The Youth Consultation Service Institute for Infant and Preschool Mental Health is a nonprofit training and clinical facility caring yearly for about 300 families and their children in an innercity location near Newark, New Jersey. As a psychiatrist/psychoanalyst, I help our trainees appreciate the value of psychoanalytic ideas to organize diagnostic and therapeutic approaches. Thereby, emerging mental health professionals may recognize the value of understanding the mental and emotional lives of children and their families, as well as within themselves. This teaching occurs mainly during weekly case conferences.
Psychology interns and externs at the institute have had a variety of prior educational orientations. We educate our students in the relevance and value of a comprehensive multi-pronged “model of the mind,” which includes three important themes: developmental, psychodynamic and dyadic (or relational). Such an approach helps students understand the nature of the child's and family's adaptive and maladaptive actions and symptoms, going well beyond a DSM diagnosis.
Throughout our work with the students, we stress that although childhood disorders are always characterized by clusters of emotionally charged behavioral symptoms—defiance, opposition, hyperactivity, inattention, distractibility, irritability, aggression, withdrawal—the concept of defense helps students understand that these behaviors are a result of the child trying as well as (s)he can to adapt to difficult circumstances. The goal of the institute is to promote the best adaptation possible. Even outbursts that appear chaotic or “dysregulatory” may be highly organized adaptive responses to ward off worse suffering.
The following case conference format facilitates our students' understanding of psychoanalytic models of the mind:
There are two 90-minute meetings: In the first, a written narrative is distributed to the group for discussion; in the second, we observe and discuss a videotape of a patient and therapist.
The written narrative usually includes a genogram, and a time line outlining the story of a child's development—details of the pregnancy, delivery, naming, bonding, nursing, motor and emotional milestones, family and medical history, and any prior or current disruptive events within the child's family life. The time line is an effective way to teach concepts of developmental progression and regression, disruptions of developmental tasks by inner or outer stresses, and is a useful visual metaphor for thinking developmentally. The time line will be illustrated in the clinical examples in Part 2 in the next TAP.
We review the intake process, the child's life (or life-book) narratives, the story of the child's affect and object hunger, mother's appropriate or erratic reading of her baby's signaling, prior therapeutic work, medications, the state of the therapeutic alliance, and especially the therapist's ongoing concerns, difficulties and worries.
Videos may be of family members with the child, but always include the therapist. Before viewing the video, we review our first discussion and ask the therapist for his or her thoughts, questions and suggestions about what we are to observe. The tape may run without comment or be stopped intermittently if there are observations to discuss. If the sound is inaudible, the presenter fills us in about the narrative. No one takes notes.
From time to time we point out a sequence and ask students what they think it means, and ask that they not respond by guessing what the analyst had in mind. That would be the wrong answer. The right answer is to say whatever comes to mind. It usually takes several months before students feel free enough to do that with spontaneity and frankness. When they do, we build up a rich composite picture of what is being observed—which always goes far beyond what any one of us (including the analyst moderator) may contribute to the discussion. The group's participation always offers new and useful perspectives to the therapist presenting his/her clinical material.
The concept of “psychodynamic” is explained in everyday language as we discuss with our students how to think about a child's (and parent's) inner experiences. In this way, the students begin to appreciate the value of looking for windows into their patients' subjective conscious or unconscious mental and emotional lives. This process introduces into our case conferences the idea that a theory of mind is necessary for informed therapeutic work.
We want our students to understand that each of us has a number of relatively stable internal mental relational narratives, which have their beginnings in the minds of mother (or other caregiver) and infant within their earliest mirroring and intersubjective relationships, as Daniel Stern and other infant developmental researchers have demonstrated. The students learn how these complex interactive processes between caregiver and child result in a variety of internalizations. The concept of countertransference enactments is introduced.
Students are reminded to listen to their own subjective responses, in order to learn how the inner lives of children and families may evoke our own responsiveness and become useful within these transference-countertransference experiences. To understand this fully we must remember our own subjective littleness and be willing to observe our own inner mental and emotional lives.
We want our students to understand that each of us has a number of internal mental narratives, which have their beginnings in the minds of mother and infant within their earliest mirroring and intersubjective relationships….
As noted, we emphasize that during development, there is a gradual mastery and stabilization of cognitive and emotional tasks that every child in every culture needs to master. The eventual organization and balance among various developmental tasks create an individual's personality or character, which may differ within families and between cultures.
Three developmental tasks, similar but not synonymous, require early mastery: Mentalization refers to a person's ability to recognize he has a mind and to know other people also have minds. Reflective functioning goes one step further. Based on a person's awareness of the mental and emotional experiences in his or her own mind, a capacity for reflective functioning helps a person become aware of and sensitive to the mental and emotional experiences of others. And finally, empathy helps us feel what others are experiencing.
An empathic connection between two people can be achieved very early in a toddler's life. Two dramatic video clips from the Brazelton Center, used by Kevin Nugent (Your Baby Is Speaking to You, Houghton Mifflin, 2011) illustrate. In the first, an 18-month-old child, sees that a man carrying a stack of books has dropped one and cannot pick it up. He references his mother's face as she nods her encouragement, crawls down from her lap and across the floor, picks up the book and hands it to the man. A second toddler, 15 months old, notices that a man carrying a stack of books tries several times but cannot open a cabinet. Similarly, after referencing his mother, he crawls off her lap and across the floor and opens it for him.
Helping students to understand a psychodynamic perspective (forces at play within the mind) helps them grasp the concept of the evolution of intrapsychic conflict throughout development. As an urgent wish is gradually controlled, a child develops a capacity to delay, and can begin to tolerate uncomfortable feelings of conflict. Dyadic/relational themes are illustrated by discussing the many complex relational narratives that occur in the lives of all children and their families.
These three themes (developmental, psychodynamic and dyadic/relational) form the basis of our discussions in our case conferences. We develop thereby the concepts of developmental lines, ego (cognitive) mechanisms, morality (superego), and mechanisms of defense.
We teach students the benefit of organizing developmental tasks from a variety of perspectives. Two of the most important perspectives are from attachment theory and from Anna Freud's concept of developmental lines. In working with children and their families, especially families from deprived situations, we stress that our task is to help the children and families experience a resilient sense of security.
We remind our students that healthy development may be disrupted or deformed by neuro-developmental disabilities, such as learning, perceptual or sensory integration disturbances, by the family's approaches to anatomic birth defects or medical illnesses, as well as by neglectful, abusive or inconsistent care-giving. We pay careful attention to the body's signals of distress, to its somatic channels for anxiety: abdominal pains, headaches (including migraines), musculoskeletal aches and tensions (including back and neck pains and stiffness), gastric reflux and irritable bowel syndromes, sleepiness, fatigue and others.
In our traumatized clinic population, the need to maintain a bond with another may become a priority despite other life needs. A child may sustain the most abusive or neglectful relationships in which they are repeatedly emotionally abandoned, shamed, ridiculed or treated brutally, rather than feel alone; thus, their relational life narrative becomes a traumatic narrative. We once watched a three-year-old bring his psychotic and distant mother a belt to beat him. Apparently, he felt it was better to be hurt than to be alone. When stressed in any subsequent relationship such a child will tend to behave in ways which repeat such early relationships so that trauma may be re-experienced endlessly during subsequent interpersonal encounters.
The video presentation is a useful tool to illustrate the evolution of developmental lines: conscience, ego/cognitive development and defense mechanisms. When development is disrupted, we observe how coping strategies may get stuck—a “developmental arrest”—and behaviors will be out of sync with chronologic age.
Our teaching program includes the notion that both therapists and patients need an affective vocabulary to communicate their interior lives to others, particularly for dysphoric states evoked within a child's trauma narratives, which always feel endless. We try to use terms or phrases that are powerfully evocative and within a child's understanding. Phrases describing such painful affects could be, a feeling that:
“Something terrible is going to happen” (terrifying anxiety)
“I don't matter” (catastrophic collapse of self-esteem)
“I WILL cry forever” (profound sadness)
“I can't do anything about it” (helplessness)
“I'm missing mommy” (emptiness or longing)
In our discussions, we stress the many important functions of therapeutic play, which include: the creation of a psychic narrative in an interplay with another; an opportunity to experience and label both simple and complex affects; and the enhancement of mentalization and reflective functioning by stimulating an awareness and thoughtfulness with a play partner. We communicate to our students the value of exploring fantasy and dreaming and how these help children master their conflicts and promote development.
For young children, play takes place in a micro-universe (Erickson) at a safe distance from the child's conscious experience—removal or displacement—which is to be respected. With older children and adults, playfulness without action may appropriately occur within shared imaginary worlds. In all play, earlier relational yearnings for being special to someone can flower within the safety of the therapeutic space.
In Part 2, I will discuss therapeutic work with children based on the above principles and methods.
From the Issues in Child and Adolescent Psychoanalysis Editor
Many child and adolescent analysts spend a significant portion of their professional week working with a variety of mental health professionals and students. It is crucial for this work that the analyst develop a collaborative atmosphere; not one in which the analyst makes judgments about the staff's work, as if from “up high.” In this issue, Nathaniel Donson, who is the psychiatric consultant at the Youth Consultation Service Institute for Infant and Preschool Mental Health in New Jersey, describes his work helping professionals understand childhood. It is significantly titled as a work in process because working as a consultant is an ongoing developmental process in which, ideally, both consultant and consultees continuously learn from one another.
In this issue, Donson describes the theoretical grounding of his work and the work at the institute. In the next issue, he will provide us with detailed clinical vignettes to help us further learn so that our own work will be enriched.
—Leon Hoffman