• psychoanalysis
• psychotherapy
• in-session
• introduction

Much has been written about psychoanalytic perspectives on the impact of digital media on culture and development (e.g., Cantor 2011; Goetz, 2017; Meersand 2017; Singer and Singer 2007; Sugarman 2017; Turkle 2005, 2011), but the literature has been relatively sparse (e.g., notable exceptions being Chung and Colarusso 2012 and Lapi, Fattirolli, and Firenze 2018) about how to conceptualize and intervene when a child or adolescent patient engages or wishes to engage with digital material¹ within an analytic or therapy session. My own experience has been that not quite all, but most, of the kids whom I see in my practice seek to introduce digital media into sessions at some point; and many seek to use digital media as a primary means of interaction. But without an extensive literature and because the current generation of psychoanalytic supervisors did not grow up – neither personally nor professionally – in this era of accelerating digitalization, I have often felt uncertain about my clinical responses and not quite sure where to turn to refine my analytic thinking and technique. Based on peer consultations and discussions with colleagues, I know I am not alone among child clinicians.

The digital frontier of child and adolescent clinical work – with challenges to traditional notions of the frame/boundaries and the nature of play – has often felt to me like the Wild West. I began my child psychoanalytic training just before smartphones and social media began to permeate our culture. Over the past 15 years, I have struggled with questions such as: If requested, should I let my child or adolescent patient use my desktop computer? How about if they ask to play with my iPhone? Should I permit them to bring their own devices into the session? If I do, when should I set limits and, if I do, what kind of limits? By allowing my patients to access digital material, what will/would my supervisor think of what I am permitting to unfold? Their parents? When should I conceptualize in-session Internet use as a kind of free association and expansion of analytic space to be not only allowed but encouraged versus a resistance meriting limits, confrontation, or interpretation? When kids are in my office watching (sharing?) a YouTube video, such as one of someone else playing a videogame, and my eyes glaze over, to what extent is my countertransference boredom meaningful or does it reflect my middle age out-of-stepness? How do I get at the meaning of what the patient is doing – when it seems that they are more engaged with the device than me? By allowing access to digital media in sessions, to what extent am I promoting our alliance or impeding it? Maybe I should remove my computer from my office – but what would happen if I did? Then kids might be more likely to engage in more traditional ways. But would they know how, and what then? I could go on, but this ought to more than offer a flavor for the kind of doubts and dilemmas that have run through my mind during sessions in my career as a child analyst.

Thus, upon joining the editorial board of The Psychoanalytic Study of the Child and given the opportunity to edit a special section involving a topic of my choice, I had no doubt of the topic I would propose. It has been a privilege to be able to assemble a group of four skilled psychoanalytic child clinicians to share their experiences and ideas about working with kids who wish to access digital material in their analytic and therapy sessions.

Ann G. Smolen illustrates her conceptualization and clinical interventions around in-session use of digital devices in six diverse cases representing ages from preschool to late adolescence. She organizes her illustrations according to her assessment of the extent to which digital access and engagement deepened the analytic process and promoted growth, in terms of: “negative/malignant influence,” “questionably positive,” and “positive/helpful.” Interestingly, one of the two cases that she includes in the positive/helpful category, that of Payton, exemplifies her confident and skillful use of limit-setting of access to devices within session and, via parent work, at home. Dr. Smolen also shows in her description of her work with Susan the way that sometimes even when digital involvement becomes the medium for complex “malignant” enactments, subsequent analytic reflection and understanding can still pave the way to growth. But Smolen strikes a realistic, humble balance in her article, showing us in her case of Bernard that with some kids, even the most thoughtful, attuned, and skilled analyst who is open to and curious about their patient’s digital world and device-use will still struggle to reach them.

Roderick S. Hall’s premise is that child analysts and analytically oriented child therapists have always relied on their creativity to engage their patients and deepen and optimize treatment. Essentially, he views in-session access to communication tools involving digital media and devices to be on the same continuum of historically creative tools of engagement as Legos, dollhouses, other toys, board games, and crayons and paper. Dr. Hall takes the position that in today’s world, where digital access pervades a child’s life, that the question for clinicians is less whether they should permit kids to make use of digital modalities within sessions but, rather, how analysts and therapists can facilitate this in the most creative, therapeutically constructive, and growth-promoting ways. Dr. Hall offers a series of compelling case vignettes in which he engages his child and adolescent patients around text messages, YouTube videos, apps, or videogames. Like Dr. Smolen, Dr. Hall also illustrates the occasional necessity for limit-setting around digital media access, and he shows how the extent and type of limit-setting can vary depending on the way that the patient engages digitally.

Monisha Nayar-Akhtar introduces a concept that she refers to as the “third reality,” a digital realm of experience that is necessary to understand alongside a child’s internal and external worlds. Dr. Nayar-Akhtar offers two in-depth case reports – separated by about a decade – that together illustrate how cultural shifts associated with technological advancements have impacted her own attitude toward and comfort with in-session use of digital media. In both the cases of David and Evelyn, otherwise difficult-to-reach youngsters, Dr. Nayar-Akhtar shows us how allowing each to access digital devices and media within sessions enabled them to establish a deeper connection, share hidden aspects of themselves, and explore their identities. Dr. Nayar-Akhtar’s illustrations also demonstrate how following the in-session lead of child patients toward their preferred digital modalities and contents enable them to (a) safely regulate their pace of moving toward greater closeness and emotional expression and (b) experience and demonstrate a sense of mastery and competence in a therapeutic context in which they are otherwise vulnerable.

In the final article in this section, Robin Holloway presents and illustrates a nuanced framework for conceptualizing the range of psychodynamic functions served by child and adolescent patients’ in-treatment use of digital media. He proposes and defines a preliminary list of sixteen such functions, which he organizes into three categories based on their facilitation of therapeutic engagement and communication: enhancing, defensive, and straddling (i.e., including both enhancing and defensive functions). Dr. Holloway’s evocative case examples and his associated commentary instruct us how clinicians’ clarification in their own minds of the psychodynamic function(s) can illuminate potential therapeutic interventions. Importantly, Dr. Holloway’s examples also show us how such interventions can contribute to a child’s shifting from more defensive to more enhancing use of digital media in a way that is vital to furthering the aims of treatment.

I hope that the articles in this section, with their cumulative abundance of case illustrations and commentaries, will help readers sharpen their clinical conceptualization and cultivate creativity in their technique when their young patients seek to engage digitally during the analytic/therapeutic hour. As importantly, I hope that this section will inspire other psychoanalytic clinicians to write and publish about their experiences to expand this still nascent, but essential literature. Encouragingly, the up-and-coming generations of child analysts and therapists, digital natives (Lapi, Fattirolli, and Firenze 2018) themselves, will no doubt have much to add.

A postscript while putting the finishing touches on this section prior to publication: We are in the midst of the global COVID-19 pandemic, and mental health clinicians of all stripes are scrambling to figure out how to best connect and stay connected with – both pragmatically and relationally – their patients remotely via digital modalities. There is reason for hope that these dire and urgent circumstances will expedite processes of understanding, creative innovation, learning, and dissemination around how to engage children and adolescents digitally in a way that opens up analytic space, advances treatment, and promotes growth.

Acknowledgments

I am grateful to Claudia Lament, Ph.D. for her support and guidance of my editorial work on this special section.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Notes on contributors

Anthony D. Bram

Anthony D. Bram, Ph.D., ABAP, FABP, is a child and adult psychoanalyst in private practice in Lexington, MA. He is an Associate Supervising Child Analyst at the Boston Psychoanalytic Society and Institute and is on the faculty in the Department of Psychiatry at Cambridge Health Alliance/Harvard Medical School.

Notes

1. In this section, digital material refers to use of smartphones, iPhones, computers, and other devices to access social media, Internet (e.g., e-mail, YouTube, Google searches, online games), and videogames. Authors in this section may alternately use terms such as “screens” or “electronics” to capture the same types of activities.