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Clinical commentary by Debbie Hindle, a child and adolescent psychotherapist working

in Glasgow and organizing tutor of the clinical training at the Scottish Institute of

Human Relations

From a research perspective

In the background to the clinical material, the therapist identifies these sessions as a

turning point in the work. So I thought I would begin by considering the research

on turning point sessions in child psychotherapy before thinking about the complex

issues that this young child and her therapist were grappling with together.

Carlberg (1997: 331) defined a turning point session as

a session where the therapist notices that something qualitatively new may be identifiedconcerning the behaviour of the child or the childs way of showing his/ her inner world,or where something new enters the interplay between the child and the therapist.

Carlbergs small qualitative study is fascinating to read, as he was able to identifycommon features, as well as a range of themes that emerged in the cases reported

over a two-year period.

In relation to the clinical material described in this commentary, I was struck

by the directness of Graces communication to her therapist, and the way in

which they came together to create a narrative, with the therapist giving voice to

Graces feelings. These moments also captured by Graces words and actions

seem to exemplify what Carlberg (1997: 345) described as a key principle behind

these kinds of changes a moment of emotional meeting underlying the turning

point. That is, it is in the context of the relationship and the emotional quality of

the interplay between child and therapist that seems to pave the way for suchchanges.

Carlberg (1997: 342) also noted that there is often an extended significant

process preceding the turning. In the therapists background information, we hear

that in the initial period of the therapy, Grace was often silent or spoke only in

whispers . . . or was hidden in corners of the room or under the blanket. She

describes how sessions appeared more like infant observations, with only fragments

of play discernible. I found myself wondering if the therapists observation skills, her

capacity to accurately and attentively observe, as evidenced by her detailed

recordings of the sessions given, provided an important context for the work we

see emerging in these sessions.

There have been numerous publications about the importance of infant

observation and its implications for clinical work. In particular, it is worth noting

Sternbergs (2005) study of infant observation and its influence on clinical training in

psychotherapy. Through her interviews with clinicians, she was able to demonstrate

how the experience of infant observation initiates or at times catalyses processes of

development in its participants (p. 226), opening the door to a deeper understanding

of unconscious processes, the countertransference and a capacity to tolerate

uncertainty. In the clinical sessions given, I would hypothesise that the therapists

emotional availability, gained through her experience of infant observation, enabled

her to gather even the smallest fragment of play and to begin to imbue these

fragments with meaning. The therapeutic relationship seems to have provided amuch-needed containing environment, which facilitated the emergence of this young

i l l

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Defensive structures and primitive anxieties

At the start of the first session, the therapist describes Grace as petite and swamped by

her school uniform, almost immediately alerting us to her prematurity. Later in the

same session, the therapist notes that when Grace (as a cat) slowly emerges from

underneath the blanket she is in charge of how much light and sound she lets in, as if

needing to regulate sensory experience. Cohen (2003) gives a stark and vivid account of

a neonatal intensive care unit and how premature babies may experience their world.

We can only imagine how this may have affected Grace, seen in her difficulties in

establishing feeding and in settling at night. The fact that her mother was largely

unsupported no doubt contributed to Grace and her mother not getting off to a good

start. This sense of things not coming together is beautifully illustrated towards the end

of the second session when the therapist was able to talk to Grace about things not

happening at the right time . . . or coming to her in the wrong way at the wrong time.

What emerges is how this early experience seems to have coalesced into a

defensive structure. From the first miaow, a story unfolds. We learn that the cat isstuck up a tree . . . it is night time and the therapist ventures that the cat might be

feeling frightened and alone. Similar to the owl in the cage in the second session,

both images allude to the position she finds herself in high up or caged in, unable to

access the help and comfort she needs. Like being silent or under the blanket in the

initial sessions, this state of mind may have afforded her some protection, but also

left her in an isolated and vulnerable position. With the birth of her sister when she

was two years old, unresolved issues became centred on the developmental task of

toilet training. By the time she was referred to the CAMHS service at four-and-a-half

years of age, she was refusing to use the toilet and was troubled by constipation,

requiring medical interventions. Her parents understanding of Graces presentingproblem as a symptom of a wider problem seems to have set the scene for positive

engagement with the clinic and with the process of therapy.

But what do we make of her presenting problem? Barrows (1996) reviewed the

literature on soiling in children and reflected on three cases in which the children

were constipated or showed retentive functions. He suggested that in each case the

symptom was indicative of a particular type of object relationship characterized by

an excessive need to exercise omnipotent control over the object (p. 240). He linked

this defensive function with difficulties in the child fully accepting the psychic reality

of the Oedipal couple. But at the end of this thoughtful paper, he also notes Boston

(personal communication) in which she says that

the same symptom can also be an expression of a defence against very primitive terrorssuch as those described by Bick and Tustin, as well as a fear of losing all the bodycontents along with the faeces (p. 259).

Although we cannot know definitively, I found myself wondering about the primitive

anxieties that may have beset this young girl as an infant anxieties that so disrupted

her relationship to the breast and to all those aspects of her earliest relationship with

her mother which could have provided comfort and security.

The psychoanalytic processIn reading the process notes, I envisaged myself reading a musical score with each

i i b h hild li i i fi l d f h

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In the first session, I thought there were two significant points. The first was when

the therapist linked what the cat might be feeling directly to Grace.

I said I wondered if Grace sometimes shared the cats feelings, of darting off quickly,wanting to be the highest and the first and then feeling quite worried about things.

This soon leads to a surprising rescue when Mummy and Daddy arrive with a

ladder to help the cat and the other children down from their position high

up in the tree. Clearly, active intervention was needed, similar to what Alvarez

(1992) describes as reclaiming. Grace has not been able to get down or to

overcome her more encapsulated position on her own, but has needed the help of

her parents and therapy. Only then, as a cat, does she sleep and then drink and eat

hungrily.

Keeping her comments in the context of the play, the therapist notes the

importance of the cat needing time to recover. Slowly as Grace emerges from

under the blanket, a bit at a time the therapist acknowledges how upset the cat hasbeen. It is this sensitivity to the childs need for time to communicate that sets the

tone of the session. Nothing seems rushed or intrusive; rather the material unfolds,

leading to a tender moment when Grace says It likes stroking you know, which

in turn is affirmed by the therapist saying that it needs to be close and comforted.

I thought this was the second significant point in the session. Only at this point

does Grace say that the cat is a girl kitten, her voice become stronger and a family

is introduced.

Although at first she portrays an idyllic scene, this is soon shattered by conflict

between the children. The oldest kitten feels pushed out, but also removes herself to

what the therapist describes as a cold hard place, all alone. Only gradually does shereturn, and with the parents introduction of the idea that the children could take

turns, the possibility of a second chance enters the frame. Like the initial rescue of

the cat, this stands as another resolution in the session. In musical terms, resolution

refers to the process by which dissonant elements in intervals move to consonant

ones to ensure satisfactory closure and completion (Latham, 2002: 1051). This

seems an apt metaphor for what was being conveyed. I thought the session

beautifully conveyed the tension between being alone and being part of a family, and

also the problem of having to wait for her session, feeling shut out, alone and

displaced by other children. In a sense, the session also represents the childs struggle

in finding an analytic home.

In the second session, Grace again draws attention to an inside space a cocoon

and an egg which the therapist says for both one just has to wait. In the story that

develops, the mother has died and the owl is being looked after by neighbours. She is

in a cage to protect her, but the cage is problematic because it also restricts the owl.

The therapist identifies that the poor owl, it feels so misunderstood. What is

striking is the childs response when these issues are taken up in the transference.

Almost immediately, the owl is said to need a bigger cage and is given the name

Fluffy. It was as if this transference interpretation opened the door to exploring

complexity the familys frustration at never being able to get things right for her

and the owls reluctance to come out. The session ends with the emergence of two

ideas: that the owl has been inside so long that it doesnt want to come out; and thatthe second baby fed easily and grew quickly. This acknowledgement of her

diffi l i d h h i h d l d i h

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At different points in these two sessions, there is a tension between Grace being

outside the reach of the family, her perceived rejection by them (You go to a

different home) and her longing to be part of a family where Grace (as a kitten) is

given a second chance. I thought this therapy was also providing Grace with a

second chance and a different sort of medicine than that which she plays out as

tasting bad and spoiling her food. In these sessions, she seems to be offered

something in the right way and at the right time, and also by her mother, who

generously waits for her and warmly relinquishes and receives her at the beginning

and end of the sessions.

I was particularly struck by Graces use of the image of the owl. Many years ago,

I was seeing a latency aged boy with many debilitating anxieties in intensive therapy.

At one point in our work together, he brought Jill Tomlinsons book (1968), The Owl

who was Afraid of the Dark from home and we read and re-read this in the sessions

over many weeks. The baby barn owl in the book Plop is wide-eyed, helpless and

totally dependent on his parents for food. Like the little cat in Graces first session he

is high up in a tree and like her use of the blanket, he takes refuge in his nest. Butbecause he is afraid of the dark, he cannot join his exasperated parents in their

nightly hunts or learn to feed himself. In the story, he cannot be persuaded or cajoled

to relinquish his fears, but must explore the problem by talking to a series of other

people he encounters in the day and come to his own realization and resolution. The

links with psychotherapy seem evident here in that the process involved in

overcoming his fears takes time and involves learning about himself and others

and seeing the world from different perspectives. It is only after this that Plop is

able to use his parents patient help.

In the Introduction to The Psychoanalytic Process, Meltzer (1967: xii) briefly

defines analytic activity as a search for truth. I think we see this at the end of thesecond session, when Grace approaches what Bion would refer to as K the

knowledge of her own resistance and the difference between her and her sister. But in

The Apprehension of Beauty, Meltzer and Harris Williams (1988) further describe the

way the K-link overrides yearning for gratification and control over the object,

making it possible, even essential, to give the object its freedom (p. 27). One wonders

in this case whether such a shift in this young girls position might also enable her

symptom and its unconscious link with omnipotent control of internal objects to

resolve. In reading this clinical material, I was time and again struck by the beauty of

the analytic method, its resonance, tone and rhythm which brought to life the very

essence of emotional engagement and reciprocity in the context of a therapeutic

setting.

References

ALVAREZ, A. (1992) Live Company: Psychoanalytic Psychotherapy with Autistic, Borderline,Deprived and Abused Children. London: Routledge.

BARROWS, P. (1996) Soiling children: the Oedipal configuration. Journal of ChildPsychotherapy, 22 (2): 24060.

CARLBERG, G. (1997) Laughter opens the door: turning points in child psychotherapy.Journal of Child Psychotherapy, 23 (3): 33149.

COHEN, M. (2003) Sent Before My Time: A Child Psychotherapists View of Life on a Neonatal

Intensive Care Unit. London: Karnac.LATHAM, A. (ed.) (2002) The Oxford Companion to Music. Oxford: Oxford University Press.MELTZER D (1967) The Psychoanalytic Process Strath Tay: Clunie Press

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