Flourishing Child Analytic Therapy in the South Bronx

Sitting on the floor surrounded by toys, my young patient and I are both deeply engaged in play therapy. Her intrapsychic life unfolds and takes shape through a family of several small dolls, uniting us in the delicate and complicated task of working through and mastery. She directs my play while I closely observe, attempting to judge the nature and timing of the most useful interventions. Although this scenario seems no different from any other psychotherapy of a young child, it is, in fact, quite unusual. This treatment, like many others, takes place in a South Bronx housing project of New York. Heavy metal bars on the windows and blasting music from next door are constant reminders of the reality of my young foster patients' lives.

Unlike most children who receive psychoanalytically informed psychotherapy in the luxury of private offices to which they are brought by biological parents, many children I have treated receive clinical care in their foster residences. The agency for which I work requires that most therapeutic visits occur in foster homes to increase patient treatment compliance. Amidst the chaos of family life, I have engaged meaningfully with children who were, in many cases, seriously traumatized prior to their foster home placements. Reasons for their placements include parental substance abuse, psychiatric disorders and/or cognitive limitations, which are often exacerbated by economic constraints. The children, placed from birth to age 21, have been selected to receive psychotherapy to help them cope with their psychiatric and behavioral disturbances.

Providing these foster children with psychodynamically informed psychotherapy is a formidable task, as it involves the recognition of both reality-based and intrapsychic factors that constantly compete for consideration. While all treatments demand an awareness of both, the foster children with whom I work are constantly imposed upon by dramatic life circumstances at a time when their intrapsychic worlds are molded by external realities. Present day decisions over which they have little control, such as termination of parental rights, multiple placements in different foster homes, and separation from siblings, are given meaning in the context of previous traumas, such as sexual/physical/emotional abuse and/or neglect. Neonatal HIV or drug related conditions further predispose them to a life of unarticulated pain and anguish. Essentially, these children's histories influence their lives in ways that allow tragedies to overlap and intertwine, creating the risk of mental illness, drug abuse, and degeneracy. The calamities with which they struggle are not only fueled by the interworkings of their minds but also by the harsh realities that actualize them.

My role at the intersection of these children's real and intrapsychic lives demands that I juggle equally their ungratifying past, current grief, and fantasies. This work has allowed me to recognize the possibility of stretching analytic bounds to fit the most unlikely recipients. These children often lack a cohesive sense of self that would normally cultivate an ability to tolerate their affects and reflect on their thoughts and feelings. Thus, I have worked to help them appropriately express and label their feelings, delay gratification, and engage in acceptable conflict resolution before exploring their thoughts and fantasies. After some years of treatment, several foster children with whom I work have been able to express their difficult feelings through writing, playing symbolically with dolls, or engaging in games of hide-and-go-seek that allow them to be found again and again. Regardless of the form in which their affective expression occurs, my effort is aimed at allowing for the emergence of these children's adaptive compromise formations within difficult and often tragic circumstances.

Despite my attempts at carefully constructed statements intended to productively shift the dynamic organization of my young patients' intrapsychic lives, perhaps my most useful intervention has been my physical presence. My zest for the practical application of psychoanalytic principles does not overshadow my clinical and emotional knowledge of these children's level of deprivation and subsequent need for stable adult involvement. Through consistent home visitation, I have attempted to defy their beliefs about disappointing adults. It is my hope that these unruly toddlers, defiant school-aged children, and brooding adolescents know they are tolerable and able to be helped.

It is a rare opportunity to introduce meaning to the lives of children where it has often not existed before. Moreover, it is enormously gratifying to witness how children's play and verbal and written expressions spring to life in response to psychoanalytically based interventions. Working within the foster home setting has allowed me to witness, firsthand, the potentially universal application of psychoanalytic ideals. Thinking and working psychodynamically has allowed me to effectively treat these underprivileged children in a way that both considers their difficult pasts and allows for the unfolding of their potentials in the future.