Chapter 4: Engaging the Child in the Therapeutic Process

When I consider the task of engaging patients in the therapeutic process, I recognize the limitation of the idea that a therapist's attentive listening, thoughtful understanding, and

careful articulation of his1 patient's conflicts and painful emotions provide all that is needed to establish a therapeutic alliance, and that such an alliance will provide all that is needed to sustain the treatment during moments of intense transference resistance. During my training as a psychiatrist and psychoanalyst, these statements, and others much like them, were part of the gospel, and proved useful in work with neurotic adults. They helped me remain abstinent in those difficult therapeutic situations, when, in response to strong transference demands, my initial impulse was to be conciliatory or defensive. However, there were times when abstinence, and I mean true abstinence and not silent withdrawal, was not useful; situations in which my attempt to understand a question rather than answer it was heard as evasive, when my refusal to take sides, to advise or enthusiastically support a particular behavior, was seen not just as cold and indifferent but as sadistic.

Now I am an optimistic analyst, who believes that if I experience the transference and work hard to understand rather than react, both the patient and I will be able to tolerate most transference perceptions and learn from them. I have had patients yell and curse, even spit or kick at me (those in the under 12 set), and have remained relatively calm, convinced as Winnicott (1969) was, that their expression of aggression and my tolerance of it were an essential part of the therapeutic work. And often, a transference perception of me as sadistic, combined with the later discovery that I am not as malevolent as expected, proved enormously useful. However, when an adult patient stormed from my office one day, never to return, because of my adherence to what I considered a neutral and abstinent therapeutic stance, I realize