History of the Problem of How to be a Child Therapist
By Andrew Guthrie, Ph.D.
As a beginning therapist learns to practice therapy, he or she is exposed to at least three main theories in the literature that indicate ways to intervene in a therapy session with a child patient. Interventions are drawn from each theory’s understanding of the relationship between the means and ends of therapy, or therapeutic actions of the therapist and the psychological changes that occur in children. This relationship has been investigated in an attempt to understand what actions of the therapist lead to psychological changes that occur in the child. If a beginning therapist knows from the existing literature that one of his or her actions will have an effect on a child, then theoretically, learning how to practice therapy involves applying the intervention of the theory the therapist subscribes to and observing the expected effect. What one quickly discovers, however, is that the problem of how to learn to be a therapist is much messier than the application of a theory drawn from the experience of other therapists.
As the psychoanalyst James Strachey notes in 1934, “The nature of change in
psychoanalysis and the explanation for the effectiveness of psychoanalytic interventions has been one of the perennial problems in the understanding of the psychoanalytical process” (p. 3). This quandary is the problem of psychoanalysis, and our curiousity about how change occurs during therapy remains with us three quarters of one century after Strachey noted it. Orange (1995) states that, “None of the official explanations provides an answer to why it works when it works, and why it does not when it does not” (p. 98).Currently, psychoanalysts still do not have a clear understanding of how therapy acts on the child, or how therapists should behave within this action. There are at least three theories that offer solutions to this problem.
In psychoanalytic therapy, children play with toys, make art or talk and relate to the therapist, according to their capacities and inclinations. The traditional viewpoint in the therapeutic action problem, which began with Sigmund Freud at the end of the 19th century, purports that children change when they have developed conscious insight into the nature of their problems, and the way to facilitate insight is by offering the child verbal interpretations that make connections between the child’s play and reality, his past and present, and his unconscious and conscious realities.
In the 1940’s a second group began to emerge that believes insight-producing interpretations play a role in therapy, but one that is secondary to the therapist’s provision of parental functions such as reliability, attention and empathy. It is not conscious insight that helps children change but the unwitting, implicit learning that results from transactions which take place in the long-term relationship that is formed between the therapist and the child.
Coinciding with the emergence of this group was the introduction of a third perspective comprised of analysts who found value in both the interpretive and relational theories, but believed instead that change in therapy is primarily caused by playing itself. The therapist is interested in the play and may participate as a player, and play is viewed as a language used by children to symbolize their internal conflicts. If a child has a worry it will be evident in the type of play that occurs, and the analyst elaborates this play with zest and warmth, occasionally making interpretations within the metaphor of play in order to facilitate the child’s implicit understanding of their internal and external conflicts.
When one first approaches a child as a beginning analyst, it is unclear what theory of therapeutic action should be used. As I will describe later in this introduction, it is tempting and not unusual for the beginner to look for the single best theory in order to escape the ambiguity of analytic work and to provide focus to his or her fledgling and confusing practice. If this was merely a theoretical quandary it would not carry as much import for psychoanalysts, but the problem is that in psychoanalysis theory and practice are often inseparable, and therefore our theoretical confusion and lack of consensus represents our bafflement about technique, particularly for psychoanalytic candidates. It may be surprising for the beginner to learn that experienced analysts “ . . . still do not know what it is that is curative, or what the decisive factors may be in any given treatment situation” (Ornstein & Ornstein, 1996, p. 103). Although contemporary authors admit to being confused about why the psychoanalytic discipline has not progressed further in the area of therapeutic action, the hesitancy to fully investigate this problem seems to have always existed.
As early as 1934, Strachey communicates his surprise “. . . at the relatively small proportion of psychoanalytic literature that has been concerned with the mechanisms by which its therapeutic effects are achieved . . . There has been a remarkable hesitation in applying these findings in any great detail to the therapeutic process itself” (p. 3). Seven years later, Dalbiez (1941) comments on the dearth of attention paid to technical matters in analysis, a subject that is central to an exploration of therapeutic action: “It is strange indeed that so little emphasis has been laid on the absolutely primal role of methodology in psychoanalysis . . . methodology is the very essence of psychoanalysis” (p. x).
The consensus in the psychoanalytic community remains today that we lack sufficient understanding of why psychoanalysis works when it does work, including why patients change and what actions of the analyst enable change during a therapeutic process. Although literature on what the psychoanalyst should do exists, it is a literature bounded by particular theoretical perspectives. There is no literature that articulates the nature of the experience of becoming a psychoanalyst from a learner’s point of view. There are few stories about becoming a psychoanalyst that emerge from actual conversations with child analysts that specify the challenges and experiential details of learning and practicing analysis. This is one of the aims of the present study.
Another, more obvious goal of the study is to develop a tentative understanding about executing analytic work with children, that is more complicated than my current understanding. Definitive conclusions about what theory is most correct, or what practical tools one should believe in and use exclusively, will not be sought after, but it should be expected that the researcher reach some kind of decision at the conclusion of a study, even if it is decided that a decision can not, or should not be made.
Strenger (1991) comments on the importance of the analyst making a decision about his or her technique. He writes: “The psychotherapist must do something, and one of the few things known about curative factors in psychotherapy is that the therapist should believe in what he is doing, which means that a choice must be made” (p. 157). If belief is an important constituent of success in therapy, one aim of this study is to discover what, if anything, I believe.
It is now evident that answers to technical problems in psychoanalytic practice are not obvious, and require on the part of practitioners much difficult, reflective work. Should the psychoanalyst interpret, be warm, present, and empathic, or become involved in play and facilitate the play of the children in his or her care? The answer to this question may depend on how psychological change is viewed. Is it insight, the internalization of missing parental functions, or the playful symbolization of internal conflict that leads to psychological change in children over the course of therapy? Solutions to these questions will not be attempted, but the questions themselves will be highlighted as epistemological tensions that lie behind one’s practice which can be reflected upon as psychoanalysts learn to closely study their own experience.
As Rilke suggests in the quotation that opens this study, we must try to be patient towards our lack of understanding and learn to love our questions, almost like locked rooms. The keys we create will always be unsatisfactory. They will never fit perfectly. Freedom from the ghost of perfection allows us to devote our attention to refining the types of keys we make, polishing them and making them more persuasive as objects of interest in and of themselves. This may bring us to a point beyond obsession over whether our theories can solve all of our problems beyond doubt.
