‘Altman, N; Briggs, R.; Frankel, (2002). Relational Child Psychoyherapy. New York: Other Pres: 226 | Child and Therapist in the Treatment Room Winnicott realized that a prime factor in the treatment of chil- dren (and adults) was the analyst’s participation (Altman 1992) in the process. He wrote honestly and movingly about how he gauged his in- volvement. He attempted, as the above quote demonstrates, to moni- tor the affective shifts and needs of the patient so that he could be re- sponsive to them. Winnicott (1958) interpreted early in the treatment, in keeping with Klein, but this did not stop him from quickly involving himself posi- tively with the child, 4 la Anna Freud. He wanted both to “orientate” the child to an analytic model (and thereby demonstrate the benefits of the treatment) as well as to provide a “holding environment.” For ex- ample, in The Piggle (1977), Winnicott’s record of his psychoanalysis of Gabriella from age 2% to 5, he good-naturedly played any role she as- signed him and willingly answered questions about himself such as how old he was. He also interpreted psychological material directly as it arose, including such issues as the Piggle’s (Gabriella’s nickname) fear of ob- ject loss. After the Piggle angrily said that she wanted to eat Winnicott during a session prior to his vacation, he replied: “If you eat me that would be taking me away inside you, and then you would not mind going” (1977, p- 101). Here Winnicott alludes to the oral incorporative wish a la Klein, but with his light touch. Moreover, in his work with the Piggle, one is particularly impressed with how carefully Winnicott monitored the re- lationship he had with Gabriella in terms of the holding environment, even though he also demonstrated how deft he was with interpretations based upon either the Kleinian or ego-psychological theory. Not surpris- ingly, Winnicott’s work has become a beacon to child therapists today since his warmth and openness have an almost magnetic appeal to those of us who struggle in our work with children to find a place for our countertransferential tendency (or wish or need) to have warm and ful- filling relationships with our child patients while also being respectful of an interpretive psychoanalytic tradition. RELATIONAL PERSPECTIVE ON TRANSFERENCE AND COUNTERTRANSFERENCE Thus Winnicott’s influence is strongly felt in the practice of child psychotherapy today particularly in the aforementioned beliefs in| | Transference and Countertransference in Child Treatment / 227 (1) an endogenous striving toward health, that is, toward the “true self,” as well as (2) an interest in the actual influence of the real (not intro- jected) mother and famil in. 1992, Winnicott 1956, 1960). This shift_in emphasis onto the vicissitudes of the actual mother-child re- lationship heralded a sea change in the way child (and adult) psycho- analysts began to theorize about the workings of child development and hence child psychotherapy. Now the shift was more toward the mother— child relationship as the key clinical paradigm instead of the oedipal triangle, and toward interpersonal life as a basis for personality instead of an exclusive focus on the introjected intrapsychic world. Theories proffered by Bowlby in England (attachment theory) and Sullivan in the United States (interpersonal theory) continued in this trend toward recognizing interpersonal relatedness as a key building block of person- ality functioning and therefore significant to any exploration of the therapeutic relationship in a clinical setting. Mitchell (1997), in his updated exposition of a relational position, amplified the interpersonal nature of psychological functioning when he stated “what actually happened matters” both in early life and in the session. This statement of Mitchell’s echoes an earlier question of Levenson’s (1972, 1983) who, in delineating his interpersonal position, said that he asks himself during a session, “What’s going on around here?” Thus, in pursuing the lead of adult relational theorists, the child informs the therapist how i i rated various relational patterns (Mitchell 1997) learned throughout her young life as her pri- mary means of adapting to her environment, including the psycho- therapy sessions. How adaptive or maladaptive, flexible or rigid, active or passive, are the play patterns? This information tells not only about the child’s adaptive struggles but also how these same struggles are acted out interpersonally with others, including the therapist. Thus the transference and countertransference inform the thera- pist about old objects (parents in daily life and in introjected objects) and new objects (the relationship to the therapist). Current relational thinking about the transference does not leave out the typical process whereby the therapist enters the child’s psychological life as an old object who becomes the vehicle for projections. What is added bya relational perspective about transference and countertransference is that the therapist eventually must become a new object for the therapy228 / Child and Therapist in the Treatment Room to have its optimal therapeutic value. As the therapist demonstrates therapeutic handling of problematic situations in both the child’s life and her interactions with the therapist, the child’s psyche makes room }& for the new and healthier experiences that therapy provides for her— experiences that run counter to many of the prior relational patterns. The therapist is simultaneously an old object and a new object and thereby positioned to be a therapeutic force in the child’s life (Aleman 1992, Greenberg 1991). The following clinical vignette illustrates the intertwining of trans- ference and countertransference, along with the internalization of in- terpersonal patterns in the family and how these get replicated in the treatment room. The vignette also shows how therapeutic intervention, from a relational point of view, can interrupt the internalization of pathological interpersonal patterns. A 5-year-old girl, Jennifer, was being seen individually for pro- vocative and disruptive behavior at home and at school. The fa- ther worked long hours, while the mother was a rather passive woman who was also busy caring for a toddler-aged boy. Jennifer would poke at the brother, refuse to clean up messes that she made, and in a thousand ways make an annoyance of herself at home. The mother, overwhelmed with her behavior and the demands of caring for two children alone, threatened her by saying the father would punish her when he got home. The father would arrive home exhausted, quickly becoming resentful of his wife’s demand that he now take care of Jennifer’s misbehavior. One day, this normally nonabusive man, fed up, kicked Jennifer when she refused to clean up her room as mother had been asking her all day. The therapist was informed of this event the next day, shortly before he was due to see Jennifer. Jennifer entered her session in an agitated state, behaving more provocatively than usual. By the time the session was com- ing to an end, every toy in the room was strewn over the floor and Jennifer was refusing to stop throwing them around. The thera- pist, of course, had another patient waiting. He was getting increas- ingly irritated as he contemplated running late for the rest of the day because of the need to clean up this formidable mess. At one point, he found himself standing over Jennifer, who was lying onTransference and Countertransference in Child Treatment / 229 her back on the floor in Passive-aggressive fashion, surrounded by a chaos of toys. The fantasy of kicking her alerted him to the con- text of the father’s kicking her the night before. He relaxed and said: “Pl bet you're wondering if I’m going to kick you like your father did last night.” Jennifer smiled, and got up. A moment later, she began to clean up the room. As she left the session, she ran up to her mother and said, “I helped Dr. X clean up today!” This vignette, unprecedently magical in its outcome, should not be taken as a paradigm for what usually happens in child treatment. It does, however, serve to illustrate many points. First, one can see the very be- ginnings of how a traumatic relational event gets internalized through tepetition outside the original context. Then, one can see how the other person’s subjective reaction to the child (the therapist’s reaction, in this case) gets inducted into the process. The therapist's rage at the child is fully his own (the therapist felt responsible for not having set limits ear- lier in the session, and for the tension level he felt about keeping the next patient waiting, for example), even as it is induced by the child. Coun- tertransference, in this sense, always feels like an jective reac- tion for which the therapist is entirely responsible, even as it seems to be induced by the patient and to replicate a relational pattern that was already there in the patient. This synchronization of subjectivities con- makes psychoanalytic work within the transference/countertransference matrix, perhaps all deep human relatedness, possible. But the rage at Jennifer was not the entirety of the therapist’s re- action. At a certain point, a certain perspective, the effort to under- stand from a therapeutic vantage point, came into the foreground. The, therapist was able to metacommunicate about the entanglement he and Jennifer had co-crea oth of them from the sense of necessity associated with it. In the end, the therapist’s having got- ten temporarily “sucked in” to the enactment proved useful; without anger having been felt powerfully on both sides, the therapist’s ulti- mately thoughtful and boundary-defining intervention would not have had the same impact. The therapist said to the patient, in effect, “You are making me angry; I am affected by what you are doing. But I am Not going to stop with being angry with you, and I will not hurt you. I know that although you mean to make me angry, that is not all you230 / Child and Therapist in the Treatment Room mean to do. I will do my best to think about how you are communicat- ing to me about the situation with your father, and how it feels to you and to him to be involved with each other in this way.” The value to the child of this intervention is that it provided a new, in the sense of unexpected, relational experience in the context of a potentially self- defeating repetition of a traumatic experience. The patient gave a smile of recognition when she and the therapist together discovered the na- ture of the evolving engagement, as well as a way out. This sequence of events also promoted her self-observing capacity and her capacity to symbolize her experience verbally. In microcosm, one can see here one way, at least, in which psychoanalytically oriented work with children can forestall pathological developments and lead to change in patterns in the process of being internalized.it Launching the Therapy - with the Child In these two chapters we address nuts-and-bolts aspects of work with children and parents. Our effort is to develop an approach to tech- nique that goes beyond interpretation toward a full engagement with child and parents. We see the therapist as always responding to a unique clinical situation, though guided by general principles applied flexibly. Throughout, we consider how therapeutic change takes place within an interaction in which there is mutual influence between patient and eK The core element in the approach we wish to describe is a playful engagement of the child and the therapist. In our, view, the entire thera- peutic process has an important play dimension, and that includes the work with parents, siblings or the whole family. In this section, how- ever, we wish to focus on the specific challenge of developing a creative and private play space for the therapist and the child.