David Sisk dissertation

The Institute for Clinical Social Work

Working with Parents In Psychodynamic Child Psychotherapy

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the degree of Doctor of Philosophy

By David A. Sisk

Chicago, Illinois February 2020

Copyright © 2020 by David A. Sisk

All rights reserved

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Abstract

This social-constructivist grounded theory study explored how psychodynamically oriented child psychotherapists conceptualize and conduct their work with parents of children in treatment. The sample consisted of 16 psychodynamic clinicians, each having between 7-40 years of post-graduate clinical experience with children and families. Each clinician was interviewed once for 45-90 minutes about the nature of their clinical work with parents and their conceptualizations of the theoretical and experiential background for their approaches. This study found that parent-work is an essential component of child treatment and is best conducted by being individualized on a case-by-case basis. The individualization of parent work is informed by a thorough assessment of parents, through which clinicians make a personalized definition of the focused target of treatment. This is further aided by a deep knowledge and awareness of both child and parent development, particularly an understanding of parenthood as a developmental phase. As a general approach, parent-work in psychodynamic child psychotherapy is focused on supporting the child’s development, working with the parental aspect of the parent and treating the parent-child relationship.

Keywords: Parent Work, Working with Parents, Parental Therapy, Parental Development, Parenthood as a Developmental Phase, Parent-Child Relationship, Child Psychotherapy, Psychodynamic Child Psychotherapy

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Acknowledgments

I am grateful to the staff and consultants of the Virginia Frank Child Development Center who taught me a tremendous amount about working with children and families and were immensely supportive in shaping the foundation of this project.

I am thankful to my committee (Joan DiLeonardi, Woody Faigen, Barbara Berger, Madelyn Greenberger, and Kerstin Blumhardt) for being a dependable source of insight and encouragement throughout this process. I would like to especially thank Madelyn, Barbara and Woody for their years of dedication to mentoring me in my clinical work and generously bestowing their wisdom and guidance in the development and production of this dissertation. My chairperson, Joan DiLeonardi, was a steadfast and incisive guide, always keeping me, the project and the committee on task and was a delightful companion throughout.

DAS

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Table of Contents

Page Abstract………………………………………………………………………………….iii Acknowledgements……………………………………………………………………...iv Chapter I. Introduction……………………………………………………………………1 General Statement of Purpose Significance of the Study for Clinical Social Work Statement of the Problem Studied and Specific Objectives Question Explored Theoretical and Operational Definitions of Major Concepts Statement of Assumptions Epistemological Foundation of the Project Foregrounding II. Literature Review………………………………………………...…………14 Introduction History and Psychodynamic Theoretical Factors Modalities of Parent Work Crucial Psychodynamic Factors in Parent Work

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Table of Contents – Continued

Chapter

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III. Methods……………………………………………………………………..64 Introduction Research Sampling Information Collected About Participants Research Sample Research Design/Data Collection/Data Analysis Ethical Considerations Issues of Trustworthiness Limitations and Delimitations The Role and Background of the Researcher IV. Findings …………….....................................................................................76 Finding 1: Parent Work Is an Essential Component of Child Treatment Finding 2: Parent Work Is Individualized on a Case-By-Case Basis Finding 3: Parent Work Is Rooted in a Developmental Framework Finding 4: Parent Work Is Focused on the Child, the Parental Aspect of the Parent and the Parent-Child Relationship

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Table of Contents – Continued

Chapter

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V. Discussion of Findings …………………………..………….......................168 The Absence of Clinicians Who Do Not Work with Parents Parent-Work is Individualized on a Case by Case Basis The Assessment Process and Definition of the Patient Parent Work is Rooted in a Developmental Framework Parent Work is Focused on the Child, the Parental Aspect of the Parent and the Parent-Child Relationship Implications for Future Research Appendices A. Recruitment Letter…………………………………...................................194 B. Consent Form………………………………………………………………196 References……………………………………………………………………...201

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1

Chapter I

Introduction General Statement of Purpose The purpose of this grounded theory study was to discover the critical conceptual factors psychodynamic child psychotherapists assess and use in engaging therapeutically with parents of children in treatment.

Significance of the Study for Clinical Social Work Clinical Social Work, as a discipline, is committed to understanding human behavior as it is shaped and influenced by interactions with a social environment. The person-in-environment perspective (Rogge & Cox 2001, Saari 2002, Zastrow & KirstAshman 1997) is a fundamental tenet of Clinical Social Work and is ingrained in all students of the discipline through the course of their advanced education. Psychoanalytic theory adds a critical deepening of awareness about the dynamics of an individual in relationship with the social environment. The person-in-environment understanding in Clinical Social Work is often referenced as a means of understanding macro-level distress, social injustice, and various forms of social oppression. Clinical Social Work programs directly emphasize advocating for the underprivileged, underserved and oppressed. The core values of the National Association of Social Workers (2017) include service and social justice. They also include “the dignity and worth of the person� and the

2 “importance of human relationships� (p. 1).� These latter aspects can be seen as more individual (or micro-level) concerns, which correspond with the expertise of Psychoanalysis and the nature of work with parents of children in treatment.

Exploring the nature of work with parents in child psychotherapy through a psychoanalytically oriented lens served to examine an inadequately scrutinized area of clinical practice. Due to the historical theoretical discord (King & Steiner 1991) and the historically degraded position of work with children and parents in psychoanalytic theory (Chethik 1978, 2000, Novick & Novick 2005, Siskind 1997), current students of child psychotherapy are generally trained in an idiosyncratic fashion. Programs and courses in child psychotherapy do not pay sufficient attention to the technical importance of understanding and working with parents in concert with child treatment. Agencies, supervisors, and field placements are largely responsible for shaping how a developing child psychotherapist works with parents. As there is controversy in the literature and significant theoretical discrepancies historically in the foundation of psychodynamic treatment of children, there is neither a unified nor comprehensive perspective on this issue. With a lack of comprehensive literature on the subject, child psychotherapists are essentially trained based on experience, practice wisdom and particular recommendations made by their respective superiors. Expertise on this topic is thus located within the population of working clinicians.

In the past twenty years, many psychoanalytically trained clinicians (Altman, et. al. 2002, Chazan 1995, Lieberman & Van Horn 2005, 2008, Novick & Novick 2005, 2013, Siskind 1996, 1997, Slade 2008a, 2008b, Stern 1995, Tsiantis 2000) published works advocating for increased work with and consideration for the parents of children in

3 treatment. These authors are sculpting a more unified and well-considered theoretical formulation related directly to work with parents. This study adds to this emerging body of literature by exploring how child psychotherapists practicing today think about and conduct their work with parents. This study of currently practicing clinicians adds another segment of data to the question currently being addressed by clinicians and scholars in psychodynamic child psychotherapy. These data are useful in examining the state of the practice within the sample and provides information that contributes some answers to the vexing problems theoreticians and practioners face in developing a utilitarian and theoretically sound understanding of this phenomenon. This information is also beneficial in further clarifying areas that require further and more focused study.

The present study supports Clinical Social Work’s commitment to social justice and social welfare. Many psychoanalytic theories (Badoni 2002, Blos 1985, Fraiberg, Adelson & Shapiro 1975, Hoffman 1984, Miller 1979, Novick & Novick 2005, Stern 1995) have identified the intergenerational transmission of psychological disturbance as a critical factor in influencing the development of pathology in childhood. From this perspective and theoretical emphasis on the influential nature of the parents’ role in shaping the child’s personality, psychoanalytically informed treatment has erroneously developed a reputation of assigning culpability to parents for a child’s disturbances. This has many ill effects. Psychodynamic treatment of parents can be misunderstood and possibly misapplied. Parents and children may not receive treatment that has the potential to ameliorate present distress, alter historical patterns of dysfunction, and lead to a more permeating sense of recovery, revitalization and strengthened capacity to engage meaningfully in life and relationships. In applying the psychoanalytic understanding of

4 intergenerational transmission of psychological disturbance, parents are often observed to be repeating how they were cared for in their development (Fraiberg et. al. 1975, Miller 1979). This implies that the problem does not rest exclusively within the confines of a child’s psychology and development or that of the nuclear family. The disturbance is an intergenerational one that is rooted in the history of the parents’ significant relationships.

This understanding implies that the parents, as well as the child, are subjected to a form of relational oppression that was not created personally by them. Clinical Social Work’s commitment to social justice and child welfare has a responsibility to address the inadvertent exploitations and relational subjugations of all individuals. Psychoanalysis has illuminated that many childhood disturbances root in or are exacerbated by intergenerational transmissions of disturbance and deficit. This leads to a number of ethical questions related to child treatment. At present, there is a proliferation of therapies that address only the behavioral symptoms and immediate emotional distress while ignoring the underlying complexity and psychological dynamics of childhood disturbances. With the knowledge present in the literature and professional experience that many disturbances have an intergenerational root, Clinical Social Work as a profession has an ethical obligation to acknowledge this phenomenon and develop means of addressing the actual problem. Providing treatment to manage behavioral symptoms and emotional distress without penetrating the root cause is at once a disservice and a collusion with a notion that the disturbance is located exclusively in the child. This study serves as a step in addressing this deficit in our knowledge base.

5 Statement of the Problem Studied and Specific Objectives Theorists in psychodynamic child psychotherapy are in the process of developing a unified and theoretically sound conceptualization of work with parents. In recent history, some authors (Altman, et. al. 2002, Chazan 1995, Lieberman & Van Horn 2005, 2008, Novick & Novick 2005, 2013, Siskind 1996, 1997, Slade 2008a, 2008b, Stern 1995, Tsiantis 2000) expressed their perspectives on the need to incorporate work with parents in child psychotherapy. These published accounts contradict methods utilized by previous generations of psychotherapists and theoreticians (Klein 1932/1960, Weiss 1964). Due to the increased emphasis in psychoanalytic therapy on relational and intersubjective understandings of the patient and the influential nature of context in the formation of the sense or senses of self, present-day child psychotherapists are reevaluating their views on some traditional aspects of child treatment. This study sought to explore the current state of the practice of psychodynamically oriented child psychotherapist’s approaches and understanding of their work with parents.

Within the literature on working with parents, there are few attempts to conceptualize a comprehensive theoretical and technical framework. Most authors provide commentary and guidance on certain challenging aspects of the work. Many of these authors use brief case vignettes to illustrate the therapeutic attitude and technical methods of working with parents, but do not always draw this out into an overarching technique. There is a historical debate as to whether a child therapist should work with the parents of children in treatment and to what extent the parents’ psychologies are to be engaged in this work beyond supporting the child’s treatment (Siskind 1997, Novick & Novick 2005). There are authors (Chazan 1995, 2006) that argue for the possibility of a

6 therapist working in full therapy with both the child and the parents. There are authors (Jacobs & Wachs 2002, Wachs & Jacobs 2006) that argue that children should not be seen in treatment at all, but that all therapeutic work related to the child should be conducted exclusively with the parents. There are authors (Furman 1957, 1969, 1995) advocating for work with the parents on behalf of the child in early-childhood. Other authors working in infant-parent psychotherapy and child-parent psychotherapy (Cramer 2000, Cramer et. al. 1990, Lieberman and Van Horn 2005, 2008, Stern 1995, Slade 2008a, 2008b) have developed techniques, which focus upon working with the dyad from a psychoanalytically informed perspective. These techniques typically are relegated to work with young children and taper off by adolescence. Yet, some authors advocate for continuing this method into later developmental stages (Colman 1988, Lieberman and Van Horn 2008).

Hirshfeld (2001) conducted a dissertation on a similar topic. She sought to understand the nature of work with parents in either child psychoanalysis or psychoanalytic child psychotherapy. She recommended that a future study be conducted exclusively on work with parents in once-per-week child psychotherapy. In her study, many of the subjects were psychoanalysts and provided treatment multiple times per week, which created more unique relationships between therapists and parents. She suggested that parental resistance and transferences would be more difficult to assess and address due to the limited nature of contact with the child. She also paid a significant amount of attention to the Novicks’ emerging theoretical model of working with parents at the time (Novick & Novick 2000). She recommended more formal research on this model. The Novicks later elaborated their work on this subject into a full technique

7 (2005, 2013) and they also (2005) call for further research of individuals applying their technique.

The specific objectives of the study: 1. To explore and document how current child psychotherapists conceptualize their work with parents and how they carry this out in practice.

2. To examine the manner in which psychotherapists were trained to conduct work with parents and how their current practice is consistent with and differs from their training.

Question Explored How do psychodynamic child psychotherapists conceptualize their role with parents?

Theoretical and Operational Definitions of Major Concepts “Psychodynamics,” according to Guntrip (1971), “is defined as the study of the motivated and meaningful life of human beings, as persons shaped in the media of personal relationships which constitute their lives and determine to so large an extent how their innate gifts and possibilities will develop and how, to use Donald Winnicott’s terms, the ‘maturational processes’ develop in the ‘facilitating’ or so often ‘unfacilitating environment’ of the other important human beings” (p. 17).

Separation and individuation are used in this study as the overarching developmental process of a child becoming a psychological individual or subject in his/her own right (Winnicott 1965). The child’s level of separation or individuation from

8 the parent is to refer to the extent that the child has formed an independent psychology of his/her own. This is not a fixed accomplishment or status, but rather a theoretical concept, which places the child in a process of developing an autonomous and relatively independent sense of self.

Intergenerational transmission of disturbance refers to the unconscious transmission of unresolved conflicts, psychological deficits and historical trauma within the parents and previous generations in the family to the child.

Simultaneous treatment refers to full psychotherapy for both at least one parent and the identified child patient provided by the same clinician.

Statement of Assumptions The primary assumption in this study is that in most child treatment cases there is an element of the child’s disturbance that is rooted in or exacerbated by intergenerational conditions within the family. The assumption is not that this is the exclusive cause of the child’s disturbance. Rather, to the extent to which there is an intergenerational problem, the role of the child psychotherapist is commensurately impacted. Intergenerational problems directly impact the manner in which child psychotherapists conduct individual treatment with children and work with their parents.

This study assumes that child development proceeds from a child beginning life in a state of dependence upon a primary caregiver. While the child is born with innate propensities, this primary relationship is formative in building the psychological structure and personality of the child.

9 Parent, in this study, is assumed to mean the individual with primary responsibility for the child. Parent is not assumed to be a biological designation.

Parenthood is assumed to be a developmental phase (Benedek 1959), in which each parent is confronted both with unresolved aspects of their early psychological formation in parallel with their child’s development and new developmental challenges that had not hitherto been encountered.

Epistemological Foundation of the Project This project is rooted in a social constructivist epistemology. Social constructivism contends that all knowledge is rooted within a culture, shared history and interaction among members of a given group. Meanings are not exclusively individual, but rather embedded within a social and interpersonal context. This perspective offers a view of the development that is consistent with the nature of contemporary psychoanalytic developmental theories and the subject of clinicians working with parents and children treatment.

Foregrounding Upon completion of my MSW, I worked as a child and family therapist in a psychodynamically oriented therapeutic nursery. My role was to provide daily group therapy to four children between the ages of 2 and 6 years old. The group ran for three hours per day, five days per week and 11 months per year. Many of the children I treated in this context returned for up to three years and some of them I continued to treat individually after they aged out of the program. Parents in this program were required to

10 participate in weekly family therapy with a separate family therapist. I met with the parents on a consultative basis at least once every three months. I regularly collaborated with the family therapist throughout each child’s treatment and we both were provided an extensive amount of supervision on our cases both together and separately. The roles of the family therapists, the child therapists and the parents in this setting were clearly outlined.

Within this experience, I found that there was an accepted and vetted methodology of working with parents and children within the center and among the staff members. I had come to the role with several years experience working as a direct-care worker and supervisor in residential treatment. I had not in that experience or in graduate school received extensive education or training in child and family treatment. The extent of my theoretical and clinical training in graduate school had been limited to a few courses in human development and psychodynamic theory as well as field placement seminars in which we discussed our casework. Most of the learning of how to work clinically with children and families happened in the field placement and supervision.

This is not altogether uncommon or even necessarily problematic. However, I found it noteworthy that I had only been minimally prepared for the complexity of working with children and families.

In my role as a child therapist at the center, I was not the first line of contact with the parents. Thus, my initial assessments of parents and children were largely filtered through the therapist who did the intake and the social worker working with the family. I had the luxury of observing the parent child dynamics as they manifested in the child and was afforded the ability to work on promoting the child’s development and address

11 emerging pathology without extensive direct parental involvement. Yet, there were many cases in which to fully understand the child’s presentation, more information about the child’s home life and relationships with his/her parents was necessary.

Furthermore, there were special cases in which a large amount of therapeutic work was required with the parents in order for the child to be able to participate in the program and for the benefits of it to be supported by the parents. Some parents could not meet the requirements of the program. The program met only three hours per day, which placed significant demands on the parents to provide afternoon care for their children who might otherwise be in school or daycare. Some parents resisted the requirement that they participate in family therapy alongside their child’s treatment. The reasons for this were highly varied. Some parents felt that the issue resided in their children and felt that being required to participate in treatment implicitly communicated a belief that they were somehow culpable for their child’s difficulties. In a less resistant way, these parents had come to the child development center to have their child’s needs addressed and had not considered that they would be required to engage in a therapeutic process of their own.

Some parents found it perplexing that they would meet with a separate therapist as opposed to with the therapist who worked with their child on a daily basis. At times these resistances jeopardized the child’s placement.

Some parents were interested in receiving their own treatment, but struggled with the lack of contact with the child’s therapist. In some of these cases, modifications were sometimes made to provide the parent greater access to the child’s therapist and in very select cases for the child’s therapist to provide therapy for the parent or family treatment.

The latter modification almost always involved a lack of differentiation between the

12 parent and the child, in which unresolved difficulties in the parent were highly influential in shaping the child’s difficulties and the parent’s manner of responding to the child’s needs. There were cases in which a period of conjoint or simultaneous work needed to be conducted in order to cultivate enough differentiation in the dyad and trust in the therapeutic process for any progress to be made. This type of accommodation was a derivation from standard practice in the setting and required a sophisticated assessment of the parent and child, the developmental process and the therapist’s ability to therapeutically manage and address the needs of the patients and the norms of the program.

The genesis of this project is rooted in a set of cases I worked on in which the parent(s) could not tolerate having their child treated by a separate therapist. In these cases, while the parent resisted working with a separate therapist, they were willing and interested in pursuing treatment with their child’s therapist. Normally, such cases would not be taken into treatment in the therapeutic nursery. But, these families had already been participating in the program prior to this resistance or preference surfacing in full.

Thus, we made accommodations to best work with them. In the course of working with these parent/child dyads and their families, I became significantly impressed by the complex interweaving of parents’ histories and personalities, child and parent development, the separation/individuation process and the role of the therapist in assisting families. Initially, my question had to do with how a child therapist works with the child who is subjected to the intergenerational transmission of trauma as this surfaced as a central issue in more than one case. However, in reflecting upon the entire experience and after researching the role of the child therapist with parents, I observed

13 that this phenomenon is not fully articulated or theorized in the literature. Nor was it fully agreed upon among my colleagues at the child development center. Thus, I felt that a more general inquiry into this area was called for.

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Chapter II

Literature Review Introduction In the history of psychoanalytic theory of working with children and families, there have been few comprehensive works that address how to work with parents of children in treatment. There is a large body of literature relating to child psychoanalysis and psychodynamic therapy with children and families. Yet, in almost every article or text on child analytic work, authors cite the dearth of sufficient literature on the subject of working with parents. Siskind (1999) aptly summarizes the state of the literature at the time of writing her book on parental work: Some articles have been written that have work with parents as their primary focus (Bernstein & Glenn 1988, Elkisch 1971, Ferholt & Gurwitt 1982, Fraiberg 1980, Glenn et al. 1992, Sandler et al. 1980) but these are exceptions. More often one has to look to books and articles on child treatment to find mention of this aspect of our work. And then we typically find these references to the child’s parents to be brief, cursory, and confined to what are viewed as practical considerations: how often to see the parents, how much to tell them, how to gain their cooperation. Not infrequently these references carry a cautionary tone: parents can be dangerous if one does not find a way to get along with them, parents can undermine the therapist’s work, and in some situations, parents can

15 even take their child out of treatment. There is frequently an attitude of resignation, one that suggests that parents are the special burden that the child therapist must bear. (p. 4) Siskind (1997) and Novick & Novick (2005) discuss the lack of literature as a resistance among practitioners to address this aspect of clinical work and have sought to hypothesize as to why this is the case. The Novicks (2005) regard the resistance as relating to social/historical, theoretical and political reasons. They do no elaborate on the social/historical factors at length, but point to certain critical omissions, tendencies and contextual factors within early psychoanalytic culture. They cite Freud’s (1909) lack of commentary on the details of Little Hans’ mother as evidence toward the at once idealized and denied place attributed to women in society at the time. Theoretically, they cite the tremendous importance of Freud’s turn toward intrapsychic meaning as opposed to external reality as leaving a lasting impact on child psychoanalysis, including practitioner resistance to attending to the real influence of the parents on the child’s development and psychology. Further, they note the historical degradation of child psychoanalysis within psychoanalysis at large as one reason for professional resistance to child analytic work in general and critical writing on the subject as well. Siskind (1997) proposes a variety of subjective sensibilities that could deter a child analyst/therapist from exploring work with parents in the same manner as other subjects. She describes the deep frustration and confusion experienced by many practitioners in their clinical work, the complexity of the work and the preponderance of countertransference as highly influential contributors to professional resistance. Chazan (1995) cites the historical view of psychoanalysis against simultaneous treatment of children and their families as a

16 source of concealment despite practitioners employing this technique in practice quite frequently. Such compelled her to undertake the exploration, which led to her book on the subject (1995).

Despite these resistances, many authors have written on the subject of working with parents. There are many chapters in anthologies about child treatment over the past 50 years that address the topic of working with parents from a psychoanalytic or psychodynamic perspective in general (Altman, Briggs, Frankel, Gensler & Pantone 2002, Chethik 2000, Cooper & Wanerman 1977, Furman & Katan 1969, Geleerd 1967, Glenn 1978/1992, Mishne 1983, Palombo 2001).

There are numerous articles and case studies since the dawn of child psychoanalysis that speak to various aspects of clinical work with children and parents and demonstrate the evolution of thought within the field in various schools of psychoanalytic theory, some of which will be reviewed in context of their relevance here.

In the past twenty years, there have been two comprehensive works about working with parents in psychoanalysis and psychodynamic therapy of children and adolescents (Novick & Novick 2005, Siskind 1997), a dissertation surveying predominantly analysts about their work and methodology of working with parents (Hirshfeld 2001), three collections (Jacobs & Wachs 2002, Tsiantis 2000, Wachs & Jacobs 2006) which addresses work with parents in general and around special topics from various contemporary theoretical orientations. There is a recent book addressing and arguing for the simultaneous treatment of children through the lens of general psychoanalytic developmental theory (Chazan 1995) and a few extended works

17 elaborating on Infant-Parent Psychotherapy and Child-Parent Psychotherapy (Stern 1995, Lieberman and Van Horn 2005, 2008).

Chazan’s (1995) work on simultaneous treatment draws heavily upon Mahler’s separation-individuation theory (Mahler 1945, 1958, 1974, Mahler et al. 1975) and is also proposed as one method of working on problems of intergenerational transmission of disturbances (Badoni 2002, Blos 1985, Burlingham 1955, Colarusso 1990, 2000, Elkisch 1971, Fraiberg et. al. 1975, Hellman 1960, Hoffman 1980, Levy 1960, Miller 1979).

Chazan differentiates her model from related models by stating that the focus of her technique is on the internal representational world of the constituent parties. She is focused on behavior, but more focused on the intrapsychic of each individual. By contrast, Infant-Parent Psychotherapy and Child-Parent Psychotherapy are conscious of such dynamics, but the focus of observation and intervention is predominantly the overt relational patterns in the dyad or family in these models. Intrapsychic matters are not worked with in the same internal and separate manner.

Infant-Parent Psychotherapy (Stern 1995, Lieberman 1992) and Child-Parent Psychotherapy (Lieberman & Van Horn 2005, 2008) draw upon Selma Fraiberg’s pioneering work (Fraiberg 1980, Fraiberg, Adelson & Shapiro 1975), Attachment Theory (Bowlby 1958, 1969, 1973, 1980, Main & Cassidy 1988, Main & Hesse 1990, Main, Kaplan & Cassidy 1989, Wallin 2007), Infant Research (Cramer et. al. 1990, Emde 1981, 1988a, 1988b, 1992, 1999, Fonagy 1993, 1996, 2002, Fonagy et. al. 1991, 1993 Greenspan 1981, 1992, Slade 2008a, 2008b, Stern 1985, 1991, 1995, Stevenson-Hinde 1990), and field experience of working with infants/young children and their parents and such dyads/families that have experienced domestic violence or trauma. These are

18 comprehensive methodologies in themselves, but they are not exclusively about parental work in traditional child psychotherapy or analysis. Rather, they are focused on working with parents and children together. Additionally, they are distinct in that they are addressing work exclusively with infants/young children (Lieberman 1992, Stern 1995) or primarily addressing work with victims of trauma and domestic violence (Lieberman and Van Horn 2005, 2008).

Within this review of the literature, the early history of child psychoanalysis and parental work will be briefly traced from Sigmund Freud through Anna Freud and Melanie Klein to the increased theoretical attention paid to the role of parents in the middle of the 20th century. A further theoretical examination of separation-individuation theory and intergenerational transmission of disturbance will be covered as crucial concepts in understanding the complexity of parental work and some of the major theoretical foundations of working with parents. The remainder of the review will focus on technical considerations in working with parents in the contemporary context.

Beginning with the evaluation, the setting of treatment, understanding parents in a developmental context, and determining who the patient is will be explored. Then, the various approaches to parent work being practiced today will be outlined. Finally, common psychodynamic factors in working with parents in all treatment methodologies will be discussed including the therapeutic alliance, parental resistance, and transference and countertransference.

19 History & Psychodynamic Theoretical Factors

Early history.

The first published account of child psychoanalysis was Freud’s (1909) supervision of Max Graff providing psychoanalytic treatment to his son, Little Hans (Herbert). Freud provided consultation and guidance to Mr. Graff throughout the published account of the treatment, only meeting Little Hans on one occasion. Freud himself wrote little about technique in child analysis. The purpose of the Little Hans case was to demonstrate the actuality of Freud’s emerging theories of infantile sexuality and the oedipal complex by rooting these theories in recorded observations of a child.

Nonetheless, it remains the first documented case of psychoanalysis conducted with a child, which left a number of technical questions and further theorizing to be advanced by later generations.

Regarding the case itself, many authors have revisited it over the past century to examine specific aspects (Frankiel 1992, Fromm & Narváez 1968, Garrison 1978, Glenn 1980, Midgley 2006, Ornstein 1993, Silverman 1980). A comprehensive review of this case from various contemporary vantage points is presented from several authors in a special issue devoted to revisiting Little Hans in The Psychoanalytic Study of the Child in 2007 (Abrams, Bierman, Blum, Halpert, Neubauer, Wakefield, Young-Bruehl). While many of these authors are speaking to address the case of Little Hans from various theoretical orientations, all the authors cite a number of noteworthy aspects of the case as it was written up at the time. These include Freud supervising the treatment as opposed to conducting it, the absence of case material related to the mother’s mental health and her

20 history of psychoanalytic treatment with Freud, the extent of domestic abuse observed by Little Hans and its contribution to his illness, marital conflict between his parents, and the omission of Hans’ tonsillectomy and its potential role in the etiology of his bodily anxiety.

From today’s standards and lexicon, we would consider the Little Hans case as an example of providing treatment for the child through the parent, one of many options of parental involvement available to the modern therapist. At the time however, such a methodological choice was not in Freud’s purview. Rather, he was attempting to find verification of his previously published theories and those that he was actively developing. These concerns, too, were not directly related to the psychoanalytic treatment of children and their families, but rather to find the developmental corollaries of his emerging conceptualization of the adult neurotic patient as an intrapsychic phenomenon.

Thus, the field of psychoanalytic theorizing as it pertains to children was left to subsequent generations to furnish.

Anna Freud and Melanie Klein.

Within the history of psychoanalytic theory, Anna Freud (1929, 1935, 1946, 1949, 1953, 1962a, 1962b, 1965, 1966b, 1972a, 1972b, 1978) and Melanie Klein (1932, 1946, 1958, 1961) are considered to be the pioneers of child psychoanalysis. Freud, Klein and their respective adherents (King & Steiner 1991, Baudry 1994) had differing opinions on what the methodological focus of psychoanalysis with children should be and within their respective frameworks had likewise differing opinions on the nature of the analyst’s work with the parents.

21 Anna Freud (1929, 1945, 1946, 1951, 1954, 1966b) believed that a child was not sufficiently differentiated from their parents in order to directly translate the procedure of adult psychoanalysis to children. Rather, she focused largely on supporting the development of the ego of the child (Altman, Briggs, Frankel, Gensler & Pantone 2002) and fostering a positive alliance with the child (King & Steiner 1991). Her writings likewise attest to the development of ego capacities and analyzing where these capacities did not develop (1952, 1953, 1965, 1962a, 1966a). Her focus in her clinical work was not to make transference interpretations of unconscious conflict, but rather bolster the development of ego capacities. As the child developed more mastery and more differentiation from the parents, Freud was inclined only then to begin to make psychoanalytically informed interpretations of intrapsychic conflict. To do so prior to these developmental achievements was considered to be overwhelming to the child.

Thus, Anna Freud made use of her child patient’s parents in her effort to support the development of the child’s ego. Freud speaks of providing child guidance to the parents as an auxiliary task of the child analyst in order to support the child’s growth and the work of the therapy. This work with the parents was centered upon educating the parents around the child’s general functioning and overall development. Questions related to the parents’ use of the analyst were likewise organized around this theme. To the extent that parental involvement aided in the ego supportive and later more typical psychoanalytically informed interpretive work, it was provided for parents. Being that transference was not considered the object of therapeutic action within child treatment, Freud found it important to educate parents about developmental matters as a support to

22 the developmental initiatives of the treatment. This is what became known as child guidance in the Ego Psychological tradition.

Klein (1923, 1926, 1927, 1929a, 1929b, 1930, 1932, 1952a, 1952b,1961), conversely, developed a purer translation of adult psychoanalysis in her work with children, treating children’s play material as free associations would be regarded in adult analysis (King & Steiner 1991, Klein 1927). She interpreted unconscious fantasy life, often from the first session (1929a, Klein 1961, Altman, et. al. 2002). Klein’s perspective was that transference does develop in children and that interpretive work was the mechanism that had psychotherapeutic value. She describes (1932) that not making transference interpretations is tantamount to the analyst colluding with the active pathology in the child. From this standpoint, Klein (1932, 1961) spoke mostly of the need to maintain congenial relations with the parents to ensure the child’s ongoing analytic work and as a source of information about the child’s extra-analytic life. Otherwise, Klein was primarily focused on protecting herself and the child’s treatment from the unconscious factors in the parents that would interfere with the work of the analysis. She shared as little information as possible with the parents and was not inclined to guide the parents on matters of parenting. Klein’s patient was the child and all matters of treatment and theoretical writings are organized around the direct psychoanalysis of the child.

Klein and Freud became not only representative figures of the beginning of child psychoanalysis, but also major contributors to different theoretical traditions within the psychoanalytic discipline. Anna Freud was an Ego Psychologist and Melanie Klein was an Object Relations Theorist. In the United States, Ego Psychology became the predominant theoretical orientation of psychoanalysis in the middle of the 20th century. In

23 each of these disciplines as well as that of Sigmund Freud, psychoanalysis was considered to be a practice of analyzing intrapsychic conflict. In theory and practice, thought was given to the nature of reality, but psychic reality was the predominant focus.

The role of the context, the environment, the parents or any other influential aspect of material reality was not factored into the method and theory in the early decades of psychoanalysis. In a broad sense, unconscious conflict was considered the root of psychopathology and the method of cure was interpretation in both Klein and Anna Freud’s view. The difference between them was in their estimations of the relative maturity of the child in order to undergo the psychoanalytic process and the appropriate methods by which to engage the child in that work.

Theoretical examinations of the role of parents in human development.

In the wake of the Freud/Klein controversies, several currents in psychoanalytic theory were being revised or articulated in light of ongoing experience of working with individual adults as well as parents and children. These important developments have led to the contemporary foundation of child and parental work. In each major revision, consideration was given to how adequate or inadequate parenting in early life led to psychological structure and personality, often revising fundamental tenets of the previously held theory. Several theorists writing at the time were aware of the inadequacy of Freudian psychoanalysis to fully describe early development. The sample of authors covered here point to the advancing complexity in theoretical trends that provide the backdrop for ongoing debates in theory and practice. Each of these authors brings unique attention to the nature of the parent-infant or parent-child relationship. The consequences

24 of their thinking are instrumental in considerations of working with parents of children in treatment.

Fairbairn (1946, 1952, 1963) proposed a revision to Freudian theory by positing that libido is object-seeking as opposed to pleasure-seeking. He did not fully elaborate on the developmental reality of what constituted adequate parenting but theorized the development of internal object relations as a compensation for inadequate parenting.

Mitchell and Black (1995) state, “For Fairbairn, healthy parenting resulted in a child with an outward orientation, directed toward real people, who would provide real contact and exchange (p. 117).” In the face of frustrating or deprived relations with parents, individuals in Fairbairn’s view were thought to develop schizoid tendencies in which libido was tied up as existing internally between fantasized gratifying and frustrating objects.

Winnicott (1945, 1953, 1958a, 1958b, 1962, 1965, 1969, 1971, 1975, 1980, 1993, Palombo, Bendicsen & Koch 2010) paid significant attention to the subjective experience of the primary relationship between children and their caregivers and its relation to the development of psychological structure. He was highly concerned with the nature of maternal care in meeting the core emotional needs of attunement and holding in the infant. Winnicott felt that with good enough mothering, a child would develop a vital and thriving true self that is fully situated in objective reality. In situations where the child experienced his/her mother as misattuned to the child’s early needs for subjective omnipotence or as impinging on the emerging self, the child would eventually form a compliant adaptation to the mother. This adaptation can lead to a manner of being in which the child is continuously presented with an external reality to which he/she must

25 oblige. Such individuals may superficially function but are devoid of passion and zest.

Conversely, a child who remained fixed in a state of subjective omnipotence would be unrelated to external reality and demonstrate autistic, schizoid or narcissistic features.

Guntrip’s (1967, 1968, 1971) Object Relations Theory combined aspects of Fairbairn and Winnicott’s, both of whom were his analysts (1975). Guntrip situated the deepest layers of psychopathology as resulting from schizoid withdrawal from frustrating early experiences with parents. Guntrip theorized a regressed ego in addition to Fairbairn’s libidinal ego. The regressed ego is characterized by the absence of object relations and a deep longing to merge with a pre-disturbed state of relatedness with the object. Mitchell and Black (1995) state, “Guntrip presented his concept of the regressed ego, frozen in isolation, as encompassing both the self in flight from frustrating objects (a split-off portion of Fairbairn’s libidinal ego) as well as aspects of the self never actualized because of the lack of an appropriately facilitating maternal environment (Winnicott’s true self). (p. 138)” Spitz (1945, 1946, 1950, 1957, 1965) was one of the first analysts to conduct and advocate for direct infant research (Palombo et. al. 2010). He sought to formally research and theorize on Freudian concepts in early development. Spitz’ most regarded studies are the Hospitalism papers, in which he documented the impact of maternal deprivation in a girl’s prison in Mexico and an orphanage in Argentina (1945, 1946). He concluded that maternal deprivation and inadequate care in the first two years of life had crippling consequences, which led to severe impairment and death in many cases. Spitz was influential in beginning to answer the question of what an average expectable environment actually provided in Hartmann’s (1939) contribution to Ego Psychological

26 Theory (Mitchell & Black 1995). Spitz traced development from undifferentiated and non-differentiated states of the first few months of life through the advent of recognition of pleasure in the distinction between self/other at approximately three months, stranger anxiety in the eighth month and the achievement in identification with the parents of the child practicing and mastering the use of the word “no” beginning at 15 months.

Bowlby (1958, 1960a, 1960b, 1961, 1969, 1973, 1980, 1988) followed in the footsteps of Spitz (1946, 1965) by researching early maternal deprivation and its impact on psychological development. Bowlby was critical of classical psychoanalytic theory in that he felt it paid insufficient attention to the actual nature of a child’s tie to his primary caregiver (1958). He conceived of attachment theory as a further extension of Darwinian biology. Bowlby considered infants’ needs for safety and security as instinctive and determined by the need for survival. Situations that arose environmentally and internally within the child that threatened feelings of security and proximity to one’s caretaker give rise to attachment behavior, in which the child seeks proximity and protection from the adult. He differentiates these impulses from other psychoanalytic understandings of motivation. Bowlby was criticized at the time (Freud 1960, Schur 1960) as presenting formulations that were not psychoanalytic. Yet, his work has left a lasting impact on theories and research in child development as well as psychoanalytic theory.

Bion’s (1959, 1961, 1962, 1970) elaboration of Kleinian theory specifically the concept of projective identification, containment and attacks on linking has interpersonalized Klein’s concepts (Mitchell and Black 1995) and provided yet another means of considering the nature of the early formative aspects of the parent child relationship. His reworking and interpersonalizing of projective identification provided

27 important insights into the nature of communication between the infant and the mother in the earliest stages and the derivatives of this concept in clinical practice.

Kohut (1971, 1977, Ornstein 1978a, Ornstein 1978b) expanded Freudian theory by creating a method of applying psychoanalysis to pre-oedipal disorders. His focus on empathic attunement and immersion into the adult patient’s psychological life and positing distinct needs at this level of disturbance provided a useful clinical and conceptual means of appreciating earlier developmental failures.

Mahler, Pine & Bergman (1975) and Mahler (1945, 1958, 1974) provide a theoretical view of the separation-individuation process in early childhood. This model has been criticized because it posits a primary autistic phase at the beginning of life (Gergely 1998, Lyons-Ruth 1991). Critics believe that such a state does not exist, rather that infants are vitally engaged in a relational matrix from birth.

The theoretical considerations inherent in the question of the formation of psychic structure lead to considerable differences in perspective about the child therapist’s role in working with parents. From a technical standpoint, the question is often where to locate the source of the difficulty or pathology. This is further complicated by a string of developments connecting parent pathology with childhood disturbances.

Johnson (1953), Jacobson (1954) and Benedek (1959), all working from an Ego Psychological lens, sought to understand the reciprocal nature of the child’s development and parental contributions. Johnson (1953) concludes that one source of childhood pathology is in the parent’s vicarious satisfactions of their own hitherto unconscious and unmet libidinal needs. Jacobsen (1954) sought to examine normal development in this context. Benedek (1959) expanded on both of these findings by detailing the

28 development of symptoms in children due to parent pathology and she expanded the appreciation of the normal nature of human experience in development when becoming and being a parent. Most psychotherapists working with parents view this latter point as a crucial addition to our theoretical lens. Parens (1975) provides further theoretical questions related to Benedek’s formulation. Schmidt (2004) describes the influence of Benedek’s work in the history of psychoanalytic theory.

Fraiberg, Adelson & Shapiro further examine and distill the findings of Johnson, Jacobson and Benedek in their seminal paper Ghosts in the Nursery (1975). They present in a more nuanced fashion and less bound to theoretical terminology stemming from structural theory that there are situations in which the parent’s unconscious conflicts and unresolved situations are reawakened in raising their child. They note that these intrusions onto a child’s development are deeply embedded in the parental unconscious, highly influential in determining childhood pathology and much more challenging to the therapeutic endeavor. They maintain an accepting attitude toward parents by conveying that parents are often naturally inclined to protect their infant from harm and are willing and eager to align with the therapist in order to address aspects of their own parenting and environmental conditions that are causing difficulties in the early life of the infant.

However, when it comes to the reawakened “ghost” of their own psychological past, parental resistance is extremely high.

Fonagy and his colleagues at the Anna Freud Centre (1991, 1993) conducted outcome studies to assess whether parental reporting of their own childhood prior to the child’s birth would predict the level of security of a child at 12-18 months. Their findings confirmed Fraiberg’s original paper within the lexicon of Attachment Theory. Lieberman

29 and Van Horn (2005, 2008) have developed a model of child parent psychotherapy that is imbued with Fraiberg’s concept. Lieberman, Padrón, Van Horn, and Harris (2005) have also developed a concept of benevolent forces stemming from the parent’s background as a way to bolster parental functioning and promote healing within the parent/child system.

While not a child analyst, Alice Miller (1979) presents a similar intergenerational phenomenon by focusing on aspects of Winnicott’s concept of the true self and the SelfPsychological concept of mirroring needs. She presents children who are not truly mirrored in their early childhood, the developmental complications of this and the source of this disturbance as a parallel narcissistic deprivation in the parents. She claims that left untreated this disturbance is perpetually carried through the generations.

Stern (1995) has drawn out the normalization of parental experience and parental development in his model of Infant-Parent Psychotherapy. His model is also drawn upon extensively by Lieberman in her work on Infant-Parent Psychotherapy. She also, along with Van Horn has drawn out this model to extend developmentally further in ChildParent Psychotherapy (Lieberman and Van Horn 2005, 2008).

Much infant research (Emde 1981, 1988a, 1988b, 1992, 1999, Fonagy 1993, 1996, 2002, Fonagy, Steele, Moran, Steele, & Higgitt 1991, 1993 Stern 1985, others) has subsequently sought to document and theorize about the earliest stages of life from standpoints of relationality or intersubjectivity (Stern 1985), attachment and separation/individuation.

In concert with the increasing awareness of intergenerational phenomena, many authors have written up cases that demonstrate the challenges and process of conducting a treatment where an intergenerational problem exists. (Anzieu-Premmereur 2004,

30 Badoni 2002, Barth 1998, Blos 1985, Brady 2011, Faimberg 1998, Hoffman 1984, Manzano, Palacio Espasa & Zilkha 1999, Palacio Espasa 2004, Pantone 2000, Shapiro, Zinner, Shapiro & Berkowitz 1975, Shapiro, Shapiro, Zinner & Berkowitz 1977, Sherik 2009, Silverman & Lieberman 1999, Sutton & Hughes 2005, Warshaw 2000). These cases are highly sophisticated analyses of deeply intensive psychoanalytic work over extended periods of time. There is a question that extends from these cases as to how a psychodynamic child therapist might approach such daunting dynamics in the relatively limited scope of their generally weekly or biweekly contact with patients. Many of these cases, too, rework historical prohibitions of a single therapist working analytically with both the child and the parent at the same time. One sweeping theoretical rationale for this is the emerging development of Relational Psychoanalysis (Altman 1994, Altman 2000, Altman et. al 2002, Jacobs & Wachs 2002, Pantone 2000,Wachs & Jacobs 2006).

Evaluation and Diagnostic Assessment Each author conceptualizes the evaluation and diagnostic assessment of parents and children in a manner that is informed by their theoretical orientation, professional attitude, and methodology of treatment. From this perspective, authors focus upon different aspects of the parent(s) or parent-child relationship in the evaluation period. All writers on the subject speak to the central need for developing a therapeutic alliance with the parents and root the formation of the alliance in the early period of the evaluation.

Siskind (1997) argues that in order to form a working alliance with the parents, the therapist must understand the parent(s) in a thorough manner.

31 Siskind (1997) points out the following areas child therapists are to assess in the course of an evaluation: We need to consider the following: the age of the child, the nature of the problem, the relationship between child and each parent, and the relationship of the parents to each other. We need to explore the attitude of each of the parents to the child’s treatment and gain an impression of how psychologically minded they are. We need to have a working diagnosis of the child and of the parents; we must be realistic about the availability of therapeutic resources, and aware of the parents’ time constraints and their financial picture. We need to know whether treatment is voluntary or mandated by an outside agency. Finally, we need to arrive at what might be an ideal plan, and then, if necessary, trim it to what is realistically possible (p. 210-211).

Furman (1969) stresses that a basic mentality regarding assessing parents is that “we are not trying to assess – or work with – the parent’s total personality but only with the aspect that functions as a parent and manifests in the parent-child relationship” (p.

67). This orientation pervades the literature on work with parents and is the guiding rationale for most forms of parent work except for the simultaneous treatment of children and parents by the same therapist (Chazan 2003). Furman states that while it may seem paradoxical to organize psychoanalytic work in this way, experience has shown its efficacy. This conceptualization is rooted in the idea that the parenting function of the adult personality is to some degree distinct from the overall personality of the individual parent.

32 Siskind (1997) asks the question, “When the parent of a child in treatment is seen by his or her child’s therapist, is that parent to be viewed as a patient or something other than a patient?” (p. 6). She argues that the answer to this question stems from the clinical material, the facts and experience of the case itself. She suggests that it is advisable to err on the side of considering parents as patients due to the ubiquitous power of the unconscious. Beyond that, she applies her method of considering each case and each parent’s use of the therapist and participation in the clinical process. Conceptualizing a parent as a patient, in her case examples, does not mean a total treatment for the parent, but regarding their personalities and ways of consulting the therapist from a therapeutic perspective.

Bernstein (1958) describes the essential characteristics a parent should optimally possess in order to take a child into analysis. His conceptualization of this is particular to child analysis. He has elsewhere compared the indications for considering analysis and psychotherapy for a child (1957). Nonetheless, these characteristics are commensurate with those attended to by other authors (Mishne 1983, Novick & Novick 2005, Siskind 1997). Bernstein’s characteristics are as follows. He states parents should be “sufficiently well to provide the following: 1. recognition of conflict, suffering and inhibition present in the child; 2. ability to tolerate frustration, narcissistic injury caused by admitting that the child is ill, other object relations of the child and privacy of the child’s treatment; 3. a desire for the child to be well and independent which exceeds the neurotic gratification to be derived from the child’s neurosis;

33 4. sufficient ability to detach themselves from the child to attain a somewhat objective attitude so that they can report daily activities, cooperate with the analyst regarding practical arrangements, and refrain from acting out or permitting the child to act out; 5.

a scale of values which places mental and emotional health above the expense, inconvenience and deprivation required by the analysis (p. 73).

Bernstein stresses that these are optimal or ideal characteristics and that most parents do not fully possess all of them or maintain them at all times. Nonetheless, he states that some degree of these characteristics is necessary to carry out the effective treatment of a child.

The Novicks (2005, 2013) echo many of the sentiments of both Siskind (1997) and Bernstein (1958). They stress the need for an extended evaluation period in the service of cultivating a therapeutic alliance. This can be designed to enlist the parents’ support of the child’s treatment, but also is used as a treatment itself, which may eliminate the need for the child to be seen at all. They identify several areas that should begin to transform within the parent during the evaluation period and state that these may be sufficient to resolving the presenting difficulty. The several areas they work on transforming within the parent are: 

Guilt to usable concern,



Self-help to joint work,



Circumstantial explanations to internal meanings and motivations,



Externalizations onto the child to attunement with the child,



Parental helplessness to competence,

34 

Despair to hopefulness,



Idealization or denigration of the child to primary parental love (p. 24).

Most authors discuss parental guilt as a paramount issue in the treatment of children and working with parents. Parental guilt is often a powerful motivator for the parent to seek help for the child. Furman (1969) states that the healthy mother will feel guilty in response to her child’s emotional disturbances. She adds, however that all forms of guilt are not the same and some have debilitating or counterproductive effects. The Novicks (2005) point out that guilt can be a barrier to the parent’s actually demonstrating differentiated and useable concern for their child. They seek in their work with parents to create separation between the parents and the child and to transform parental guilt into a sense of meaningful personal responsibility and infused with a sense of competence and love for their child.

Frick (2000) notes that the parental therapist must assess for the capacity and motivation of the parents to cooperate with the therapist and carry out a treatment. She states that without sufficient capacity and motivation, a child treatment should not begin, but rather the emphasis should be on cultivating the capacity and motivation in the parent.

Historically, in child guidance clinics or therapeutic nurseries, parents have been required to be in individual or family treatment in order for the child to be able to receive therapy (Furman 1969, Mishne 1983). The implication of this stance can be that parental pathology is contributing to the child’s disturbance and needs to be addressed for the child’s treatment to be successful. While this may be true, authors have argued for our profession to demonstrate greater respect and flexibility with parents by not making such

35 rigid demands in our treatment methods (Anthony & McGinnis 1978, Lane 1980, Mishne 1983 and Siskind 1997).

Chethik (1976, 2000) identified a set of criteria he feels parents must meet before considering providing more interpretive work with the parents in concert with their child’s treatment. He (1976) states that parents need to have “a level of ego intactness and psychological-mindedness that would make them accessible to limited insight therapy” (p. 461). Additionally, he states that parents should have a capacity for self-observation.

He portrays these attributes in case examples, in which parents can be seen to develop insight into their internally held meanings and relational patterns in their relations with their child that have led to impasses in the parent-child relationship and the child’s development.

In Child-Parent Psychotherapy (Lieberman and Van Horn 2005, 2013), the assessment process is thorough and focuses on specific areas. They (2005) highlight the following general areas as crucial areas to assess and have created methods to inquire about and evaluate each: 1. Observation of the child in interaction with the primary caregiver(s); 2. Observation of the child in interaction with the assessor; 3. Observation of the child in different conditions (for example, on at least two different occasions; in different ecologically valid settings, such as home and the child-care setting; and/or in different circumstances, such as during free play and structured tasks); 4. Developmental history of the child, including presenting symptoms 5. Parental description of the child and of the family situation;

36 6. Evaluation of the parent’s psychological functioning and history; 7. Assessment of the family’s cultural background, socioeconomic circumstances, and the implications of these factors for the family’s childrearing values and practices. (p. 8-9) They note that one contra-indication for this method is in situations where there is ongoing domestic violence. They argue that physical safety is a precondition for engaging in meaningful psychotherapeutic work.

Modalities of Parent Work Historically psychoanalytic treatment of children was separated from work with parents, which invariably led to inconsistent outcomes in the treatment of children. Child analysts and therapists came to recognize and embrace the need for working with parents in some capacity in concert with working with their children. Yet, authors are not in agreement as to how this should be conducted. The universal standard at present is to determine whom the patient is, who is to be seen and to establish a frame of treatment that is sensible based on the presenting problem and available resources. Across contexts and settings, there are several modalities of treatment being practiced and conceptualized currently. In many circumstances, practitioners make use of multiple modalities in a given treatment. For the purpose of clarifying these modalities, in the overview of various modalities that follows, each of the predominant methods of conceptualizing work with parents will be reviewed as distinct forms of treatment. These include minimal parental participation, parent guidance/education, transference parenting/ego supportive work with parents, parents and child individually with separate therapists, treatment via the

37 parent, and treatment of the parent-child relationship. Finally, an overview of the Novicks’ (2005, 2013) model will be provided, as it is one published method of providing parent work that attempts to address most areas of parental need seen in practice.

Minimal parental participation.

Klein (1932) explains that parents carry an unconscious attitude of ambivalence toward a therapist and the various resistances that parents feel toward exposing themselves to their child’s therapist. She highlights the preponderance of parental guilt in all cases. She concludes that when conditions are such that parents are amenable to their child being analyzed and able to support it, there is no reason for significant contact between the child analyst and the parents. Klein approached work with parents as a means of developing support for the child’s analysis and made every precaution to protect the child’s analysis from parental interference. She refused to discuss the details of the child’s analysis with the parents, found it unnecessary except in cases of gross mistreatment to interfere with the child’s upbringing and was unconcerned with the day to day extra-analytical details of the child’s life except as they surfaced in the child’s analysis. She mandated that children be dropped off for treatment and picked up without parents waiting in her home where she provided treatment. The nature of Klein’s analytic work with children can be observed in detail in Psychoanalysis with Children (1932) and Narrative of a Child Analysis (1961). Her approach was to directly translate the method of free association and interpretation, the hallmarks of psychoanalysis with adults, to the work of children. Thus, her confidence in the method itself made all manner of working with adults in the child’s life extraneous to the task of child analysis.

38 Weiss (1964) cites the historical difficulty of translating the method of adult analysis to child analysis. He roots his discussion of these problems in Eissler’s (1953) paper, which established a way of thinking about derivations from strict analytic procedure as parameters. In child analysis, Weiss comments that the diagnostic period and ongoing work with parents are rife with situations that introduce parameters.

Regarding the diagnosis, he suggests via Anthony (1960) that separate analysts conduct the diagnostic evaluation and treatment. Weiss submits that in then current practice this division of labor was uncommon and it remains so today. He describes the narcissistic need he experienced to see parents in concert with his work with children in order to have a footing in the child’s extra-analytic life and to receive validation for successful therapeutic work, neither of which the child provide in the same way as adults in treatment. From a strictly classical or structural theoretical view, it is conceivable that a child’s analysis could be conducted without significant parental participation. However, he alludes parenthetically that this may not be the most psychotherapeutic method.

In contrast to Weiss’ comment upon Anthony’s (1960) stance on having separate therapists evaluate and treat a child, Glenn, Sabot & Bernstein (1992) note the individualized manner by which Anthony approached his cases. They state, “He ‘treats every child…as a specific instance requiring specific decisions…’ Sometimes Anthony sees parents, and sometimes he does not. He asserts “that there are just as many problems connected with seeing parents…as with not seeing them…” (p. 423). They also note that while Klein is often regarded as being against working with parents, she did write (1932) of the benefits of having contact with parents in terms of learning about the child’s

39 external life. She maintained, though, that if this is to cause a disruption in the treatment it is not worth it and ultimately unnecessary.

Abbate (1967) describes the analysis of a three-year-old child who was able to successfully participate in an analysis without the active participation of her parents. The child was suffering from separation anxiety and prone to extreme tantrums. The parents were highly indulgent and attempted at great lengths to ameliorate the child’s distress in the form of bribes. Abbate describes the mother’s inability to participate in treatment after a brief introductory period as leading to the minimal contact. The mother could not tolerate sessions and while acknowledging her own need for treatment herself, felt incapable of pursuing it at the time. Nonetheless, she supported the child’s treatment and faithfully brought her child to sessions and provided needed information about the child’s life via brief telephone contact. Abbate states that the treatment was able to move forward because the treatment led to relief and amelioration of guilt in the mother and provided the child with much needed early parental responsiveness by the therapist.

Parent guidance/education.

Many authors have written about parents’ needs for information and guidance regarding their parenting and the frequent occurrence of parents asking for advice, guidance, and strategies in the course of treatment. Jacobs and Wachs (2002) highlight the lack of education parents receive in general in our culture and how natural it is to feel insecure about one’s own knowledge and capacity in their role as parents in general and especially in the situation where their own childhood experience of parenting was less than optimal. Benedek (1959) and Stern (1995) discuss the significant internal

40 transformations that occur during parenthood for all parents and the common need for guidance and emotional support during these transformations. Mishne (1983) cites Anna Freud’s defense of parents’ ability to develop new skills. Furman (1969) noted that parents can effectively function as parents even when they experience significant mental health problems individually.

Parent guidance and parent education are approaches to work with parents that are not technically concerned with the intrapsychic psychology and historical dynamics of the parents, but rather on conscious material (Chethik 2000, Frick 2000). In this situation, parents may be significantly distressed, but the nature of the request for help and the presenting problem in the child may be a matter of commonplace developmental challenge, which can be addressed through educating the parent about child development.

Siskind (1997) states “as things stand in our current knowledge, brief consultation with parents on ordinary problems of childhood is not a treatment modality that has a theoretical base or that has a body of literature that offers technical application of existing theories of human development” (p. 94). The nature of this work is based on the expertise and observational powers of the clinician as well as the general nature and demeanor of the parents in their request for assistance. Siskind mentions a pitfall in this orientation to work with parents by noting that at times clinicians can eschew some of their powers of analytic observation when confronted with parents who are not seeking help directly for themselves but soliciting input on helping a child with seemingly ordinary difficulties.

She argues for maintaining an analytic stance even within these encounters. She also posits the functionality of the therapist at times functioning as an auxiliary ego for the parents.

41 Providing parents with education about child development is a common aspect of all forms of treatment. However, this is generally described as a child therapist imparting information about general child development or translating the child’s internal life into a way that the parent can understand what is occurring in the child or the family. The therapist is not necessarily advising the parent on what they should do about the situation but may be. Providing parents with direct guidance or advice on commonplace problems can at times resolve the presenting issue. However, this places the child therapist in a complex theoretical position, and yet one that also can afford further diagnostic insight if the parents or child have a significant reaction to either the process of being advised or an inability to carry out the advice.

Glenn, Sabot & Bernstein (1992) highlight the historical and practical concerns in having the child’s analyst serve in an advising capacity with the child’s parents. While these concerns are geared toward psychoanalysis, they can be applicable to psychotherapy as well. They note that the child can feel that his analyst is manipulating his life and resent that. They mention that parents have varying degrees of understanding of psychoanalytic methods and suggest that analysts will often need to explain this to parents. They may need to be instructed to report significant changes or developments in the child’s life to the analyst as well as told not to probe the child for information about his sessions or use the treatment in a perverse or threatening or demeaning manner. They emphasize the need to guide parents in order to “preserve the analytic situation and its arrangements or to protect the welfare of the child” (p. 410). They note there are situations in which the parents’ child-rearing practices are such that analytic progress will

42 not be able to occur without environmental intervention. They give the example of a child who does not have reasonable limits or situations of chronic abuse/neglect.

There are risks involved in providing advice to parents. Glenn, Sabot and Bernstein (1992) state that if the advice does not work or they are ineffective in following it, this may interfere with the treatment. Conversely, if the advice does work, parents may experience it as a magical solution and one they routinely expect. Parents may use the advice masochistically and repeat patterns of submission in receiving advice. They also may deliberately sabotage or undermine the advice for deeply entrenched reasons. Glenn, Sabot and Bernstein (1992) warn against analysts who continually guide parents in the hopes of constructing an optimal home environment, stating that this is “very likely to compromise the analysis” (p. 414). Ultimately, they state that “Advice interferes with the analyst’s neutral stance, and usually implies his values and ambitions for the patient” (p.

414).

Palombo (2001) argues, “caregivers are entitled to the best explanation available of their child’s problem. To the extent possible, it is desirable to give caregivers general advice on the management of the child and on ways to provide the child with positive experiences” (p. 293-294). He notes that parents can respond very well and proactively when provided with explanations and information about their child’s situation. Further, they may alter their behavior based on new information that can lead to improved parenting and reduction or eradication of symptoms in the child.

Cooper and Wanerman (1977) suggest that advice can be given to parents based upon the parents’ ability to integrate and use the information in a productive manner and that the difficulty is the result of a lack of information as opposed to stemming from

43 conflict. They warn that providing advice and guidance runs the risk of arousing guilt or shame in the parent.

Chethik (1976, 2000) describes a range of work with parents including parent guidance, transference parenting and treatment of the parent-child relationship. He includes a relatively broad range of activities under the heading of parent guidance. He states that generally this is work that is designed to create an alliance with the parents and enlist their support of the child’s treatment. The therapist providing child guidance is working with the parents’ conscious and pre-conscious attitudes and, from a theoretical standpoint, stays away from interpreting unconscious dimensions of the parents’ personalities, communications and potential contributions to the child’s pathology.

Within parent guidance he posits two broad headings: issues that affect the emotional balance in the family and issues that center on the child patient primarily. He also emphasizes the importance of describing the child’s subjective experience, internal world and interpersonal dynamics to the parents.

Sherick (2009) advocated for a revival of parent guidance work, suggesting that it has fallen out of favor in current practice. His emphasis is to work on parenting as the primary problem and the parents’ impact on the child’s pathology. This can be done without meeting the child, but he does recommend meeting the child in such a format.

While he conceptualizes his approach as directed toward improving parental functioning, his method includes some emphasis, however, on interpreting the parent’s contributions to the child’s pathology and the manner in which the child embodies parental projections.

This method is consistent with the approach advocated by Pantone (2000).

44 Mishne (1983) and Palombo (2001) add that parent guidance and education can be usefully provided in a group setting, which provides technical assistance, learning of skills, and emotional support.

Transference parenting/Ego supportive work with parents.

Chethik (2000) recognizes that there are parents who need further emotional support beyond parent guidance. He describes this emotionally supportive work in a similar manner as Mishne (1983), Frick (2000) & Sherick (2009). The focus of this work is to provide emotional support for the parent who is experiencing difficulty in their parenting role due to significant stress or historical challenges in their relationship with their parents. Frick (2000) notes that parents may lack suitable models in their own upbringing, which can lead to deficits in knowledge and empathic capacity. Chethik (2000) created the term transference parenting to exemplify parents’ periodic need to have their own needs attended to in the process of parenting their children. These needs may stem from their own early deficits, but having their needs met in consultation with their child’s therapist may be a sufficient intervention without interpreting the transference or internal dynamics of the parent. Simply listening and responding to the emotional need of the parent has therapeutic effect toward restoring the parent’s ego and improving their capacity to parent.

Treatment via the parent.

Treatment via the parent has the longest history in psychoanalysis dating to Freud’s (1909) treatment of Little Hans. However, it was not formally conceptualized as

45 such until Furman (1957) described the method of treating children under five-years old by way of their parents. Treatment via the parent is based on the particular emotional access a mother has into her child’s emotional life as well as influence upon it. Furman (1957) describes “three main approaches: (1) To advise the mother directly as to educational methods…(2) To treat the mother – by psychoanalysis, psychotherapy, or various social work techniques – in order to bring about changes in her own personality” (p. 251). The third approach focuses on the child directly, providing advice on some areas and using the mother’s unconscious closeness to the child’s conflicts and defenses to provide her with insight and ideas about how to work with the child’s conflicts. In a later related paper, Furman (1969) recasts the three aims of this intervention as (1) helping the parents as educators; … (2) enabling the parents to help their child with conflicts between the child and his environment; and (3) helping the parents to do therapeutic work with their child when the child has internalized conflicts” (p. 66). It is noteworthy that the direct treatment of the mother became separated from the method in the later version.

While Furman (1992) is largely writing about working with toddlers and young children, Jacobs and Wachs (2002, 2006) and Pantone (2000) advocated for exclusively working with parents for children of all ages. They derive this model from a relational perspective. Jacobs and Wachs (2002, 2006) liken the therapist-parent relationship to the supervisor-therapist relationship in clinical consultation.

Furman (1995) warns that: When we relate with only one partner of the parent-child relationship, we usually fail fully to respect the personality of the other one and deprive them as well as

46 ourselves of understanding and addressing the many important aspects each contributes to the complex mutuality of the relationship (p. 23).

Parents and child individually with separate therapists.

There are many situations in which the parents’ needs are greater than what can be addressed in parent guidance or ego supportive work. Most authors describe situations where deficits and conflicts in the parents routinely interfere with their ability to parent and maintain positive relations with their child. These parents are often referred for individual psychotherapy. Glenn, et. al. (1992) add that when supportive encouragement and parental guidance techniques fail, parents may need to be referred for personal therapy.

Mishne (1983) citing Hamilton (1947) notes that parent-child relationships that are markedly aggressive or hostile should have separate therapists. She notes that children will struggle to make an alliance with a therapist who also sees their parents in this situation. She further states that it is likely for the therapist to experience intense negative countertransference in the face of abusive parenting and that this would be a complicating factor in the therapist maintaining a neutral stance in holding both treatments. She does comment on what level of interaction with the parent the therapist should have in direct connection with this. She raises the question of what should be shared and the frequency of contact between a child therapist and the parental therapist.

She recommends addressing this based on the specifics of the case. Specifically, she states “the child’s private concerns, fantasy material, unacceptable wishes, etc., are not

47 shared with the parent’s therapist or counselor, though the overall course of therapy and the child’s age-appropriate and special needs should be shared” (1983 p. 253).

Siskind (1997) adds the observation that parents do not always discuss their parenting in their individual therapy and that child therapists cannot assume that referring a parent for individual therapy will directly or indirectly address the impetus for the referral. She explains that parenting is only one aspect of the parent’s overall psychology and the most pressing matters for them may not be their child.

Treatment of the parent-child relationship.

Treatment of the parent-child relationship is a method of devoting specific focus upon the dynamics and nature of the relationship between the parents and the child.

Where many techniques technically work to affect change in this area, the literature reviewed here are authors who discuss the dedicated focus upon this as an area of assessment and treatment. The main methods with this designated focus are designed for work with parent child dyads prior to the child entering latency. Bowen’s Family Systems Theory (1978) and Minuchin’s Structural Family Therapy (1974) also seek to alter the dynamics in parent-child and sibling relationships, but the focus is more oriented to the interconnected dynamics of the entire family as opposed to considering individual psychologies in their own rights.

Chethik (1976, 2000) proposes a form of ego clarification and limited insight psychotherapy with parents of children in treatment, which he calls treatment of the parent-child relationship. He (1976) contextualizes this form of parental treatment as “between advice-guidance and total treatment” (p. 453). He notes the importance of this

48 method as addressing a criticism of child treatment as too readily accepting the child as the identified patient and not adequately exploring the parental contribution. He describes a process of working with parental identifications in a manner that makes use of interpretation as its main distinguishing feature. The historical concern about a child therapist interpreting parent’s unconscious material in relation to their child is that it muddles the boundaries of standard technique, gives rise to problematic transference reactions in the parents and potentially threatens to undermine the treatment. Chethik states, however, that transference within this method is held within bounds because “there are constant opportunities to redefine the boundaries of the work” (1976 p 462). He focuses his interpretations on the impact of the parent’s unconscious material as it pertains to the child. This emphasis implies an alignment with the parents’ concern for their child’s welfare and their own desire to parent well. The emphasis on how unconscious aspects of the parents are relived and re-experienced with the child are not addressed as to how the parents are organized, but rather in providing insight that enables the parents to understand what is happening in their relationship and helping them gain an ability to alter the situation.

Infant-Parent Psychotherapy (Cramer 2000, Fraiberg 1980, Lieberman 1992, Lieberman & Pawl 1993, Lieberman, Silverman & Pawl 2000, Stern 1995) and ChildParent Psychotherapy (Lieberman & Van Horn 2005, 2013) also make use of Chethik’s (1976) technique of working with “the parental imago” (p. 463). Both models are an integration of psychoanalytic theory and attachment theory and make use of behavioral techniques. The distinction between the two is that Child-Parent Psychotherapy extends the age range of the child to six years old whereas in Infant-Parent Psychotherapy the

49 target population are between zero and three years old. In Infant-Parent Psychotherapy, a significant method in the technique is upon assessing parental representations of the child, querying the historical roots of this in the parents’ history and helping the parents to disentangle their current relations with their child from past relationships. In ChildParent Psychotherapy, this can remain a focus if it is relevant, but the parent’s narratives are generally less emphasized. The focus is more on the here-and-now interactions between the parent and child, the child’s play and verbalizations and working with modifying means of interacting, helping to translate childhood communications to the parent and promoting developmental growth in the child.

Stern (1995) describes two methods within Parent-Infant Psychotherapy. One is aimed at altering the parents’ representations and the other is directed at changing interactive behaviors. His conceptualization of the treatment situation is system based and he emphasizes that making an alteration in any one aspect of the system will alter the whole. Additionally, this model is embedded in a developmental perspective, in which the child is continually shaping internal representations of the parents (Stern 1985, 1995).

Cramer and colleagues (1990) performed an outcome evaluation of this method, which demonstrated enduring changes in parental representations and symptom reduction.

Cramer has elsewhere (2000) provided an overview of short-term conjoint psychotherapy with parents and children under the age of 3. In this model, he states “In all cases, parental projective identifications distort the representations of the infant who appears in a light that produces anxiety in the parents, leading to defences and secondarily, to pathological enactments (or interactions) that contribute to the infant’s symptomatology” (p. 136). In this method, the therapist and parent(s) develop a shared

50 focal point and while they trace the historical unconscious dimensions of this in the parents’ history, they are not concerned with the parent’s total personality. In situations where extensive negative transferences or resistances are present, parents would require a longer-term psychotherapy.

Mishne (1983) discusses the method of seeing the parent(s) and a very young child as a useful therapeutic approach. This method allows for observation of the parentchild relationship, modeling of appropriate caretaking and strengthens the therapeutic alliance among all parties. One concern she cites about this method is that some parents after termination continue to interpret their children’s behavior in a manner that the therapist would, which can lead to negative effects.

Some contemporary authors have begun to focus on integrating the various strands of historical theory covered here in forming an approach to childhood problems that focuses on the parent-child relationship (Altman et. al. 2002, Berlin 2002, 2005, 2008, Pantone 2000). These authors focus on integrating relational psychoanalytic thinking with attachment theory, affect regulation theories, and separation-individuation in a developmental context. These authors promote exploring the unconscious historical dimensions of the disruption in the child’s functioning and development and see this as the primary focus of the treatment. Chazan (2003) also focuses on these issues but has argued specifically for the usefulness of therapists conducting traditional individual therapy with both the parent and child concurrently in some circumstances.

51 Parents and child individually with the same therapist.

Chazan (1995, 2006) conceptualized the practice of treating child and parent individually by the same therapist as simultaneous treatment. This is described elsewhere as tripartite therapy (Berlin 2002, 2005, 2008, Siskind 1997) Chazan differentiates this form of treatment from similar methods including family therapy, behavioral or parent/child interaction therapies, and parent-infant psychotherapy. Simultaneous treatment maintains the traditional psychoanalytic approach and conceptualization of the treatment setting as being an individual enterprise within a context. She states that simultaneous treatment adds an additional level of analysis by affording the therapist an ability to observe dynamics in parallel that might not otherwise be seen. Chazan (1995) states “Contamination of feelings within the transference and the use of the parental role as a defense have been cited as reasons for avoiding treatment of the parent and child by the same therapist” (p. 2). However, she argues that these need not be complicating factors for the treatment, but rather other elements to be analyzed and interpreted.

Another distinguishing factor in simultaneous treatment is that it is not limited to early childhood or latency. Chazan presents cases of young children through adolescence treated through this model. She (2006) also later adds the possibility that simultaneous treatment occurs for only part of the overall treatment based on the therapist’s understanding of the state of the case and the individual participant’s needs.

Helmann (1992) reviews a number of cases treated by simultaneous analysis and various rationale for conducting a treatment as such. From her perspective, simultaneous analysis stemmed from cases in which parental pathology was linked or has contributed to the child’s symptomatology and interfered with previous more traditional attempts to

52 address the child and parents needs. Helmann notes the usefulness of simultaneous analysis in observing and determining the unconscious contributions in the parent-child relationship and the symptoms evoked in each. She also points out the benefit of being able to find the “link between parent’s and child’s pathologies” (p. 476) and to observe how the parent’s influence the development of their child’s difficulties. Finally, she also finds that simultaneous analysis has the potential to undo the oversimplification of attributing fault to parents by developing a thorough and well-informed understanding of the child’s difficulties.

Burlingham (1955) and Helmann (1960) reported on cases, which were conducted by what was at the time called simultaneous analysis of parent and child, but separate therapists under the supervision of a single supervisor conducted these treatments. Kohn (1976) notes that the issue of the contamination of the transference was not adequately explained in these earlier papers. Kohn (1976) demonstrates how the transference was impacted in his own case. He also adds other areas of question for this method, including the continual presence of extra-analytic information about either of the patients in treatment and the potential for countertransference reactions and identifications with either patient.

Nilsson (2006) considers the rationale for simultaneous treatment by a single therapist as opposed to separating the case and she details the dyads and families that may benefit from this approach. She highlights single parents, parents with social problems and parents in conflict with one another as groups that may benefit from such an arrangement. In regard to children, she states withdrawn children may benefit from the presence of their parents as well as children who have attention difficulties that may be

53 tied to attachment problems. She further notes that the complexities of attachment and identity formation in adopted children may also benefit from this model. She regards cases of physical or sexual abuse as generally not amenable to simultaneous treatment due to the challenges of the child patient in forming a trusting bond with the therapist.

Further, some children are overexposed to their parents’ problems and in order to promote more differentiated boundaries, simultaneous treatment would be counterproductive.

One deficient area in the literature on simultaneous treatment is the nature of confidentiality. Nilsson (2006) promotes maintaining a classical stance that parents and children not be privy to or pressured to divulge the contents of their own therapies.

Rather, she emphasizes exploring with both parties the significance of this arrangement.

Chazan (1995) states that children and parents need to know what type of information will be shared with the other party and what part remains private. However, she does not make a definitive statement about where this line should be drawn.

Novick & Novick’s model.

Novick and Novick (2005, 2013) have created a comprehensive model of parent work, which does not neatly fit into the various delineations made above. Their model is focused on two primary aims: “the restoration of the child to the path of progressive development” and “the restoration of the parent-child relationship to a lifelong positive resource for both” (2005 p. 17). Within their approach, they argue for making full use of available psychoanalytic tools in working with parents including interpretation, analysis of transference, resistance and countertransference, as well as educational and ego-

54 supportive techniques and external referrals for parents. They (2005) state “Parent work focuses on the parent-child relationship; other issues in the parents’ lives are engaged with only as they have relevance to their relationship with their child” (p. 22). The main thrust of the Novicks’ work is to advocate for the inclusion and utility of including parents in the therapeutic process. The Novicks use cultivating a therapeutic alliance with the parents as an organizing principle of their model. Parents are engaged extensively at the beginning of the treatment with the aim of fully understanding the presenting problem in context and building a sense of mutual alliance.

Another organizing feature of their model is the concept of two systems of selfregulation and conflict resolution. They note (2013) that the “aim of self-regulation is to protection against helplessness” (p. 333) and that individuals can employ self-regulatory operations according to either a closed or open system. “The open system is attuned to reality and characterized by joy, competence and creativity… The closed system avoids reality and is characterized by power dynamics, magical thinking and stasis” (2013 p.

333). They integrate this concept with their overall goals of restoring progressive development and improving the parent-child relationship.

The Novicks (2005, 2013) have divided the treatment into phases: (Evaluation, Beginning, Middle Phase, Pre-Termination, Termination and Post-Termination). In each phase, there are therapeutic alliance tasks that are the focus of the parental work. The Novicks’ model is also embedded in a developmental context, in which they emphasize interdependence and the continual presence of needed others in forming and maintaining a vital sense of self. The Novicks detail the therapeutic alliance tasks for the parents, the

55 common anxieties and resistances they face, and the therapist’s techniques and aims during each phase of the treatment.

Crucial Psychodynamic Factors in Parent Work Therapeutic alliance.

Virtually every contemporary author writing on the subject of parent work in child treatment emphasizes the critical need for a child therapist to form a therapeutic or working alliance with the parents. The Novicks (2013) note that the quality of the therapeutic alliance with the parents determines the outcome. Others (Siskind 1997, Mishne 1983, Cooper & Wanerman 1977) have also agreed that without such an alliance, a child’s treatment would not be successful and in many cases even possible.

The therapeutic alliance has also been referred to as the working alliance, the treatment alliance. Each wording of the term has historical controversy and significance to its precise meaning and development. Hausner (2000) and the Novicks (1998) detail this history and the controversy surrounding these theoretical divisions. However, the nature of this phenomenon in child treatment and parent work literature does not make significant overt references to the historical literature and theoretical debates. In short, Zetzel (1956) and Greenson (1965) considered the therapeutic alliance as a nonpathological, rational aspect of the individual which partners with the analyst in order to engage in the analytic work. Brenner (1979) objected to separating this aspect of the individual from transference.

56 Mishne (1983) speaks of the alliance in a casual manner, emphasizing the cooperation necessary between parents and the therapist around their concern for and understanding of the child patient.

Sandler, Dare and Holder (1992) define the treatment alliance as: Being based on the patient’s conscious or unconscious wish to co-operate, and his readiness to accept the therapist’s aid in overcoming internal difficulties. This is not the same as attending treatment simply on the basis of getting pleasure or some other form of gratification. In the treatment alliance there is an acceptance [by the patient] of the need to deal with internal problems, and to do analytic work in the face of internal or (particularly with children) external (e.g. family) resistance (p. 29).

The Novicks for example have extensively reviewed and reformulated the concept of the therapeutic alliance (1970, 1998), but do not in their expanded book (2005) on the subject of parent work provide this background or a precise definition of the therapeutic alliance. Rather, they outline the following tasks for parents during specific phases of their child’s treatment: 

During evaluation, the task for parents is to begin various transformations (listed in the evaluation section of this review)



At the beginning of the child’s treatment, parents have the task of allowing the child to “be with” another adult, accepting physical separation.



In the middle phase, allowing the child to work together privately with another person means integrating the child’s psychological separation.

57 

Enjoying and validating the child’s progression is the task for parents in the pretermination phase.



During termination, parents work to mourn their own loss of the therapy, to internalize mastery of alliance tasks, and to consolidate their own development in the phase of parenthood.



After treatment has ended, parents allow for continued growth in the child and grow with him. (p. 23-24)

Siskind (1997) states, “The therapist has to assess each family member not only from a diagnostic point of view, but also in regard to forming a therapeutic alliance” (p. 179).

Cooper and Wanerman (1977) emphasize a common view that one purpose of creating and maintaining an alliance with parents is to garner their ongoing support for the child’s treatment.

Parental resistance.

Weiss (1995) states “Parents bring their children for help and most of the time deny them that help” (p. 79). This confounding reality is ubiquitous in the literature on child and parent work. Most authors (Cooper & Wanerman 1977, Frick 2000, Furman 1992, Mishne 1983, Novick and Novick 2005, Siskind 1997, among others) agree that there is a degree of guilt involved in bringing one’s child to treatment. Parents may feel that they are not adequately functioning in their role as parents and naturally feel guilt as a response to their helplessness. The Novicks (2005) describe guilt as a closed system response to helplessness and target transforming this feeling state into constructive

58 concern. They note that guilt and parental anxiety are powerful motivators for seeking treatment for the child. They also cite a myriad of unconscious meanings and dynamics that may be operating when guilt predominates in the parents. For example, they (2005) state: If their response to helplessness is the invoking of feelings of hostile omnipotence, they may feel overwhelming guilt. This can lead to frantic attempts to being traumatized by guilt, which may take the form of blaming others, especially the child, and eventually the analyst, for their own failures (p. 27).

Resistances related to guilt and feeling inadequate as parents are sufficiently challenging to any parent and therapist, but the situation becomes far more complex when the repetition of the parents’ early history is intertwined with the child and the presenting problem. Benedek (1959) described the opportunity inherent in parenthood of reworking early difficulties in the parent’s own childhood. Yet, this is not always a welcome experience for many parents. Rather, as Weiss (1995) states, “There are important reasons that we need to avoid the child in ourselves and that parents need to avoid the child in themselves” (p. 84). Frick (2000) describes the pain a parent may experience when they are faced with their child’s distress and do not have an available internal object upon which to draw from their own early history. Thus, the deficit may give rise to powerful defenses against helplessness, which can derail their ability to parent and relate to their child in a differentiated manner in a variety of ways.

Thus, there becomes an ambivalence that arises in parents when seeking treatment for their children. Frick (2000) notes “Parents want their children to be happy; at the same time, they need to maintain their own defences. This makes them ambivalent in

59 their search for help” (p. 67). Klein (1932) states, “The degree of difficulty they (the parents) will cause will of course depend on their unconscious attitude and on the amount of ambivalence they have.” (p.116). This ambivalence can be related to deeply unconscious aspects of the parent’s personality that have been warded off prior to the child’s birth and development. For example, as Furman (1969) notes, “there are mothers for whom the child or his difficulties have an important but pathological unconscious meaning; e.g., the child represents part of the mother’s person or he stands for the partner in one of her early object relationships. In such cases the unconscious tendency counteracts the mother’s conscious efforts too strongly to enable her to alter her attitude” (p 260).

The issue of differentiation is crucial in understanding the nature of parents’ uses of their children. Weiss (1995) states that “Externalization and projection are frequent mechanisms that are used by parents to deal with the onslaught of feelings that threaten their repression” (p. 85). The Novicks’ (2005, 2013) too are focused on the preponderance of these defense mechanisms in parents. Their model is designed to assess for the level of differentiation and aimed at promoting separation and individuation, which they state will often put the parents in touch with their ability to parent their child as a separate individual.

There are also ways where the child’s difficulties are not as obviously related to problems in the parents’ early history, but quite immediately challenge the parents’ sense of security and sense of cohesion in the present. Typically, these issues are not formidable unless they are connected to a strand of defensive compromise or serious

60 deficit in the parents’ own history. Mishne (1983) lists some major resistances that surface in a child’s treatment: Jealousy and rivalry with the therapist, displacement of conflict with the spouse onto the therapist, child and parent sharing the same constellation of defenses or symptoms, the need to fail per masochistic character traits, and/or anxiety about the results due to fear of the unknown… resentment of authority (p. 243).

Many authors, too, have relayed anecdotes that portray how resistance shows up in child treatment. Glenn, Sabot & Bernstein (1992) suggest keeping the child from appointments for minor illnesses, forbidding the child consciously or unconsciously from sharing information about the family and deliberately misleading the therapist as typical resistances. The Novicks (2005) add that parental demandingness for treatment to be conducted in a highly particular way is also a common resistance.

Transference and countertransference.

Transference and the transference neurosis are often seen in psychoanalytic treatment as the main avenue of therapeutic action and psychological change. In an individual treatment context, the psychoanalytically informed clinician works toward understanding and interpreting the transference of, depending on the theoretical orientation, intrapsychic conflict, defenses, object relations, deficits and unmet psychological needs. The thinking is that where problems existed in the individual’s history, these compromised aspects of the individual’s development continue to assert an unconscious influence and organization on the individual. Greenson and Wexler (1969) define transference as follows:

61 Transference is the experiencing of impulses, feelings, fantasies, attitudes, and defences with respect to a person in the present which do not appropriately fit that person but are a repetition of responses originating in regard to significant persons of early childhood, unconsciously displaced on to persons in the present. The two outstanding characteristics of transference phenomena are (1) it is an indiscriminate, non-selective repetition of the past, and (2) it ignores or distorts reality.

In the situation of working with parents and children in treatment, transference is even more complex for a variety of reasons. First there are more individuals involved in the therapeutic encounter, which raises the possibility of multiple transferences being active at any one time. Further, when parents present their children for treatment, they are not necessarily engaged in the therapeutic process strictly as a patient (Siskind 1997).

Most authors have organized their work with parents as directed only to the sector of their personality that functions as a parent (Chethik 1976, 2000, Furman 1969, Novick and Novick 2005). Green (2000) suggests that therapists frequently make use of transference data even if they do not explicitly interpret the transference or even refer to it indirectly in work with parents. She raises a further point that parents also form transferences to their children.

Palombo (2001) summarizes the formation of transference in child treatment as a result of predetermined factors in the parent’s psychology or the referral and as a result of the way a child therapist responds to parental requests for guidance, information or understanding of their child. Palombo (2001) notes that working with parents of children in treatment is not intended to be a process of working on the transference that is evoked

62 in the parent in the treatment process. Rather, he argues for more educational, informational and supportive methods. He states, “Some child therapists prefer to retain the ambiguity of their position so as to maximize the effectiveness of future interventions.

By so doing, they allow caregivers to form transferences.” (p. 287-288). He notes that historically, practitioners have often sought to take a parental history in advance of conducting a child treatment, but that this has aroused negative reactions in parents who do not want to be the subject of inquiry and resist its relevance to their child’s specific problems. He argues that therapists should remain alert to parental transferences because it could threaten their alliance and the child’s treatment and that transferences can provide useful diagnostic information about the parent-child relationship. Toward the latter point, he suggests that therapists can use this information to give shape to their communications to the parents in a manner that will be most meaningful to them.

Transferences also occur from the therapist to the patient. Glenn, Sabot and Bernstein (1992) state, “Transference reactions to the parents, and identification with the child are extremely likely throughout the analytic process” (p. 399). They and others (Mishne 1983, Kohrman et. al. 1971, Siskind 1997) emphasize the potential for the therapist to identify with the child and have reminiscences of their own parents. In positive iterations of this, this experience can provide a means of empathizing with the child and knowing their situation intimately. Negatively, it also has the potential of distorting the therapist’s understanding of the child’s reality or introducing the therapist’s dynamics into their formulation of and interaction with the parents.

Kramer and Byerly (1992) cite that working with parents elicits the most challenging sources of countertransference in practitioners. In addition, they list the

63 following sources of common factors contributing to countertransference in practitioners: “the analyst’s rescue fantasies, his continuing identification with the authority of his own analyst or of his parents, the revival of traumata from his own childhood by the child analytic experience, his reactions to patient’s aggression and seduction, and his guilt feeling because he is very occupied with child patients when he has young children of his own” (p. 229-230). They also mention that jealousy or competitiveness with the parents can be countertransference reactions and lead to problematic interactions with the parents.

64

Chapter III

Methods Introduction This study sought to explore and document how practicing psychodynamic child psychotherapists work with parents. Palombo (2001) states the reason there are few widereaching explanatory studies on work with parents “may be because this topic does not lend itself to being formulated into general principles” (p. 283). The nuances of work with parents are often fleshed out in the close examination of individual cases. There have been authors who have devoted greater attention to formulating a conceptual framework for parent work in general (Chethik 2000, Jacobs & Wachs 2002, Novick & Novick 2005, Siskind 1997) and a dissertation on the subject (Hirshfeld 2001). These works, however, do not fully encapsulate the breadth of ideas and approaches that are present in the literature on individual cases and various significant aspects of parent work. As it stands, a comprehensive theoretical model does not exist, and most authors argue for developing a method of working with parents based on the needs in a given case. Cresswell (2007) states, “grounded theory is a good design to use when a theory is not available to explain a process” (p. 66). Thus, this study utilized a grounded theory approach to how work with parents of children in psychodynamic psychotherapy is conceptualized by working clinicians.

65 This study was conducted using a social constructivist approach (Charmaz 2014).

Social construction (Gergen 2015) and social constructivism (Charmaz 2014, Cresswell 2007, Schwandt 1995, 2000 Lincoln 1990), are rooted in the idea that individuals negotiate meaning through discourse and interaction with significant others in their lives and the internalized representations of these others in their own minds. Meaning making is a discursive process that is continuously shaped and renegotiated through the agency of an individual subject. Whereas positivism or objective realism might seek to find a universal fact or truth, social constructivism allows for the extreme localization of meaning making. This epistemological perspective corresponds squarely with both psychoanalytic theory and the complexity of parent-child relationships. It also provides the greatest flexibility in allowing subjects in research to define their particular experience and point of view and for the researcher to assess and account for various contributing factors to the individual’s perspective.

The goal of social constructivist research “is to rely as much as possible on the participants’ view of the situation. Often these subjective meanings are negotiated socially and historically… they are not simply imprinted on individuals but are formed through interaction with others (hence social constructivism) and through historical cultural norms that operate in individuals’ lives” (Cresswell 2007 p. 20-21). Expertise in parent work is often regarded as existing in individual clinicians. Each clinician determines how they will approach working with parents and generally has the sole vantage point from which to observe and speak to their process professionally. Thus, this study engaged closely with each clinician’s specific experience and perspective. The social constructivist perspective allowed for analysis of each clinician’s subjectivity and

66 the environmental and historical influences, which have influenced and informed the clinician’s perspective.

Research Sampling The sample in this study was drawn through purposeful sampling (Cresswell 2007). The initial sample sought was to consist of at least 15 child psychotherapists who have at least five years post-graduate experience providing psychotherapy to children and families and self-identified as working from a psychodynamic perspective. Clinicians were not required to possess particular training in psychodynamic theories or clinical methods, although all members of the sample did have formal education, trainings, supervised field placements and independent supervision/consultation which contributed to their approach and methodology. The initial purpose was to collect a sample of individuals who simply identify as working from a psychodynamic perspective in order to allow for the presence of any individuals who identify as practicing psychodynamically. There are many psychoanalytic institutes and some institutions of higher education that provide training and education in psychodynamic theory. However, many individuals who identify as practicing from a psychodynamic perspective have not necessarily received formal training from an institution. The rationale for each clinician having at least five years post-graduate experience was to ensure that each clinician has sufficient experience working with children and families and likely had the experience of seeing cases through from intake to termination. There were no further criteria for the original sample.

67 The sample was recruited through email solicitation (Appendix A) to the following organizations and collectives of practitioners who work in the area of psychodynamic child psychotherapy: National Association of Social Workers, American Association of Psychoanalysis in Clinical Social Work, Chicago Psychoanalytic Institute, Chicago Center for Psychoanalysis, American Psychological Association, Erikson Institute Center for Children and Families, Jewish Child and Family Services, The Kedzie Center, and The Family Institute at Northwestern University.

Information Collected About Participants Within this study there were several areas of each participant’s practice setting and experience that were explored and deemed influential in shaping each clinician’s perspective and approach. The setting in which a psychotherapist works has a significant influence on the manner in which the therapist practices. Many agencies have a prescribed or preferred method of working with parents, which was assessed by the researcher when it was relevant to the participant. Additionally, in an agency setting, therapists are provided with individual and at times group supervision, which also has an impact on the therapist’s approach. In private practice, the therapist may or may not operate with full autonomy. At times, therapists work under the aegis of another therapist who supervises and guides the casework of a therapist. In other settings, the therapist may seek outside consultation. These aspects of the framework of a participating therapist’s practice were explored to assess influences on each clinician’s methods and personal conceptualization of parent work.

68 The therapist’s educational background, familiarity and training in psychodynamic work also had a significant impact on the therapist’s conceptual framework and clinical approach. How each clinician received training in psychodynamic work and what impact they feel their training has had on their practice was routinely explored. The number of years since completing their graduate education was an exclusion criterion but also had relevance in exploring how each clinician’s practice has changed over time.

Demographic information was not initially regarded as inherently significant in this study beyond the therapist meeting the criteria for participating in the study. The gender, race, ethnicity, age and sexual identification were seldom referenced through the interviews as critically significant to each clinician’s practice or conceptualization of working with parents. It did surface in moments of recalling case vignettes particularly involving gender dynamics (e.g. being a man working with a mother or being a woman with a father), however, these aspects were not preponderant in the interviews. It was noteworthy, however, that the sample entirely consisted of white and middle or upper middle class individuals.

Each therapist needed to have the capacity to reflect on their practice and speak at least minimally to how their psychodynamic orientation informs their practice, which was certainly the case. This study was predicated upon a pluralistic psychodynamic theoretical perspective, which drew from all the major schools of psychoanalytic theory.

This included classical drive and structural theory, ego psychology, object relations, selfpsychology, interpersonal, intersubjective and relational psychoanalysis, and

69 neuropsychoanalysis. Each participant situated their conceptual framework in one or more of these areas, and all did identify as practicing from a psychodynamic perspective.

Research Sample The sample consisted of 16 psychodynamically oriented child psychotherapists. This included individuals with graduate training and licensure in social work, psychology, counseling, marriage and family therapy, psychiatry and for approximately half of the sample post-graduate training in psychoanalysis. Clinicians were practicing in various major metropolitan areas throughout the United States and Canada. Clinicians in the sample ranged from having 5-40 years of post-licensure experience. The average range of experience was approximately 20-25 years in clinical practice. Almost all of the participants work in private practice to some degree and a majority of the participants were in private practice full-time. Half of the participants worked in family service agencies and school settings either as an employee or a consultant. Several participants teach in institutes of higher education and provide clinical supervision to younger professionals. All of the participants described ongoing efforts throughout their careers to engage with literature and learning communities to continually expand their knowledge base and deepen the efficacy of their clinical work.

Research Design/Data Collection/Data Analysis This study was conducted using the social constructivist grounded theory as designed by Charmaz (2014). The initial step was to recruit participants as described above through purposeful sampling. Volunteers were screened through phone or email to

70 ensure that inclusion criteria were met. Participants identified as psychodynamic psychotherapists working with children and families for at least five years since graduating from a master’s program and qualifying for licensure, which enabled the individual to practice clinically in an independent fashion.

Once the individual expressed interest in participating in the study and had met the criteria, arrangements were made for the researcher and participant to meet in person or via electronic video conference. Participants were required to sign a consent form (Appendix B) in advance of the interview. The researcher conducted one 45-90 minute in-depth interview with each participant. These interviews were audio-recorded through digital recording software and subsequently transcribed. The researcher also made notes during interviews. These notes included impressions of the participant, the setting in which they work, key points related to the topic or approach, etc. These notes were reviewed along with the transcription after each interview. In some cases, these notes became a formal memo, which related to emerging theoretical points that were explored and evaluated in subsequent interviews.

Data was collected through in-depth qualitative interviews. Each interview was 45-90 minutes in length. To the extent that it was possible, interviews took place in the office or consulting room of the participant in order to afford the researcher the ability to observe each therapist in his/her treatment setting. Several participants were not local to the Chicago area were met with via a HIPPAA compliant video conferencing software.

Interviews began with an introductory question about each participant’s background, education, and practice setting. After collecting such information, each participant was asked the question: How do you work with parents in your practice?

71 Participants were encouraged to elaborate on their answers and provide examples and vignettes where appropriate. There was not a formal interview guide or a set of preformed questions as this would have been inconsistent with a grounded theory approach. Rather, participants were encouraged to present their thoughts and practices on working with parents. Participants were asked at the conclusion of the interview if they were open to being in later communication with the researcher in order to verify findings and for further exploration, though no follow-up contacts were deemed necessary.

The transcription of each interview was put through a process of initial coding (Charmaz 2014). This was conducted by coding through incident-by-incident and lineby-line methods. Each segment of the participant’s narrative was analyzed for specific themes, which were summative statements that made a shorthand phrase of the essential category, focus or specific terminology of the narrative text. In the initial coding process, interviews were examined closely, and a broad swath of data was coded for its initial and potential analytic importance. These initial codes served as the basis for the emerging theory and areas to be explored in subsequent interviews.

As subsequent interviews were conducted and more data aggregated, focused coding was employed. In focused coding, data that repeated across interviews or demonstrated comprehensive explanatory reach were organized into core theoretical statements. After being sufficiently compared with earlier interviews and explored in subsequent interviews to a point of saturation, these statements were aggregated to form the outline of the grounded theory.

72 Ethical Considerations Within this study, there were minimal risks for participants. Each participant was fully informed of the purpose and process of this research and was required to provide written consent of their willingness to participate. Each participant was a licensed professional clinician and had requisite command over the emotional contents of their practices and the information they chose to share in the interview. In no interviews were the contents significantly distressing to the participants.

Participants used anecdotes from their clinical practice in order to explain their methods of working with parents and their manner of conceptualizing their work.

Participants were notified that their narrative would be transcribed, and their material would potentially be used as an anecdote in a final write-up. Participants were required to use pseudonyms when describing individuals and employ other reasonable measures to protect the confidentiality of their patients in their dialogue. In analyzing and writing up the findings within the research, careful attention was paid to protecting the identities of both clinicians and their patients.

Issues of Trustworthiness Credibility, dependability and transferability were ensured through the research process by employing the constant comparative method of data analysis (Glaser & Strauss 1967), providing rich illustrations drawn from the data collection and making clear demonstrations of how the data was ultimately consolidated into the resulting theory. Data that was categorized was compared throughout and assessed for consistency.

73 Emerging theoretical notions indicated by these integrations were brought into interviews with subsequent participants and explored as to their credibility in practice.

Limitations and Delimitations The primary limitation in this research is that it was confined to a small sample of practicing clinicians within the field of psychodynamic child psychotherapy who voluntarily offer to participate in the study. Participants were solicited from as many practice settings as possible in order to capture the widest reach in terms of potential for how clinicians practice and what influences these choices. This study also took place geographically in Chicago, which to some extent, further limited the potential sample.

However, participants were allowed to volunteer to be interviewed via online videoconference, which allowed for participation in other geographical areas. That individuals practicing from a psychodynamic perspective who do not or minimally work with parents and chose not to volunteer was a limitation in this project in that it left open a number of possibilities as to why these individuals opted not to participate. Their perspectives and practices were not represented in the findings. Data were also exclusively collected through self-report. This relied upon the practitioners being forthcoming, honest and descriptive of their views and practices. There was no reason to suspect that participants were otherwise or that they intentionally concealed their true views on the topic. Finally, this research was conducted by an individual researcher who is a clinician practicing psychodynamically with children and families. This informed the data collection and analysis, but ultimately led to rich data collection and informed

74 analyses. It is plausible that the findings would not be replicated in the same manner by a different researcher.

A delimitation in this project was the exclusion criteria of the sample. Individuals who have practiced for less than five years post-graduation or do not identify as psychodynamic practitioners were not eligible to participate. Thus, beginning notions or initial impressions of practitioners in the field were only accounted for in a retrospective manner. This project was intended to understand how clinicians work with parents. Child treatment and development were a predominant feature of the interviews, but these were outside the direct focus of the research. The theoretical orientation and focus of the research were psychodynamic and psychoanalytic. Practitioners who work from other perspectives were not considered for participation. Within the field of psychodynamic child psychotherapy, there are numerous relevant factors informing a clinician’s choice of assessment and treatment, which had the potential to make the research project include excessive factors. Delimiting the findings in the constant comparison process of the theory development enabled the researcher to isolate the core conceptual factors in this area of practice and provide the boundaries within the theoretical construction.

The Role and Background of the Researcher The researcher is a psychodynamically oriented child, family and individual adult psychotherapist. He is ten years post-graduation from a Master’s in Social Work program, has fully completed coursework for a PhD in psychodynamically oriented clinical social work and had additional training in psychoanalysis. The researcher currently works in private practice providing individual therapy to children and adults,

75 family therapy and clinical consultation to practitioners. The researcher has previously worked in social service agencies, residential treatment, grief counseling and in a therapeutic nursery program.

The researcher’s role in this process was to solicit participants, conduct the interviews, analyze the data, and organize and present the findings. The researcher used his experience in the field to identify appropriate questions to encourage comprehensive responses from the participants and to aid in the data analysis. The researcher was not engaged in the process to verify a hypothesis stemming from his education or practice.

Rather, his role was to collect data from the participants on their views and to organize these findings in a manner that accurately represents what was conveyed.

76

Chapter IV

Findings Finding 1: Parent Work Is an Essential Component of Child Treatment Parental involvement as commonplace.

Each clinician interviewed in the study works with parents of children in treatment and emphasized the importance of this in their work. One clinician captured the general sentiment of the entire sample in this study: “We just kind of came to it as though the parents were part of the work and we couldn’t do it without them.” Another clinician echoed this sentiment in describing supervisors in her training: While I would say it’s not in the books that you have to do parent work, all of them would be very shocked if you did an analytic case; like you wouldn’t get supervision from any of them and work with a child and them be approving of it if you didn’t work with the parent.

Many clinicians were matter of fact about their commitment to involving parents and conveyed this point in a variety of ways. Some clinicians simply expressed their desire to work with and to engage with parents. One clinician noted, “If I’m working with a kid, I want to be in touch with that parent.” Another said, “I make a lot of effort, if you can’t tell, to engage with both parents.” Another clinician remarked, “I try to take a very collaborative approach with parents. I welcome their involvement and engagement in trying to understand their perspective on the child and the child’s experience.” Some

77 clinicians expressed an unwillingness to conduct child treatment without parental involvement. One clinician remarked, “I won’t see a child unless I can meet with the parents pretty regularly.” Others treated the subject as though it were an uncontentious matter of course. One clinician stated, “The infant child and adolescent cases are all accompanied with some kind of parent work.” Many clinicians described the frequency of their contact with parents in ongoing treatments to convey the regularity with which they involve parents alongside the child’s treatment. Several clinicians described a range of weekly to monthly contact in frequency. For example, one clinician noted: The maximum that parents are in is once a week. Often, it’s twice a month as cases become more intensive. For instance, the adolescent cases and that patient is basically managing most of the treatment themselves, I’ll go to once a month with the parents.

Analysts typically met with parents more regularly for a longer period of time during a child’s analysis. One clinician described her approach, which was consistent with a typical analytic schedule: I’d meet with the parents on a weekly basis. It would only be after a couple of years of the analysis that the work with the parents might become less frequent.

Maybe every other week or gradually maybe monthly toward the end of a treatment.

Another clinician emphasized her desire to meet with parents more frequently but noted the challenge of accomplishing this in practice. She stated: “I mean at least once a month. But, for me actually once weekly would be ideal, but… it’s hard to get parents to come in once a week. So, sometimes it’s every other week.”

78 While all clinicians embraced working with parents and expressed its importance, each therapist conveyed their orientation to working with parents to the parents in the beginning of the child’s treatment. One clinician spoke to her method of introducing this with parents by saying, “In my initial consultation with the parent I always, even on the telephone, say you will be a participant in this treatment.” Another clinician captured a common sentiment among participants: “There are just approaches and trying to regard the parents as essential. I often say to parents, Look, I can’t do this alone. I need your help.” Another clinician described how she expressed to parents her expectation of their involvement: I want you to come in. I want a meeting with the two of you. I want to learn a lot about what’s been going on. And then I’m going to call you and I’m going to see you every so often because, you know, we need to stay in close touch.

Several clinicians noted that some parents did not expect to be involved extensively in the child’s treatment, though this was on the whole infrequent. This was also immediately addressed whenever it emerged. For example, one clinician said, “I would never say, Yes, bring your child in, drop your child off and I’ll let you know what I think. I would always start with meeting with the mom and dad first.” Another clinician noted, “They may think that’s what’s going to happen, and I very quickly say that they’re part of the team. And I’ve never had anybody not agree to that.” While parental resistance to continuous involvement did arise in discussing challenges to maintain parent work as treatments progressed, there was a casualness that most clinicians exuded about how natural their expectation of parental involvement was and how easily parents responded to the invitation to be involved.

79 Some clinicians remarked on the history of child analysts not working with parents of children in psychoanalysis. One clinician remarked, “I kind of balked at the old method. It didn’t make sense to see kids without parent contact.” Another stated, “I really almost never do kind of a strict child psychoanalysis where the parent has almost nothing to do with it. That just doesn’t make a lot of sense to me personally.” A few clinicians in the study referenced known associates who conduct child treatment with little or no parent consultation and expressed their befuddlement and disagreement with their colleague’s approaches. One clinician noted that in her training institute, she became aware of supervisors who do not work with parents and said “I would never work with them. They are off the table for me. I don’t understand how you could do this work without involving parents. It still makes me crazy.” Another clinician noted, “I have colleagues who will only see children and they see parents as little as possible because they are just not comfortable.”

One clinician described a case in which she was treating the father of a child in treatment with another provider “and the therapist had a complete unwillingness to speak to him at all whatsoever.” She further remarked, “I guess there are therapists that have that mindset where it’s like I’m going to work with your teenager and that’s my relationship and you pay the bill.” This situation was distressing to her patient and led to him removing his child from therapy with that particular therapist.

80 Increased parental involvement leads to better outcomes (and vice versa).

Within the sample, clinicians expressed that increased parental involvement led to better outcomes and cases which had precipitous endings or inadequate results tended to include or be attributed to lack of parental involvement. One clinician remarked: I found that the cases that I feel like that have been the most successful and the most productive, I have the most contact with the parents. In cases where that doesn’t happen for a whole bunch of reasons are cases that tend to tank.

Another clinician detailed a case in which frequent parental contact informed her ability to identify the nature of a child’s struggles. She noted, “I’ve never seen as remarkable a change as with that kid as opposed to kids who, you know, his parents are not that involved.” The case she was referring to was a school aged child who had aroused school personnel’s concern because the boy had behavioral difficulties and was prone to tell elaborate stories to refuse to participate. The teacher relayed one story to the therapist, “The boy said, I had surgery over the weekend. I have big stitches in my chest, and I can’t do this or that.” The therapist knew from weekly meetings with the parents that the boy’s father had a medical trauma in the past and realized that the boy’s difficulties were stemming from the boy’s “fears about the father’s health and... the parents’... fears about the father’s health.” She attributed the ability to identify the precipitating cause of the symptom and the working through it as possible due to the close work with the parents.

Another therapist stated, “My hope is that the parents will come as long as they can tolerate before I see the kid. That’s my hope. I’ve had cases that have not worked out I think in some ways because of that.” He provided a case example in which the parents

81 brought the child to treatment and the parents had the expectation of not being very involved with the therapist. This therapist determined “after meeting with the parents, it was clear that this was a family case or me talking with the parents.” However, this assessment proved incompatible with the parents’ wishes or capacities at the moment and the treatment did not continue beyond a brief introductory period. Several clinicians also found it preferable to have a prolonged introductory period with the parents in order to establish a working relationship and to develop an understanding of the problem in context of the family. They found parental input to be exceptionally valuable in this regard, noting that children are often not capable of providing all the needed information.

Several clinicians in the sample worked with models of treatment that emphasized meeting exclusively with the parents to affect therapeutic change in the child. One clinician described how she approaches this modality with parents by stating, “Typically I will say, come in, tell me what's going on and let's see how far you might be able to get on your own with me as sort of a therapist consultant in the background.” In these models, clinicians were typically working with younger children below the age of five.

At this developmental stage, these clinicians found it more effective to work with the parents on behalf of the child until it became clear that the child’s problem appeared to be of a more internal nature or the work with the parents had not led to desired change in the presenting problem.

Some other clinicians working in early childhood also worked more closely with parents. Some of these clinicians conceptualized their treatment as either working dyadically with parent and child and peripherally with the parents in order to work on the

82 child’s developmental struggles as well as the parent-child relationship. One clinician stated, “I have done CPP (Child Parent Psychotherapy) work with families where you know I'm doing dyadic sessions or family sessions on a regular basis and also seeing parents individually on a regular basis.” In these cases, the clinician often focused on the parent-child relationship as the object of treatment as opposed to identifying the presenting problem as existing in the child or parents alone. Clinicians found this to be effective in working through many commonplace developmental struggles as well as in situations where there was a history or present experience of trauma in the family.

Finding 2: Parent Work Is Individualized on a Case-By-Case Basis It depends.

Most clinicians responded to the question of how they work with parents by saying “It depends.” One clinician noted, “The first thing I thought about in anticipation of this, I was thinking about the different parents that I've worked with in different ways and I thought, Wow! It depends.” What the answers depended on varied by each clinician, but generally involved an assessment of each particular case. One clinician said, “I guess it depends on the needs of the family. The age of the child, the issues of the parents, the issues with the child.” Another clinician remarked: So, it's different in every case. But I certainly start off with a heavy-duty kind of assessment with the parents. And then depending on what the situation is, it really depends on the case... It kind of, it depends.

83 Another clinician noted: “It depends on the parent and the kid. So, how I feel about where the kid is and what that kid needs also will sort of determine how much I interact with the parent and what the parents need.”

Clinicians emphasized that each case is unique and that each individual in the case has particular needs to be understood and addressed in developing a therapeutic approach. All clinicians in the sample expressed a need to be flexible, responsive and to root one’s therapeutic approach in the specific needs of the case. One clinician noted, “So I have to decide. I can’t always decide one size fits all.” Another stated, “I do tend to draw what seems to me clinically useful case by case.”

While all clinicians in the sample had a preferred or generalized method of conducting treatment, most spoke against conducting treatments in a manualized fashion and underlined the need to take a flexible approach to working with children and parents. One clinician remarked, “I don't have a manual. I have an idea.” Another clinician said, “I like CPP because it's not manualized. It's very flexible. It's really more in some ways it's more a set of principles than a model.” Some clinicians expressed their critical feelings of individuals providing exclusively manualized therapies. One said, “So that's another issue. People offer these like instant soup mix, I call it.” Another clinician bemusedly expressed, “Some of them come from agencies where it just seems like they're in the dark ages. Or they're all doing manual therapy. I mean essentially they are one size fits all.” One clinician positioned the manualized therapies in contrast to psychoanalysis: And this because I'm a psychoanalyst and so I like to look at psychoanalysis through the lens of parents and children. You know in some ways it's getting

84 replaced a lot by, again, manualized approaches, problem solving approaches. Fix it sooner. We can't afford this, insurance won't pay.

All criticisms of manualized therapy were appended by comments about their usefulness in some cases. For example, one clinician stated, “the adjunctive therapies I mean the ACT's and the CBT's and DBT's are really useful.” Another clinician remarked, “I just think there's a place for cognitive behavioral therapy… Same with DBT and now there’s something called ACT.” Many clinicians noted that the age of the child was an influential factor informing their decisions related to parental involvement. One clinician remarked, “Well it sort of depends on the age of the child.” Another echoed the sentiment, “Ok. So, it depends on the age of the child.” Within the sample, those clinicians that worked with children under 5 years old all worked regularly and at times exclusively with parents. Some clinicians cited models of treatment that encouraged this practice: Treatment by Way of the Parent and Child Parent Psychotherapy.

Initial assessment.

All clinicians in the sample expressed needing to take a flexible approach toward parents. This flexibility and individualization of treatment often surfaces at the very beginning of a case. Except for a couple of clinicians, it was not given that therapists would meet with parents before meeting with a child. It was strongly preferred and sought by most clinicians except in cases where there was a rationale not to based on the child’s developmental level or some other dynamic in the family.

85 Clinicians generally had two basic approaches to gaining a sense of the situation in the family and the nature of the child’s difficulties. Some clinicians had thorough and specific areas to explore with the parents about their child, themselves, and the family.

Other clinicians had no preset agenda to bring to the initial encounter but rather allowed the inquiry to unfold organically according to what the parents presented in the initial encounters. One clinician captured the general approach most clinicians take to the beginning of the clinical interview: I usually open it up at the beginning.... tell me how I can be helpful. I try to get them to sort of enunciate why they've come, what they're struggling with and then, depending on how the parents tell their stories, sometimes I need to do more and sometimes I need to do less. All the other information sort of trickles down. I also listen very carefully to who they've seen before.

One clinician simply stated, “I’ll meet with the parents before I see the child. And I’ll listen to them tell me what the presenting problems are.” Another remarked: I tend to be more organic about it. I don't ask specific questions really about anything in an intake. I know some people have a questionnaire that they use. Ask people to fill out a history or something like that. I ask people to tell me what their life has been like with this child that they're coming about and how they see the child.

Many clinicians identified a range of areas they assess during an intake session or the introductory period with parents. Many of the areas assessed by each clinician was similar, but there were nuanced differences in how each person described what they were assessing and how this connect with their treatment approach. Clinicians also typically

86 expressed how long they would spend with parents during the beginning of treatment.

One clinician emphasized considering the parents’ relational dynamics and histories in addition to information about the child in his initial assessment: I do a pretty thorough assessment upfront. I'll have the parents come in for one or two sessions without the child just to kind of see them together, how they interact, get a really complete history of their background, their family of origin, their developmental stuff, how their marriage is, what the family's like and then a lot about the child that they want to bring to me.

Another clinician described beginning with the presenting problem and tailoring her follow-up inquiries related to things that might be relevant. She also described various considerations she generally makes about the parents’ experience of their families of origin, ways they were parented. Additionally, she highlights assessing for attachment related information about the pregnancy and history of the marriage. She stated: I get a very complete developmental history. It could take two or three sessions with the parents. I look at the history of the problem. Obviously when the child is in a program, if they're in a program, history of any therapy they've had. I don't have a specific format for that. I let that take me where I think it needs to go. And in that time, I try to tailor it. So, if there is a so-called discipline management problem, it always comes out in the treatment how their parents disciplined and what was their style of teaching their children to cooperate, etc. Sometimes, we talk about in the early stages of the treatment whether I feel there might be some other testing required that I would determine that because I don't want to take people by surprise. I try to get a little bit of history from the parents about whether

87 they've had treatment and how is the marriage. In the last few years I've been asking about very specific questions about whether it was a planned pregnancy.

Was there any fertility treatment?... I feel that that's an important piece in terms of attachment. I ask a lot about, how did you feel when you were pregnant? Both partners…. I try to get a marital history. I always start that way and if I feel like I don't have enough information I say I need another consultation.... Sometimes I do a genogram also. And in that genogram, I let them talk about what was your parents’ style of teaching you right from wrong. I always ask if they've had their own treatment and how did they find it. What was it focused around? And if I feel that they need their own treatment, I recommend it.

One clinician described the method of incorporating a screening procedure from the Child Parent Psychotherapy method. Within this model, she noted the explicit and thorough evaluation of the parent’s trauma history and how she uses the inquiry to educate parents about their reactions to their child’s behavior and safety. She stated: They (CPP) definitely recommend explicitly screening for caregiver trauma history and specifically there's a particular tool they recommend, the life stressor checklist which is pretty comprehensive. Obviously, in order to administer that checklist you have to have a conversation with the parent about why you think it's important to know about their trauma history to help their child or address whatever they're presenting concerns are for the child or family work. And that in itself can be a really powerful intervention. To talk to parents about when your child does experience something really upsetting or frightening or that's put their safety at risk that as a parent you have your own strong feelings about that. And if

88 you've had similar experiences or other experiences of having your safety threatened that feelings and memories and responses from your own experience can come off and it's really helpful for me to know that and for us to be able to think about it together as we're working with your child. So, therefore I'm going to ask you this really long list of questions about bad things that may have happened to you. I've found that to be really powerful intervention‌ It's just this long list of possible traumatic experiences and it's basically yes or no have you ever experienced it. And then for anything that's a yes, how old were you and then there's Likert scales for how much it impacted you at the time and how much it impacted you during the last year.

Another clinician described her 90-minute format for interviewing parents in which she begins with a typical assessment of the presenting problem and relevant history and moves into an in-depth inquiry into the family history over multiple generations. She described: I always do a very expansive family history when I do an intake... I don't have people fill out forms. I do a 90 minute parent intake that over the last 20 years I've developed so that I get the traditional information, if you follow it in a medical format with what we got trained as psychiatrists, with a history of present illness and then past psychiatric history and the meds and the medical history and that kind of thing. And then developmental history. I then typically, by the end of that first 45 minutes, I then can spend 45 minutes on family history and I do an extensive genogram. I do one parent at a time although the other parent often jumps in with commentary and I try to flush out, and usually by that point

89 people's defenses are a little softer, and so I'm able to really listen and evoke sort of what things were like growing up and what the siblings were like and what the parents were like and what the marriage was like and what the grandparents were like and the aunts and uncles and cousins. And then being able to get things like suicides and psych hospitalizations and who's on meds and who may just look pretty crazy and never been diagnosed. Who's had learning disabilities and who's just always been socially off and things like that without using a lot of jargon. I go back three four generations and sometimes more if that's available and really get a sense of where this kid is centered and possible trans-generational components.

So that's often laid out in the first time I meet with parents.

One clinician described focusing on building a working relationship with the parents and being sensitive to what parents can tolerate while taking a developmental history. She stated: I try to take a thorough developmental history. I value of course each parent's individual perspective on the child and individual relationship each of the parents have with that child how they perceive the child's struggles and benefits you know strengths and capacities. And how that parent is reminded by the child of other people in their own families... So, I do try to think analytically with the parents in addition to with the child... Initially I try to at least get the parents in three, maybe four times before I ever see the child, if they can tolerate it, and try to get some developmental history, hear more about the parent's own experiences being a child, being a child this age, being a boy or being a girl or whatever seems to be

90 pertinent. And try to kind of front load the work and a working relationship with the parents initially as a kind of a treatment parameter.

Another clinician also described focusing on being able to develop a positive working relationship with the parents and gathering sufficient information about the situation in order to develop a sensible treatment plan. She notes informing parents that the initial meetings are partially designed to determine whether the parents and therapist are a good fit. She stated: I always meet with parents first and I might meet with the parents anywhere from one to even 20 times before I see the child. To determine what the issues are and make sure that parents are comfortable with me and that I have a sense of what's going on so that I can make a good treatment plan... I'm always listening for how psychologically minded they are. What kind of empathy and understanding they have of their child. I'm trying to evaluate where they are in their own development, where they are emotionally, right. Have the parents been in treatment before? Are there marital issues? ‌ And then I'm assessing the child's developmental course. Siblings, extended family, history of mental illness, substance abuse. Depending on the age, how separations and transitions go, what's been happening at school. I feel like I'm kind of going back and forth between assessing is it more of an emotional issue, are there potential learning disabilities or difficulties. I think those first sessions are crucial in making an alliance with the parents. And you know the longer I've done this the more I feel comfortable and competent in assessing whether I feel like I can work with them.

I set it up that way. I say, this first meeting is to see whether we're a good fit or

91 not. In those first meetings with the parents, I'm also hopefully assessing their relationship. How do they talk to each other? Are they on the same page, are they fighting? Are they not agreeing on what the issues are?

Several clinicians specifically highlighted the importance of screening for whether one parent experienced trauma or some other problem at the same age of their child they are bringing for therapy. They observed that often repetitions can often be observed and that identifying this information can often be used in a therapeutically helpful manner with parents and diagnostically in contextualizing the child’s issue. One clinician stated: I always want to know at the point where a child is sent for service or help did the parents go through that particular time of their lives that their child is going through now. And is there something about that time of their lives that will offer us some insights as to whether they struggled and now he struggles. Sometimes you can see a repetition.

Another clinician noted: What are their concerns and then try to explore what was going on in their lives at the time of the age of their child or if their child has sickness or some trauma if anything like that ever happened to them.

Definition of the patient. “Well, I think it starts with how you define the patient.�

The clinicians in this study approach their work with parents according to who or what they see as the object of therapeutic intervention. The assessment process informs

92 each clinician’s decision in this regard. Some clinicians referred to this conceptualization as defining or deciding who the patient is. For example, one clinician remarked, “the model really has to do with how you define who is at the center of the case.” In many examples, this led to a discussion of modality by determining whether the therapeutic issue is to be addressed individually with the child, with the parents, with the parents and child together, on behalf of the child through the parents, or if multiple members of the family need some therapeutic intervention or support. One clinician described this and added the parents’ desires for a particular method to the consideration. She stated: And then there's a decision. Do they want to come individually? Do they want to come as parents or do they feel an urgency with their child and want the child to be seen? Do they want to be seen in addition? So, there are all those modality choices to make.

A few clinicians added an advisement that in all cases it is useful to view the parents and the parent-child relationship as the patient. For these clinicians, it was not to say that they were not open to various methods of working with a child or family, but that they approach child consultations from a place of viewing both the child and the parents as the patient. One clinician stated: The best thing I learned about working with parents…was from Diana Siskind's book which I think is called Working with Parents.... And in that book, she talks about the parents being the patient… Well, it's very tempting to think that you can make an alliance with a parent as a partner and we together are going to help your kids. Probably the most important thing is to keep in mind that they are just as

93 much the patient as their child. And that empathy to the parents is extremely important.

Another clinician noted, “So, to me the family is the patient even if we have to differentiate each of the individuals. And you’re dealing with at least two generations sometimes three.” Another clinician emphasized the critical importance of the parentchild relationship and the need to consider both parents and child as the patient. She stated: The client isn't the child or the parent, it's the child-parent relationship. That feels really meaningful to me and often true... So much of kids’ development and mental health and everything is so tied to that relationship with a primary caregiver or caregivers that I just think that considering that as a really essential part of treatment and then thinking about what does that mean or what does that look like, how do we work with that. If it's not individual treatment for the parent, maybe especially if it's a parent who I think could benefit from individual treatment. But either that's not happening at all or it's not happening with me.

Several clinicians focused upon improving the parent child relationship as an area of focus in child treatment and discerning whether this is the primary problem or an adjunct to the child’s or parents’ difficulties. Some clinicians expressed a need to attend to both in whichever method of treatment is employed. One clinician said, “So now I think of my role as helping the child have a better relationship with the parent and the parent have a better relationship with the child.” Another noted, “Our work together is in service of supporting the children and supporting the parents’ relationships with the children.” One clinician highlights the level of conflict in a parent-child relationship as

94 influential in her approach: “I think it kind of depends on how much conflict there is between the patient and the parents. How much somebody needs to be trying to help them deal with that.�

One clinician described some situations that would direct her attention to the parent-child relationship and seeing the parent/child together as opposed to an individual treatment for the child. She stated: So sometimes it has to do with the child not being in a place where they feel comfortable or safe being separate from a parent. So, it's almost like that's the only way the treatment is going to go. And that the goal is to help the kid be more secure. Other times it's because the relationship between the parent and the child is so problematic. So that's another place. And then sometimes I do it because the parents can't tolerate having it be separate. So, I think I feel pretty comfortable being flexible with that.

Other clinicians also expressed a flexibility of modality in their treatments. They expressed an openness and flexibility in terms of who is seen in an effort to ameliorate what they see as the presenting problem at a given point in time. One clinician stated: It's everything. Yeah, it's doing it with the parent it's doing it without. It's not either/or. There are all these ways that if there's trust established all this stuff might go in one ear and out the other, but what this kid is feeling is recognized, and that I am making a lot of effort to engage both the parents. I've even had sessions with the boyfriend and the kid when they were together. So, it's all over the map with the long-term goal being how is this kid going to be able to feel better recognized, calmer, and that the grown-ups in her life really want what's

95 best for her. And it's not perfect. It's never going to be close, but is this kid going to have good self-esteem? This kid at some point she might say I don't want my mother here. Or I'll say you know what let's stop for a while. I have felt as the therapist it's been extremely productive.

Another clinician stated more generally: And then depending on, it really depends on the case. I don't know if this is not a helpful answer. It, kind of, it depends. But depending on what the situation is, I'll do family stuff, I'll have siblings come in. I mean every case is different. Once I get a sense in the beginning.

One clinician expressed his flexibility in considering what needs to happen in treatment according to the nature of working through disruptions in primary relationships. He stated: It's the re-doing of a primary relationship. Wherever they come in, it's an opportunity to redo something...Or maybe it's a doing something, maybe it's doing something that never happened before. You're getting them... and figuring out what's needed and it's very flexible I think‌ and we can be very responsive to what the need is.

Despite expressing a flexibility in the frame of treatment, many clinicians noted boundaries of their therapeutic focus and contact with parents. One clinician stated: So, for me parent work is integrative. It's useful but it's also challenging because the idea is not to get confused with marital work and parent work. And to know the difference so that you don't lose parents because you start interfering with their marital dynamics which they're not coming about directly. But a good parent

96 bit of work. Whether it's meeting with them once a month or integrating family sessions with child sessions however you go about deciding about who the patient is so to speak.

Another clinician described referring a parent who requested couples’ treatment from her child’s therapist to another therapist. She stated, “One thing I did recommend that she came to me for... she wanted to come see me with her boyfriend for couples work and I said no. I said no but I recommended someone else.”

One clinician described a couple cases in which he was working with the parents on marital or livelihood concerns in the couple and recognized that there were problems for their children that were being questionably addressed. He spoke to the limitation of his focus in these cases: And so, I never had the opportunity and I didn't push because I wasn't really treating the daughter. But I really felt like, I don't know that the daughter was well served by the steps that they took and the way that they did it. That was kind of tough. I would hear updates from the parents now and again. That wasn't my focus with them or goal.

Regarding a different case, he stated: Yeah, and their marriage in general. I think I kind of worked into the larger family piece and the kids because I had seen the son in the past and I knew he was really hurting. And so, they were they came really for their marriage and their relationship, but they also knew they needed to work on things in the home. And then there was just this sort of the livelihood piece.

97 Many clinicians emphasized the approach of working with parents was characterized by being on behalf of the child. One clinician stated: Well one of the things that was again a very clear part of the model was that we were working with the parent on behalf of the child. And if it became clear that the parent needed or wanted his or her own therapy, the therapist of a child would work with that parent to try to find a referral that would work. So that's when we would refer the parent, but we would not discontinue the work on behalf of the child. Those two things would go on simultaneously.

Several clinicians described situations in which the clinician did more involved therapeutic interventions with both a parent and a child. In all of these cases, clinicians attempted to refer the individual parent to another clinician and explained their rationale for providing individual work for the parent alongside the child. One clinician described one such case: I mean on a couple of occasions the parent had trouble separating and I found that I needed to just sort of be all things to all people. And so, like in one situation, I can recall the mother was pretty unstable and I made several attempts to get her into treatment. Money wasn't an issue or time or any of that, but she just had very deep separation issues and so I saw her every week and I saw her son once a week. So, I saw the mother every week and when the mother was going through a breakup or a very unstable period, I would see her twice a week instead of just once. There were three children. I got both of the other siblings into treatment of their own as well and I just ended up seeing her myself. She just sort of wouldn't see someone else.

98 Another clinician noted: Right now, I have two situations where I'm doing the parent and youth. And that goes against my basic training, but I can't find any way around it. And there's nobody at this stage of the relationship with the family that I could send them out to and that and I don't think they'd accept it. So, I think I’m kind of shifting on that now. I'm not so rigid about the frame.

One rationale that emerged for a single clinician providing multiple forms of treatment was working in an area with limited resources. One clinician said, “You know but also the town you live in and the resources you have. You do what you can.� Another noted this as a reality in some of her experience, but also emphasized that in some cases, the multiple modality approach was preferable. She stated: When I have been doing... trauma work and for different reasons in different settings I have done work with families where you know I'm doing dyadic sessions or family sessions on a regular basis and also seeing parents individually on a regular basis as a combination between working in communities where there's literally nowhere else for the parent to go for individual treatment and then actually also sometimes thinking that it is going to be that both modalities might be more powerful if they're with the same person in the same relationship.

There were several cases in which clinicians described working with different members of the family at different times or transitioning from one modality or another at a point in the treatment. One clinician described: So, actually this woman and her mom came to see me to do some mother daughter work years ago. And the daughter decided to come and see me after that with her

99 husband. So, I'm seeing the husband and wife and the wife's the daughter, if that makes sense.

Another clinician described coming to the realization with a mother she had been treating individually of the desirability for a change in modality: The mother looks at me and says I think I think you need to see him instead of me. And I said to her I just had the same thought. I said I really want to think about this with you. And so, it took about three months for us to figure out what needed to be done and how to do it.

She described the complexity of making the transition and the nature of the ongoing work with the mother and child. She said: Yeah, I saw her. She came in on another day by herself. And that was for about that first year and then as the couple’s therapy took hold, she was able to allow us to do our parent work about once a month because she was still in the office with me on the playroom floor three times a week. She still had access to me, but it wasn't as explicit because we were dealing with both the play and a lot of the unconscious phenomena going on in him as well as the interaction with her. I felt very much pulled in so many directions. It was very complicated. It was very complicated and I talk a lot about this with (my consultant) because there are still reverberations of her sacrificing herself for her child.

Some clinicians spoke to some of the issues that arise when a single therapist works with multiple members of the family. One clinician shared: I've never done it so I can't speak from experience about it but I guess I've never done it because I would think that it would be too hard for me as a therapist to

100 maintain those boundaries and do justice to either patient. And I don't think patients like sharing their therapist with somebody in their family. I think it feels like just a funny boundary. I know some therapists will see siblings and I typically do not do that either for the same reason. There are situations where it's unavoidable. Maybe indicated. But those would be the pitfalls in my mind.

Another clinician shared her definitive view of working exclusively with the child: So, my focus is absolutely on the child. And so typically if I meet with parents, then it really is completely focused on the child. So, if I feel like we are not doing that or that's not possible then I would refer them for individual treatment if they're not already in individual.

Clinicians who work with young children tended to work on affecting both the child and the parent-child relationship, which included aspects of the parent’s parenting.

One clinician described her approach: With the parents specifically my goals, I feel like sort of a translator to sort of help parents understand from a child's point of view and from my perceptions of working with the child both specifically and developmentally, what the child's emotional life may be like, what challenges they may be facing, what anxieties may be going on, understand the relational piece, their parenting style, and how that may be contributing to the problem or working well for the problem. And my underlying goal especially with three-year-olds and up is to help the parent understand that their goal is to help the child develop their own locus of control so that they're not screaming and yelling and bossing their child around all the time.

And I have various techniques with which I do that, and I try to model. I often

101 have dyadic therapy sessions. I call for it or I can ask the child or parent if they want it. And in there I try to model some of the ways in which I interact with the child.

Some clinicians working with young children were largely inclined to work with the parents first and at times in lieu of working directly with the child. One clinician described her approach to beginning a case regarding a young child by saying: So if someone's calling me about a preschooler, I typically will say, come in, tell me what's going on and let's see how far you might be able to get on your own with me as sort of a therapist consultant in the background. And many times, I find that parents are so relieved to hear me say that that they're reluctant and cautious about bringing up a very young child in for individual therapy. There are situations where I think it's indicated, and we work toward it. But I always try to begin with the parents talking and trying to understand their child because they know a lot more than I do. I'm a stranger. I just think it's better all around and you don't want to interfere with the relationship between a parent and child because as you know the intensity of a relationship with a therapist takes up emotional space.

And I think that's sort of counter developmental with young children.

Another clinician provided a theoretical rationale for providing treatment via the parents of young children in a therapeutic nursery school as opposed to working directly with the child. He stated: The model of the school was called a treatment by way of the parent model. So, it was based on a recognition that until about the age of five or six, what Freud called infantile amnesia had not yet set in. So, repression had not occurred. And

102 so for these preschool-aged children, it was very sensible to work on behalf of them through their parents. So, we would meet with the parents once a week and we would observe in a school once a week to see the child in that setting and we would also meet with the teachers once a week so we get a real in-depth overview from the teachers as to what her perceptions were.

There were a few examples of clinicians feeling that the focus of the work should be with the parents and this assessment conflicted with the parents’ desires. Frequently, this situation was closely associated with treatments that did not continue. One clinician remarked: My hope is that the parents will come as long as they can tolerate before I see the kid. That's my hope. I've had cases that have not worked out I think in some ways because of that... In one case, the boy was five. After meeting with the parents, it was clear that this was either a family case or me working with the parents. They wanted me to see the boy alone. It was clear it was either a family case or me talking to the parents. And I was not really willing to see the kid alone.

In this particular case, the parents were unreceptive to working alone with the therapist and terminated treatment. Another clinician explained what sometimes occurred in cases where a parent is not in alignment with the therapist in supporting the treatment. He stated: Sure, the model is the ideal but there were always exceptions to what was going to work and those would be cases where the case might just not go and something might would inevitably cause it to fall apart. Sometimes one would try to work with one parent. So, you could try to work with the parent who is a little less

103 conflicted to try to support the work. And sometimes that might help get through a rough spot. But sometimes a case would just need to come to an end. And the only thing we could hope for was that maybe there had been a good enough experience so that over time they might return the child when he got older might come back and seek some treatment. And sometimes that would happen.

In other instances, clinicians described their method of adapting to the parents’ desires and finding a way to encourage further parental work in the course of a treatment.

One clinician stated: So, start where they are. Which, that’s a good idea. They’re the ones coming in.

And you know then if the child does have issues and the parents refuse to come you could always see the child and then hope that over time, you know you could say, I have said I’d like to meet with you once a month to talk about how things are going. Sometimes parents become more available.

Another clinician remarked about a parent’s disinterest in meeting with the therapist by saying: I wouldn’t just take it at face value… if they said I don’t think I need to come, I would try to think that through with them and I would say, well, ok, maybe we’ll try that. We’ll see how it goes.”

Finding 3: Parent Work Is Rooted in a Developmental Framework “So, I don't think there's a recipe book on how to deal with parents but I do think that having a developmental framework helps. You have to keep everybody's developmental framework in mind.”

104 All clinicians in this study expressed a developmental orientation to case conceptualization and used this to inform how they involved parents in the child’s treatment. Clinicians found it important to consider both the child’s developmental stage and history as well as the parents’ developmental status and history. This developmental information, in varying degrees, led to distinct forms of intervention in the cases each clinician described. A common statement regarding how clinicians work with parents was “It depends on the age of the child.” In general, this meant that clinicians tended to establish more frequent parent work with children in younger developmental stages.

Parental involvement did not cease in advancing stages of development, but the nature of the work changed and the manner in which parents were involved in treatment became increasingly less circumscribed. Clinicians working in earlier developmental stages emphasized the need for regular parental involvement. Clinicians working with latency age children placed a lot of emphasis on the importance of play and talking with parents about the meaning of play. Separation phenomenon was a highly influential theme in a variety of cases throughout child development and complex cases but had routine relevance during the adolescent period. Several clinicians described the importance of assessing and conceptualizing parental development in concert with working with children. Additionally, there were cases of atypical development often described by clinicians in the sample. These cases relied less on chronological age or developmental stage than on the psychological nature of the child or the family dynamics that were involved in the child’s experience.

105 Increased parental involvement at earlier developmental stages.

“Ok. So it depends on the age of the child.”

A majority of the clinicians in the sample worked with a range of children from early childhood through adolescence. A few clinicians worked more extensively and at times exclusively with young children and a few clinicians only worked with adolescents.

All the clinicians that worked extensively with children under seven viewed parent work as an assumed aspect of their practice with children. Many clinicians described their practice of meeting with parents first in early childhood cases. One clinician stated, “they wanted to meet me first which I do with young children but also who are on the border of young adolescent. So, I'll see the parents first.” Another clinician echoed a similar sentiment: And again, it was just par for the course that parent work was just how we all carried our cases. With regular weekly parent work to start out even with early adolescent kids and then just depending on the situation it might go to every other week and slow down to once a month if things were just going along and it didn't seem as necessary but often that was after a couple of years worth of work before.

One early childhood clinician stated: So, in my initial consultation with the parent I always even on the telephone say you will be a participant in this treatment. And at the beginning I will probably see you at least twice a month. I always start consulting with the parents without seeing the child and I explain to them that I don't want to get the child involved until and unless I understand what's going on and they feel comfortable with me and having their child in treatment with me.

106 Another clinician stated, “Well, you have to have them come in because they need to meet with you.... I would always start by meeting with the mom and dad first.”

The rationale for why early childhood clinicians assumed parental involvement was not always explicitly stated as it was so matter of fact in their experience. However, clinicians working with young children described some elements of child development and clinical aims that demonstrated some of the ideas influencing this orientation. Some clinicians noted that at times the child’s problem was not considered to be wholly internalized or within the realm of their personal psychology entirely. Further, they described the nature of the child’s dependence upon the primary caregivers and how this impacts their therapy. In many cases of children under five-seven years old, clinicians tended to consider the focus of the therapeutic intervention to be on helping the parent to assist the child’s developmental progression and psychological formation. One clinician stated, “My underlying goal, especially with three-year-olds and up, is to help the parent understand that their goal is to help the child develop their own locus of control.” Another clinician described a cusp in child development that provided a rationale for working more extensively with parents as opposed to the child alone: The model... was called a treatment by way of the parent model. So, it was based on a recognition that until about the age of five or six what Freud called infantile amnesia had not yet set in. So, repression had not occurred. And so, for these preschool aged children it was very sensible to work on behalf of them through their parents.

He explained further the complexity of transference in young children: When we think of transference in a child, we’re thinking of something really very

107 different because the child is still living with his parents. So while there might be some sense of transference, especially about the child trying to transfer something that has to do with the relationship with the early parent during the child’s prerepression years, maybe that’s the part that’s coming through in an unconscious way in an analysis at the very same time the child has a real relationship with real parents. And so, one of the concepts that was more readily talked about in our work was the idea that a therapist was not just a transference object, but also a developmental object.

Several clinicians remarked on the importance of the disparity of time the child spent with the therapist than with the parents as a noteworthy rationale for enlisting parental involvement in the therapeutic endeavor. One clinician stated, “I feel like the parents are so important, I’ve got the kid one hour a week, maybe two if I’m lucky and the parents have all that extra time.” Another clinician said, “You spend much more time with your child. You have a much bigger influence on your child than I do.” One clinician added the greater importance of the time discrepancy between time spent with the clinician than with the parents had to do with a young child’s sense of time differing from that of an adult. She stated, “For one of my five-year-olds, not meeting three days for him, three days is worth a month to me.”

Clinicians also acknowledged that they would only be working therapeutically with the child for a period of time and found it necessary to bolster the parent or the parent-child relationship to be a continuing resource for the child. One clinician stated: I try to help them understand that I think their role in the child’s work is just as important and to convey to them of course that they have a lifelong relationship

108 with the child. Not me. I’m here to help as much as I can for as long as I’m needed but they are the ones à la Novicks that have a lifelong positive relationship over time.

Another clinician explained her rationale for focusing extensively on the parents rather than focus exclusively on the child. She stated: If it’s possible, if there’s an available caregiver who has the capacity to support the child or who can be supported to develop the capacity to help the child, that’s going to be so much more beneficial than just the therapist helping the child in isolation for an hour a week as opposed to strengthening that primary attachment relationship and making that the resource for the child.

In later stages of child development, particularly in adolescence, clinicians work with parents tended to vary more. One clinician noted, “I meet with both parents if they’re available to meet with and I feel like that’s very important. Not always with teenagers, but with younger kids.” Some clinicians mentioned the lack of parental involvement in adolescence. One said, “I have had adolescents where I see the parents very infrequently.” Another clinician described working with an adolescent population in a school setting by saying, “They were adolescents. It was difficult to bring a parent into a session with an adolescent.” One clinician described the modification she makes in her practice in order to protect adolescents from feeling that the parents and therapist are overly allied, and that confidentiality is a concern: If the child is over 13, I almost always meet with the child and the parents together not separate. Sometimes I do it differently, but definitely if they’re 14,15, 16, I won’t meet with the parents without meeting with the child with them.

109 Another clinician described the flexibility in her approach to working with parents during adolescence. She stated: With older kids, I may do a little bit of parent work before I have them bring the child in or I may do an evaluation‌ With adolescents, with some families, I work with the parents more frequently than I do with others. I think it kind of depends on I think how much conflict there is between the patient and the parents. How much somebody needs to be trying to help them deal with that. Other situations where a child is struggling and the parent can see that and appreciates that the child is suffering but it seems more an internal kind of thing, then I may stay in touch with the parents but not work with them as regularly. I think one of the things that comes up is who do you see first. Do you bring the parents in first or do you try to see the adolescent first? And my approach to that has been to kind of get a feel for what the parent feels would be the best approach because sometimes they say absolutely you should talk to him or her first, but not always.

Other clinicians also spoke to gauging whether to see the parents first in initial interactions. One clinician described: I usually don't see kids younger than about 12 and I always talk to their parents...

But I do also meet with parents first prior to my work with them. Usually, it's only once but sometimes I'll meet with them twice before I meet with the kids. Unless that kid is probably 16 or older in which case then I kind of listen to the parents to see what their preference would be. Sometimes they want to bring the kid right away. I usually really want to meet with the parent and not have the kid in my waiting room.

110 Another clinician stated: I usually, if they want their kid to come in, I’ll ask them to come in first.

Sometimes, they’ll just tell me stuff on the phone and I’ll just have a feeling it’s ok to see the kid and I’ll see them a few weeks later.

Another clinician described assessing how the adolescent would feel about the parents meeting with the therapist before the child: I say to the parents, will your child still find me kosher if I see you first? If they say no, they’ve got to meet you first, then I’ll say fine I’ll meet them first. But if not, I’ll see the parent.

The importance of play.

In child cases, play is a common element of therapy. Many clinicians in the sample emphasized the importance of play as a developmental achievement or goal as well as its clinical usefulness. They also described the manner in which they discussed or used play with the parents in child treatments. One clinician stated, “I think play therapy is a very valuable tool and I take a lot of time explaining to parents how it works.”

Another clinician described: Well it seems like another theme that we end up talking to parents a lot about is play and the usefulness of play, especially the age of the child but not always when we're talking about kids. But the notion of play and creative problem solving if you want to put it in another way, that that sort of stuff is really helpful and useful, developmentally appropriate and good to do.

111 Some clinicians noted many parents’ concerns about how play therapy works and expressed the need to communicate its method and value to parents. One clinician noted: For people who are just not familiar with it, I think just some basic education about play therapy and how it works and how the process goes. And when they see the toys, I think there's a lot of times that the parents will come into my office and it's clear that this is a good place for a kid. But, is it just playing? And it's hard for them, especially if they're not familiar with this world, they're not sophisticated about it to sort of imagine that it's not just playing with dolls for an hour hoping things get better. But that it's sort of strategic and this is the way kids communicate and to sort of educate them about play therapy so that they don't just think this is weird. To give them some concrete examples of things I've done with children and how it works. I'll give a little vignette or two. I think that helps parents to understand it's not just throwing a ball into the hoop. We're talking while we're doing it. I see the way the child deals with frustration when I make a basket and he can't make it and how he might fall apart over it versus the kid who really tries harder until he gets it. You just learn so much about the kid and even the family. So, I think some assessment of what they know about therapy. And even if they've been in therapy as adults, you know it's different with kids.

Another clinician stated similarly: Sometimes parents say well you're not just going to play with them are you?...

And so, the whole notion that play happens is sometimes news to parents... So I think the notion of play and the notion of parents as important developmental and emotional objects, from my perspective I think they're important. I think they're

112 emotionally important to the child, that this isn't about some expert coming in to fix their kid. I try to shift all those ideas if they come in with that. The notion of play and the notion of sort of collaborative work together that we have a relationship as well and all that stuff. So, I guess that's the only other thing I would add is the notion of play how useful it is, it's a lifelong developmental line in my opinion.

In general, the clinicians in the sample wholly embraced and expressed enthusiasm about play, playfulness and play therapy. But, one clinician expressed the need to keep a child and family’s needs in mind while engaging in play therapy in a manner that matched some parents’ skepticism about play therapy. She stated in regard to her training in graduate school: Things were kind of squishy and there was a lot of sort of non-directive play therapy and let's just be in the room and see what happens. Which in some ways is sort of what I think the work is all about but also being able to be really clear about what the families actually need.

Parental playfulness, capacity to play and engagement in play therapy were raised by several clinicians as important aspects of a child’s experience and the course of therapy. One clinician noted that many parents are not aware of the meaning and importance of their children’s play. She stated: It's surprising to me how oblivious parents are to their children's play. Oh yeah.

He was playing on the floor next to me while I was working for hours yesterday.

What was he thinking about what was going on? What was he doing? I don't know. Something over there with Legos… I mean that tells me a lot.

113 Another clinician described a case in which she attempted to engage a mother around play. She said: And when the kids were little, I said, Why don’t you come in, all the kids and we'll play. And the mom said, I don't do play‌. And I was like where's the fun?

She said I don't do fun. It's like come in and I'll set it up. I'll set the games, I'll set up the sand. And even when I said I'd set it up. She brought her own game with her.

One clinician described a case in which play was a critical aspect of the treatment.

She said: In that particular case the father had never really learned how to play. This is an immigrant family where...the emphasis has always been on achievements and with a certain level of... an element of survival and necessity and so play was I think not only not understood in the culture but his particular family. But, really not cherished. And so, toys were sort of given but the kids didn't know how to play with them. And this little boy who is developing his own symbolic function and emotional regulation and language as this was all coming through. We were doing it all through play. And at one point maybe a year into treatment the little boy took a truck filled with blocks that he had piled in there and tried to fit in with his engineering mind in the most efficient way and took it to the end of the room and said to me, you need to play with my dad, he needs you. Basically, the signal was he needs your help. I can play by myself. He doesn't even know how to do this. This child really used those sessions to engage the father to get his attention.

It took almost four months to get the father to put his phone down.

114 Clinicians particularly referenced a child’s use of play to master anxieties and work through aspects of their experience. One clinician said: And especially developmentally and how brains develop and the ability to understand things more complexly. I mean really understanding how play can be a very safe way to express fears...I think really understanding how important play and listening and containing are.

Another clinician described explaining to parents a child’s use of repetition in play as their attempt to master anxiety. She stated: So, I spend a lot of time talking about how a child tries to master anxiety and that's one way in which a child tries to master anxiety by repeating the behavior that scares them to see if they'll be a different outcome or to get control over it. I sometimes directly talk about the play to the parent and what I think that might mean.

Many clinicians in the sample referenced the environment of their office and the presence or lack of play materials. Some clinicians provided tours of their space, highlighting where the toys are kept and how they are incorporated into the treatment space. One clinician remarked: It's pretty active in my in my office. Like I said a lot of everything from puppets and stuffed animals and blocks and a doctor's kit so you can play doctor and crayons and paints and an easel where you can paint or use chalk and I have a gumball machine at the end of the session they can get a gumball if the parents are cool with it. Little cars and trucks. It's a pretty wide array of stuff for the little ones.

115 Some clinicians did not have overtly child-centric office spaces, which generally corresponded to their clientele. These clinicians typically worked with adolescents and parents more exclusively and the play materials were limited and kept out of view. One clinician described not being able to see children in her office due to the lack of space for materials to conduct play therapy. She stated: I don't have a large office in my home. And so, I don't see very young children in my home because I don't have room for the toys and all the games and things that generally people use when they're working with young children.

Some clinicians spoke to how a child therapy environment stimulated an adult patient. One clinician said: And interestingly he noticed all the toys and he said This is a very good place for me. He said it's ironic because I'm an adult. But I think I have some issues with my childhood.

Several clinicians provided vignettes about play scenarios in treatments and how these were used to convey aspects of the child’s experience to the parents. One clinician said: So sometimes in the sessions I have a chance to kind of show for mom how I'm really listening to this kid whether it's around playing a game and cheating and letting the kids cheat and feel good about winning rather than you have to play the game and the rules apply because Mom and Dad didn't play by the rules right.

One clinician created a series of playful exercises for parents participating in workshops designed to teach developmental emotional capacities related to early

116 childhood needs. One example she gave was related to learning how to appropriately mirror. She stated: I teach mirroring by injuring people first (laughs). So, I’ll have like five or six mirroring injuries. So, let’s say I’m going to do over-mirroring. So, then I’ll have one of the adults pretend to be a kid being excited or upset about something. So maybe they say oh mommy look at my painting it’s so cute and I go (gushingly) Oh my god, it’s so beautiful, it’s amazing... So, I’ll ask them what it felt like in their bodies when I over-mirrored them. People will talk about feeling contracted and wanting to pull away and so then I’ll mirror it accurately.

Another clinician described observing a colleague playing with a child and finding a means of engaging with a fearful child and using his play to draw out relational themes. He said: This boy was really into snakes or something. I don't know if he had seen some PBS thing and he said he had seen a spitting cobra and she made this really big snake out of Playdoh and he had made something that looked a little like an egg and she'd put the egg by the mommy and all of a sudden there were babies.

But it was so subtle. And when she asked him, I mean now it's so elementary, but when she asked him if he needed to save that, not just to play for the next day, but that she understood something about what he was trying to do. It wasn't completely clear what he was doing but there's a mommy taking care of babies and this mommy is kind of understanding you and it's totally about you and your fantasy about this and they keep taking care of babies. He's still a fierce spitting cobra but he's, you know, it was just amazing.

117 Another clinician described a method of a child engaging in a play scenario that helped him to learn that he was still in the other person’s mind while not in direct view.

He described: There was a kid who had attachment issues and they wound up getting this giant ball of thread or yarn and did this thing where they tied his arm to the kid's belt and the kid went out the door and up the stairs and into the parking lot with the strings still attached. There was like deep symbolic stuff with the string and pulling the string back. And it was like, not so verbal, but very powerful.

One clinician described his participation in play with a young girl and her family session. He explained: So, people will tell you things they've never told anybody else. I mean a fouryear-old told me in a family session you know you're like our best grandpa. Her grandfather died before she was born, and she never met her granddaddy. She had heard things. She says you're everyone's Grandpa. And she was in the dollhouse at that point, playing dollhouse. And she was distributing the family you know. And then we have this extra room in that little house. And then she put what was the older figure into the house. Then I got on my hands and knees and crawled over to the dolls, I usually tell people who are talking, I'll be right back. What I want to do is have their eyes follow me to the dollhouse. It's like children's art. Nobody fights over children's art or over a dream. So, I see she's put a figure into the extra room all by herself and I said well who could that be? Oh, it’s my dead Grandpa, he's buried in there, but I never got to see him. And so, I gotta see, well what's the

118 context now? What's stirring up? Is she afraid of death? Is she afraid of the parents will split up? Which is like a death.

Separation phenomena.

Themes of separation and individuation were discussed by many clinicians and were prevalent in the case examples they provided. These examples and the narrative surrounding them involved the typical developmental progression of an adolescent/young adult and situations in which there was an acute and ongoing problem of undifferentiation between a parent and child at any age. One clinician described her sense of the nature of the developmental transition in adolescence: I've always thought a lot about in adolescent development the need for some kind of separation. When I was trained it was kind of this linear thing where you move from you know Margaret Mahler's symbiosis to some sort of separation which happens when you're 20 or something. I don't think about it that way anymore. I think about some of these feminist writers talking about separation with connection. And I don't think we move to some place where we don't have our parents in us anymore or that that the relationship is no longer useful or important throughout life. It is, I think. But in adolescence something significant has to happen so that kids can leave. And I've seen kids who can't leave for lots of different reasons sometimes because things aren't okay at home sometimes because they don't think their parents want them to leave sometimes because they're frightened to leave. It's a huge thing.

119 Clinicians identified the need to convey this need to parents and to help parents understand the meaning of their adolescent’s behavior in this manner. One clinician remarked, “Maybe they need information about ordinary development. There’s a difference between stormy adolescence and pathology.” Another clinician said, “You have to recognize there’s a developmental piece. Even when a child says I hate you, it doesn’t always mean they just hate you.” One clinician explained the need for an adolescent to have some privacy in regard to their parents and how she conveys the importance of this to the parents. She stated: I think there has to be space for things to be secret from the parents. I think secrets are part of separation. Not dangerous secrets. But just this is my own mind and I can have this in my mind, and it doesn't have to be in my parents mind also. I think all of that is really important. So, giving them a space. So, I will speak to parents about it that way. I will say developmentally it's really important that it's normal for your adolescent to have secrets from you. I will never keep a secret that would endanger your child's life or well-being.

The case examples offered a portrayal of the complexity and enduring nature of separation dynamics as they manifest in an individual’s life, the therapy and subsequently on being a parent. Several clinicians described cases in which they worked with new parents, who demonstrated residual conflicts and enmeshment with one of their own parents. In each of these cases, clinicians tended to identify that greater intrapsychic separation was called for and portrayed how challenging, lengthy and sometimes urgent working toward this was. One clinician discussing working with a couple of a sevenmonth-old baby stated:

120 And in fact, with this couple, this lesbian couple who came in who absolutely are the most adorable charming people in the world, one of them has her own therapist and is desperately trying to separate from her parents, with whom she's terribly enmeshed… But we worked to the point where she did go and get a consultation because I think they’re bright. I think they were able to see right away what was going on. They came in for martial treatment, but having a sevenmonth-old baby, I said I feel this is urgent that we put as much effort into solving these problems as possible because you have an infant and I think that’s a priority.

One clinician detailed a case in which he had met with multiple constellations in the same family. His current patient is an adult woman, who he saw dyadically when she was an adolescent with her mother. He noted the extent of trauma in the dyad’s family history involving the Holocaust and separately a parent death. He explained that the dyadic therapy was highly conflictual. The woman returned to treatment when she became pregnant and concerned about becoming a mother herself. He observed that similar dynamics had persisted into her adulthood and that she continued to demonstrate a level of conflictual enmeshment with her mother. He described some of his thoughts about this case: And some of it, the daughter's just like almost abusive to her mother because of old angers and so the daughter, who can be pretty healthy when it comes to her own daughter and she's done a lot of work there, is still really locked in on like almost seeking revenge on her mother. She never really kind of individuated to the point where she can say yes there are some really painful things. I'm an adult

121 now. I am competent. I can take care of myself. She lets it affect her to the point where she knows she's having a really bad day with anxiety or depression and she'll say it's her mother's fault. She'll blame her mother. She'll take no responsibility for herself and so the paying for the therapy I think plays into this idea that I can't take care of myself and I shouldn't have to take care of myself.

The money is just like this one symbolic piece... But you could say that developmentally and clinically it would be better for the daughter, who can afford it, she and her husband can afford it.... to pay for her own therapy because it's a way of separating from the mom as opposed to every time the mom pays a therapy session, it's sort of like perpetuating this dynamic.

Another clinician described the case of a 14-year-old boy who was brought to treatment due to refusing to go to school. This was a situation in which the presenting problem was rooted in various other developmental dynamics in the family. She explained her assessment of the case: I actually think that it has something to do with terror of growing up because if I grow up I’ll become my dad and I’ll lose my mother. So, you know, it’s Oedipal but it’s also that the dad’s a particular king in this kingdom and this man is very repugnant. The boy says there’s nothing wrong with his relationship with either of his parents. So, that’s where he’s completely split off.... When I was in the room alone with his mother and father, I imagined myself being that boy, if I were him, I would want to go inside myself, too.

122 This child, she mentioned would not talk for periods during sessions. She presented additional information about what it was like to observe the boy with his mother: Well she's the one that takes him to school, or tries to, and when they're in the office together it's like a merger. So, he'll either tell his mother what to say or tell her to talk and talk for him. He'll stroke her arm like a baby stroking a mother's face during breastfeeding or something. And it's just wild because he's much taller than her and so it's kind of like you don't see this as odd? This is odd.

Another clinician described a case of a woman in her 20’s who the clinician had treated since the woman was in 8th grade. She described a history of the mother having an affair with a man she later married and asked the daughter to keep it secret from the father. As time progressed, the daughter struggled to launch into a life of her own. She described some sessions during the patient’s adolescence: My mother made me lie and she's a liar. My mother is a liar. You know she still says that kind of stuff. She's a little tamer now. But they came in several times screaming at each other. You're a little bitch. You know the mother would say something like that. The daughter would go right back at her with Fuck you, blah blah. I thought, How am I going to stop this? And sometimes you just sort of let it play out for a little while and then look for your way to kind of say something.

But they were really, they would go at each other. And mother would call up and complain about her to me and I would try to sort of slow it down and say, try to help her understand what her child was going through. That's a situation where the mother needed her own therapy but she wasn't getting it. And she wouldn’t do

123 it. She would just continue to fight with her daughter because she wanted to fight, you know the mother was in that too.

The situation continued into the child’s adulthood and the clinician continued to work toward promoting more separation in their relationship. She stated: Right, she still lives at home. And the mother, though actually, the mother is getting close. Her parents are getting close to retiring and moving out of state.

They have a place and the mother wants her to move with her and all this fighting is about how enmeshed they are. I know that that's their only way of sort of orchestrating some separation, but it doesn't work. You know it's like all or nothing. They're either hateful towards each other or they're living together. So, that's our that's my work with her as a young woman now.

Parenthood as a developmental phase.

Several clinicians described the nature of parenthood as a critical area for the therapist to bear in mind while working with parents. One clinician remarked: So, let me start by saying what theory underpins my thinking. And that is this idea of parenthood as a developmental phase. So, I think of the individual person and with their psychology their personality but that within that there is a parenting part. And it's sometimes the case that a pretty troubled person can do better as a mother or a father and vice versa. Some pretty well put together people in most ways can really run into difficulty with a particular kid or in a particular phase.

And so that's really helpful to me to make that distinction.

124 Another clinician further elaborated on what he saw as developmental aspects of the parental aspect of the parent. He described a method of assessing parents developed

by Erna Furman: Mrs. Furman embedded in this model how you would assess parents even as you assess the child. And so, it would look at things like how can you tell if the child or if the parent is in the phase of parenthood? The point being that they had to be able to at least reliably put the needs of their child ahead of their own needs...

Another thing that she would look for and we'd talk about was whether the parents had what she referred to as usable guilt. So that was another one of her concepts. Meaning that they just suffered if their child suffered and they wanted their child to have help. And then this in having kind of guilt would lead to the third thing which was they were able to be motivated to support the work. So, they would want their child to have a therapy and they would want their child to have analysis. They wouldn't just bring the child in and say you know I've had it with him, you fix him. Or they wouldn't come in for a parent guidance session of sorts and just want to almost turn it into their own therapy.

He later described the evolution of narcissistic and objective investments in the child on behalf of the parent: Positive narcissism. In fact, one of her points was that at in the first weeks after birth, a woman who had carried the baby within her still felt the baby now on the outside to be literally an extension of her own body. And it would be a gradual declining process of that feeling gradually subsiding but never really completely disappearing. And then conversely the ability to have an objective investment in

125 the child would gradually increase and the child could truly then be seen as someone with a mind of his own, a person in his own right. So, she would talk about this you know this crisscrossing kind of graph of narcissistic investment waning and an object investment waxing as the child grew. If it stayed too high, the narcissistic part, it was always competing with the parents’ ability to really see the child as a person in his own right. And that would then interfere with the success of the treatment.

Other clinicians spoke to similar themes in less theoretical language. One clinician remarked, I'm always listening for how psychologically minded they are. What kind of empathy and understanding they have of their child. I'm trying to evaluate where they are in their own development where they are emotionally, right.

Another clinician described a similar cusp in parental development and what makes a parent amenable to child guidance techniques or behavioral interventions. He stated: Now, let’s say you were trying to do a parent management training, if parents understood that or are able to execute it, they don’t need what we have to offer, maybe a little. That’s the feeling to me. If you can execute an actual behavior plan and that makes life easier, you’re done.

Another clinician noted the need for many parents to learn information about child development. She stated: I see myself as an advocate for the child primarily and as a translator as you do in couple therapy and also representing what the parent may not know about a child

126 and children's development because the average parent knows very little, in my opinion.

Clinicians also described the struggle parents face in general and to varying degrees. One clinician remarked on the intensity and ramifications of parents having a child: The fact that disruption of the marriage always starts with the birth of a child anyway. Marriages get destroyed by the birth of a child, but it's temporary in a marriage you see. I mean the fact is that you have to let people know having babies is a wonderful joyful disaster. To your sex life. A woman's body takes about a year to recover. Guys feel marginalized because the baby needs to get what it wants.

Other clinicians described the relentlessness of child-rearing, the urgency childhood demands present to the parents in an ongoing fashion and the vulnerability this can evoke in parents.

One clinician stated: It’s 24 hours a day and there’s no one who thinks you’re doing okay. Everyone thinks you’re an idiot for not knowing how to do it. I mean there’s so many people who it just works for them. So, I can only imagine for the parents that have unmet developmental needs as a child and you become a parent, that’s very difficult.

Another remarked, “Parenting or having children is so relentless, like they keep putting stuff in front of you no matter how you respond.” She went on to note:

127 I think when parenting or a parent-child relationship is part of the picture, I think for me as a therapist and sometimes for the parent as well, there’s an urgency that maybe isn’t there with every other issue because of the way that children’s development sort of marches on every moment of every day for better or for worse. So, it’s not like some other issues that we see in adults for where it’s kind of like, well, things are going to change when they change and you know it’s good to slow down and be patient.

The notion of child development marching on led another clinician to raise some parents’ questions in terms of identifying what was affected by therapy and what is attributable to development. She stated: How do we know improvement isn't happening just because of development versus something you're doing in the treatment? And so, parents talked a lot about that and how they navigated that with the therapist.

One clinician described the gulf that at times exists between therapists and parents. She said: Parents obviously are really focused on a lot of concrete, here and now things.

And so a lot of times parents would express frustration if the therapist was talking about more theoretical ideas or ideas about emotional development when their kid is in a crisis at school, even if those things were related. The parent sees their child suffering enough and that's the thing they're going to respond to.

The urgency of a child’s persistent needs of the parent often leads parents to feeling a commensurate level of distress in their efficacy as a parent, which often taxes parents’ emotional resources. Parents often consult therapists when they have exhausted

128 their own resources to respond to a child’s need or demand. At times, this frustration presents as motivation to seek and sustain therapeutic support. Most clinicians noted that a common presentation by parents in concert with their child’s therapy is a demand for a quick fix. In many instances, the request for a quick fix is related to the child’s observable behavior. One clinician said, “Most parents come to therapy because they want you to change their child’s behavior.” Another clinician stated, “So, I think as everybody knows parents often have a wish to drop their child off and have them fixed.”

Clinicians respond to this request and pressure in a variety of ways. One clinician noted: I met with both her parents she was about 10 and I could tell they wanted a quick fix. OK and I knew that in order to engage them I had to be able to offer them certain tools that they could feel comfortable with.

One clinician emphasized the need to help parents develop an understanding of the meaning of a child’s behavior: I think with parents and with people out in the world a lot of times the thing they're most concerned about is the observable behavior. As a psychoanalyst or psychodynamic therapist, I think what I'm trying to do is to help them understand that what's much more important is the intention behind that behavior. What is that behavior communicating? What is going on inside the child that gives rise to that behavior? Because that's way more important in helping the child than controlling or containing the behavior. And I'll use metaphors like if you have strep throat and you take a throat lozenge, you still have strep throat.

129 Another clinician expressed: I have a child now whose parents are both psychiatrists and believe it or not they want a quick fix. And I have to find what's broken. And he's not broken. He's a human. You don't fix humans. They're not structures. But maybe when you're a psychiatrist or a certain type of person who becomes a graduate you kind of think scientifically about this. So, my awful position for these folks is you can find people out there who will try to give you what you want. Me, I need time. I gotta get to know you and him or her.

Some clinicians spoke to the emotional challenge facing this demand can evoke in the therapist. One clinician noted: I know for just my own self-awareness and reflection, sort of monitoring my own sense of urgency is important because it can get to be too much. But I think some of that is sort of reality based and appropriate.

Another clinician described her efforts to shift a parent’s way of viewing a child and the therapeutic process: But getting the father engaged, getting the father interested in play, getting the father interested in this little boy and not just in fixing him but in the development of his mind was incredibly hard work on my part. I again I had to really have a lot of patience. And the father's come some way. But there's a density to him.

Some clinicians expressed an awareness of how long therapy takes and that this can be a source of frustration for parents. One clinician remarked: I'll try to talk to the parent when I have the opportunity to do so. About what they might have hoped for and expected by calling me with that, that they might really

130 just wish that I could make everything get fixed or be mad at me that I haven't fixed that yet. That's something we need to talk about, their frustration at the slowness of therapy with children. It's something that I think all parents feel at one time or another.

Many clinicians frequently referenced parents experience of their own parents as an influential aspect of parenthood and an area of relevance in understanding a case. One clinician noted that a common aim guiding many parents is “I’ll never do to my kids what my parents did to me.” Another clinician said, “many parents say I don’t want to discipline my child the way I was and then they go to the opposite extreme and become very permissive.” Several clinicians probed for information about the parents’ experience of their parents in their initial assessments and ongoing work with the parents. For example, one clinician stated, “I try to get some developmental history, you know hear more about the parents’ own experiences being a child, being a child this age.” Another clinician remarked: So, if there is a so-called discipline management problem, it always comes out in the treatment, how their parents disciplined and what was their style of teaching their children to cooperate...What was your parents’ style of teaching you right from wrong?

Another clinician agreed that such information tends to emerge in the course of a treatment. She stated: Sometimes, it comes spontaneously what their parents were like or what they feel like they were like as a child and how this kid is similar or dissimilar. And then I think it comes out of the ongoing work that you begin to get a sense over time

131 about what their parents’ parenting styles were like and what their experiences were.

Another clinician expanded the scope of her inquiry to other significant relationships in the immediate family: So, I’m able to really listen and evoke what things were like growing up and what the siblings were like and what the parents were like and what the marriage was like and what the grandparents were like and the aunts and uncles and cousins.

Some clinicians spoke generally about parallels between a parent’s ability to provide for their children things that were not provided for them. One clinician noted, “I’ve got a few individuals that I’ve worked with who have a lot of anxiety about their parenting and usually they’ve been poorly parented.” Another clinician stated, “Most parents weren’t mirrored. So, they don’t know how to mirror.” This clinician identified moments of conflict, deficit or historically unmet needs as tender spots and would use this language to talk with parents about such dynamics.

Often, in describing a case example, clinicians made links with some aspect of the presenting problem and the parents’ history or childhood experience. In one case, a clinician described a historically informed dynamic between a set of parents, which routinely led to problems in the family’s daily life. She described: Right away I could see that they had competing themes. She complained, he would come home from work. She’d be in the house and the three kids would be doing their homework, there would be snacks. He’d walk in and start yelling at everybody because it was such a mess. And she was someone who didn’t get taken care of as a kid, so she was trying to provide everything for her kids. So,

132 they would have this fight every day practically. I helped him identify that he grew up in all this chaos, there was so much chaos and he was so distressed in the chaos and that was the tender spot. So that when he walked in and he saw everything, he’d fragment and start yelling.

Several clinicians in the sample had worked with multiple generations in a single family over the course of decades and thus were in a privileged position to track certain repeated themes and dynamics as they continued to emerge in subsequent generations.

These cases were not limited to general interpersonal style or psychological functioning, but also had the added dimension of the presence of trauma at some point in the family history. Clinicians occasionally remarked on how the trauma exacerbated an existing dynamic or deficit. At other times, clinicians simply noted the occurrence of the trauma and its residual effects.

In one case, a clinician had worked with a mother and daughter dyad during the child’s adolescence. The mother was the child of Holocaust survivors and later her husband died when the daughter was a young child. The daughter returned to treatment with the clinician later in life when she became pregnant in order to work on her pressing anxiety about “being a mother and especially being a mother to a daughter.” He described what this daughter’s mother faced in her own life: She lost her husband when she had a four-year-old and a one-year-old. She was limited, very limited by having these really traumatized parents and so she got it on that end. And then her husband dies and she wasn’t prepared to do that on her own. So, just tough, really tough.

133 In this case, the clinician provided support for multiple members of the family in an ongoing way, but largely focused his efforts on preparing the daughter to become a mother and work through areas of anxiety and conflict around being a mother.

Another clinician described the context and development of another pregnant young woman in a similar manner. This clinician had also worked with the woman when she was a child. Her father was a single father. She tracked various themes of repetition between the father and daughter’s development. He had also been raised by a single parent in his childhood after his father left. Both father and daughter were very bright and high achieving in school but became involved with a delinquent crowd and became pregnant with unsuitable partners who did not remain involved. The daughter’s mother died of a drug/alcohol related incident. The father of the baby is also involved with drugs/alcohol and does not have custody rights to the child. The father sought treatment for the daughter when she was pregnant because he wanted her to have an abortion, but the daughter had every intention of keeping the baby. The clinician described her treatment with the daughter: The work with her was on what kind of parent are you going to be. Also understanding really where her father was coming from and his hardships and why he wanted her to have an abortion… Parenting and making choices about what’s appropriate for your child and also saying what she valued in her parenting from her father which I was well aware of but I was also aware of his struggles and she doesn’t know them specifically, but I wouldn’t raise that. And then we were talking a lot about separation. She’s in her thirties and dependency and all that... So, the baby’s developing very well, and we worked a lot on developing

134 boundaries with the baby’s father, getting him out of the household, stopping enabling him, which was a very big issue with her father and the mother of this woman. So, you get to see the repeated patterns.

Another clinician described a case in which a mother had brought her child to treatment at an age in which a trauma happened in her own development. She stated: I have one woman in my practice that was left to live alone when she was in seventh and eighth and ninth grade. Her mother was schizophrenic and moved out. Her father a couple months later moved out to live with a girlfriend and just came over on Sundays to grocery shop... The first time I heard that I said no one called child protective services? Did the neighbors know?... And she never thought about it and all of a sudden you know her eyes teared up and it was because she had a child that age. That's when she came to me. When her child reached that age and the presenting problem was something else and it wasn't probably until way later, maybe a year or more later that the story came up. And then I realized that this is why she came. She didn't know what to do with her daughter. No one parented her for those years, and she didn't know what to do.

But that work has really helped her with her own parenting, but she's still a kid, you know. I've worked with her for many years and she still feels inadequate as a parent. And we just keep working on it.

This was a situation in which the clinician described the patient as not having a model from childhood from which to draw upon in parenting her child at the age when her parents disappeared. Another clinician spoke to this phenomenon occurring in some treatments. He stated:

135 Because I always want to know at the point where a child is sent for service or help, what did the parents go through that particular time of their lives that their child is going through now. And is there something about that time of their lives that will offer us some insights as to whether they struggled and now he struggles.

Sometimes you can see a repetition.

Some clinicians remarked generally on working with intergenerational phenomenon. One clinician stated: You're dealing with at least two generations sometimes three. And the generations, the job of the generations of course is to help the next generation individuate and develop and take on life as it is during their lifetime. And often that's where the problems start. The so-called trans-generational or the intergenerational transmission of secrets and with Holocaust survivors who don't talk, kids who have been afflicted by a don't go there, don't ask the questions. So, I've generally seen a family model as my beginning of how I see individuals and the context‌ Loewald talks about changing ghosts into ancestors. And I think that that's very much an issue with regard to when people were suffering, whether they can't find their ancestors. They can only react to their ghosts, the traumatic experience or neglect of someone, but they can't name names usually. So, the intergenerational stuff.

Intergenerational phenomenon was often discussed at greater length by clinicians in the sample who were providing treatment more intensively and in cases where the clinician had more contact with more than one generation in a family. One clinician remarked:

136 Sometimes in my practice, I don't know always know all these things about the parents’ lives, especially when you're working with a child. And I think that's become more and more significant to me as I've learned more about intergenerational transmission of trauma. And I remember I was sitting with a kid thinking, is this their anxiety or is this some anxiety that's come from another generation, from their parents, something that happened to their parents. And so, I, if it's an older kid I'll ask them what they know. But it doesn't even matter because sometimes it's what you don't know.

Atypical development.

In several interviews, clinicians spoke about working with children with a nonspecific developmental disorder and children that present on the autism spectrum. One clinician noted that she and other colleagues have been seeing an increase in such phenomenon in recent years and also hypothesized that these may be linked to the increase of fertility treatments. She stated: So, I think teachers and therapists have been sort of talking about how there is this increase in non-specific developmental issues that look to be somewhat correlated or concurrent with fetal life, either fertility treatment or embryo implantation.

That kind of thing and I personally think that accounts for some of the higher levels of spectrum disorder. I've been looking for them in the literature there's been a little bit of light literature on it, but nothing terribly scientific that I've found.

137 Several clinicians described working with children who present in a manner that resembles autism spectrum disorders. Approximately half of the clinicians provided a case example that involved a child with autistic features. In many of these cases, clinicians demonstrated through intensive treatment and collaborative work with parents, great improvement in the child’s condition. In one case a clinician said in regard to one of her child patients, “So, that was a child who started out on the autism spectrum and now he is no longer.”

One clinician referred to such a child as an atypical child. He stated, “an atypical child is what gets called ASD in children today.” He noted that intensive and early treatment in these cases led to better outcomes. He noted: With atypical children we might even take them into analysis as soon as we could even at the age of three or four. Just because we found that five day a week treatment provided an opportunity to really help very disturbed children, to be able to address and just feel safe enough to kind of come out whatever that atypical shell was that they were developing.

This clinician went on to describe the phenomenon further: And what I've come to understand is now there's so much work that's been done on complex trauma and its impact on young children. And I think that we were often dealing with children maybe whose parents were just kind of unaware of their particular sensitivities in some way. But children who felt overwhelmed and they would kind of develop what we would refer to as an atypical personality structure that really afforded them a kind of a protection, a shield almost that would preserve an inner core. And some of those children actually had been

138 traumatized and even sexually abused. And that came out in the analysis. And that was I think a way of helping them gain some mastery over that trauma and be able to retain progressive development.

He described the approach of working with the parents of an atypically developing child: Well we'd meet with the parents on a weekly basis. It would only be maybe after a couple of years of the analysis that they work with the parents might become less frequent. Maybe every other week or gradually maybe monthly toward the end of a treatment. But it was always focusing on helping the parents appreciate how, for a child who had really been overwhelmed and traumatized, they could do things within the home environment to work against you know further occurrences of complex traumatic kind of situations. One simple thing would be to really carefully prepare children for anything. Any change that was in the offing. And to not overwhelm them with surprise parties or movies they weren't ready for or just the kinds of things that children are often kind of a bit overwhelmed by. And sometimes it was also to really help them put words to some explanations about some things that they knew the child might have really been upset by and even traumatized by that might have happened at a time in the child's life before the child had much language. So, there hadn't been the opportunity or the ability to really explain to the child by way of preparation. Say let's say an injury that required stitches in the head or something like that. Where a child would get your held down on a papoose board and you know that that can be very terrifying for a child. And many times, in E.R. settings parents weren't even allowed to be there.

139 They'd be told this will be better if you wait in the waiting room. So, these kinds of things parents regretted afterward and they could talk with their child about it.

And they could say you know mommy and daddy didn't understand how scared that made you feel. But we do and how we think that maybe you still have some feelings about that.

Another clinician described a case in which she also was conducting an analysis with a young child and was actively engaged in trying to help the parents register and make contact with the child’s internal experience alongside conducting the analysis with the child. The treatment began with a twice weekly therapy for the mother of two children under two years old. She was under a great deal of stress due to professional demands, family tensions and having two young children. She described the initial concerns about the child: He was 17 months when I got a history about this. I think I met her the month before but didn't get the history that he had no language. And again, this is a family where everyone has a postgraduate medical degree including grandparents.

And it was very concerning to me that there were people in particular fields who should understand that there was a remarkable language delay, and nothing was happening. There were also other stereotypic mechanical behaviors going on that were fundamentally being promoted by the family and not sort of as we would as behaviorists would stay extinguished or redirected. It was almost as if they didn't want to upset the child and they would just allow him to do his repetitive behaviors over and over.

140 This clinician noted that the mother had everything going on at the time, “but was not really able to hold that in mind or process it.” She was in her final years of residency and had developed a breast problem that led to her to abruptly cease breastfeeding the child at 2 months. The clinician went on to describe some historical factors that had bearing on the child’s development: I always do a very expansive family history when I do an intake. And so, there are multiple generations and I'm just starting with the mother's side let alone the father's side of political trauma related to a cultural genocide in one part of the family. And basically, political genocide on the other side of her family. And so, there were these reverberations going on of forced immigrations, deaths, abandonments, having to survive and save oneself. What you keep quiet what you don't. What's passed on, what's not. And as she's telling me all of this and able to narrate it, it became much clearer to us what was then potentially playing out in her next generation with her babies. And so, we're able to look at that now as the little boys have a lot of aggression between them and both sets of parents, the mother and the father have a terrible time mediating the boys’ aggression, especially towards each other.

This case eventually transitioned into being an analysis for the child. The mother was present for 3 sessions per week and the father joined on the fourth session. The clinician shared her working formulation of the etiology of the child’s presentation. She said: Was this kid really neurologically autistic or was he so overwhelmed at two months of age with the abrupt traumatic weaning, her being so overwhelmed and

141 busy and consumed with another pregnancy so quickly? Did he end up putting together autistic defenses as opposed to being fully neurologically wired if that makes sense? That the endpoint looked autistic but in fact, it was a different pathway.

She further made an observation about the importance of the father’s representation of the boy and her work toward helping the father connect to the child. She said, Who this boy represented in the father’s mind was very important. And this was part of the father who had been relatively neglected when his parents moved here.... But getting the father engaged, getting the father interested in play, getting the father interested in this little boy and not just in fixing him but in the development of his mind was incredibly hard work on my part. Again, I had to really had to have a lot of patience. And the father's come some way. But is there's a density to him. I don't want to say it feels autistic but there's a kind of concreteness that's very hard to get beyond.

Through the intensive collaborative work with the parents in the child’s analysis, the child developed symbolic play and an emotional and social relatedness that had been to the point non-existent. Eventually, the parents were less involved and the case became a more traditional child analysis, but the clinician attributes the active participation on behalf of the parents as instrumental in providing needed contextual information and creating change in the parents manner of understanding and relating to the child, which ultimately served to support the resumption of progressive development for the boy.

142 Another clinician provided an example of working with an adolescent he described as being in a schizoid retreat or a psychic retreat. He stated: So, there's a person who is very insulated and is probably suffering either from trauma abandonment or neglect or some combination. And they have to live inside their shell or their cocoon for quite a while because they're terrified of dependency causing a breakdown. So that person is living inside their skin, inside their shell. Now I have to experience this.

He noted the length of time such a treatment takes and the great deal of patience that needs to be exercised by the therapist. He stated: It's going to take some time. Now, if there's no movement in the treatment and it's a year, year and a half, whatever, it is of course a question of how can you hold the parents hands through this process.

He emphasized the need to conduct a risk assessment for such children and to enlist such an assessment with the parents in the event that they express concern to the clinician. Beyond this, he expressed the importance of confidentiality in such cases and described how he might attend to the parents needs when they call with concerns in a treatment. He noted: What I want to do is take the parents at their word and look at the anxiety that makes them call and then when I do see them, I want to know what’s on their minds and what’s their concern and then see what are their internal resources.

With regard to dealing with the things that they want the child to get help with and I’ll pick that up fairly quickly.

143 Finding 4: Parent Work Is Focused on the Child, the Parental Aspect of the Parent and the Parent-Child Relationship Focusing parent work on the child, parenting and the parent-child relationship.

Clinicians work with parents in a limited and focused manner when it is in conjunction with their child’s treatment. Depending on how the clinician has defined the patient or the object of the treatment, assessments and interventions are conducted in order to achieve therapeutic progress in these areas. This differs from a traditional psychotherapy or psychoanalysis in that the information sought and the manner of intervening with the individual parent is not designed to address the parent’s complete psychological life. Rather, clinicians limit their focus to the parental aspect of the parent’s psychology and how this interacts with and influences the child’s development and the parent-child relationship. In this sample, a majority of clinicians described their clinical focus as either the child or the parent-child relationship. In a few cases, clinicians agreed to work with a parent on an individual basis, but this was atypical in the sample and the individual practices of given clinicians.

While this was a common theme in all the interviews, clinicians generally did not describe how or whether they explain this to parents at the outset. One clinician who does an extensive inquiry into parental history in the beginning of her treatments did describe how she explains to parents the importance of the inquiry and how she guides it toward working on present difficulties. She stated: Obviously, in order to administer the life stressor checklist, you have to have a conversation with the parent about why you think it’s important to know about

144 their trauma history to help their child or address whatever they’re presenting concerns are for the child or family work. And that in itself can be a really powerful intervention. To talk to parents about when your child does experience something really upsetting or frightening or that’s put their safety at risk that as a parent you have your own strong feelings about that. And if you’ve had similar experiences or other experiences of having your safety threatened, that feelings and memories from your own experiences can come out and it’s really helpful for me to know and for us to think about it together as we’re working with your child.

This clinician placed the inquiry of the parent’s history in relation to how the parent emotionally reacts to the child’s behaviors and emotions in the present.

Other clinicians seemed to embed a similar sensibility into their work and address aberrations from such a focus as it arose. One clinician described her approach to focusing the parents on the child by saying to parents, “How can we use that to understand what’s going on with your child?” Several clinicians spoke similarly to how they refocused a parent from veering into subjects which have more to do with themselves as individuals than with the child or the parent-child relationship. One clinician described how she focuses her work with parents and maintains boundaries of the focus in their work together: And if I'm working with somebody, if they start to bring up things from their past or a particular difficulty that they're having I will try to work with them on that insofar as it affects them as parents or as it's affecting their relationship with their child in one way or another. But I'll talk about it that way. And if it seems like the

145 focus is shifting too much out of that. I'll try to try to remind them about what our task is together. And then maybe ask would it help if you had somebody of your own to talk about that stuff so that we can work on what we need to work on to make you feel good as a parent. It's not always that neat and tidy.

Another clinician described acknowledging, but not delving into a parent’s emotional life. She stated: But where it feels really that it’s important even in our work that’s focused on the children to just acknowledge and name and normalize her own feelings but not necessarily to delve into them or have them become the focus. But, to just acknowledge them as part of the whole picture.

Some clinicians expressed the need to make referrals for individual treatment for parents that struggled to not use the child’s therapist for their own therapeutic needs that were outside the scope of the focus on the child, parenting or the parent-child relationship. One clinician stated: Well one of the things that was again a very clear part of the model was that we were working with the parent on behalf of the child. And if it became clear that the parent needed or wanted his or her own therapy. The therapist of a child would work with that parent to try to find a referral that would work. So that's when we would refer the parent, but we would not discontinue the work on behalf of the child. Those two things would go on simultaneously.

146 Another clinician remarked: So, my focus is absolutely on the child. It really is completely focused on the child. So, if I feel like we are not doing that or that's not possible, then I would refer them for individual treatment if they're not already in individual.

One clinician remarked that a parent’s ability to support the work of child therapy was a signal that they had usable guilt. He noted that when this was present to a sufficient degree, parents “wouldn’t come in for a parent guidance session of sorts and just to almost turn it into their own therapy.” He also noted that in some cases one or both parents may be significantly traumatized or struggling with their own mental health issues to a degree that made establishing a working relationship organized around the child difficult to achieve. He stated: The model is the ideal, but there were always exceptions to what was going to work and those cases where the case might just not go and something might would inevitably cause it to fall apart. Sometimes one would try to work with maybe one parent would be more one way than the other. So, you could try to work with the parent who is a little less conflicted to try to support the work. And sometimes that might help get through a rough spot. But, sometimes, a case would just need to come to an end. And the only thing we could hope for was that maybe there had been a good enough experience so that over time they might return, the child when he got older might come back and seek some treatment. And sometimes that would happen.

Another clinician described how she focuses parents on the child in the course of a treatment:

147 So back to how I make these choices. I'll say, and this is a trick I learned a long time ago, I never take sides. The only side I am taking is the child's side. And I say even if I'm sensing they're not taking the child's side and they're using the child to put between them, I say to them, I know the person you care most about is your child. So that's how we're going to focus on this. How does that sound to you? And they're usually like yeah, that sounds good.

Another clinician noted how a child can sometimes raise observations that expose a family history of troubled relationships. He mentions that this can at times lead the parent to feeling precipitously exposed. In others, he notes how this can prompt a parent to engage in work on their own history and how he maintains a boundary on doing such work with a parent. He stated: What if the parents figure that you're kind of on to them and their history? What if the kid says well you know I think grandma and you, you were always fighting.

And you don't even realize how much that hurt me. Oh my God. So, my me and my mother. I better work on my mind. Well that's a good thing. I mean it's a wonderful opportunity. But I won't be the one to do it. Not if it's individual therapy. I think that that should go to an individual therapist.

He goes on to explain his thinking about his rationale for having such a boundary: So, I generally will not do individual therapy with one parent in the context of a child-oriented case because I'm true to the model, right, of parent child consultation, parent child work. And I can let people reveal things in the couple consultations. Which they will do actually in order to understand their child. But

148 if they seem to be really getting more and more anxious or worried about something that's coming up or they never really dealt with it, I'll refer them out and then I'll find out whether they're serious.

Another clinician expressed how positive it is when a parent has individual therapy apart from the child’s therapy: It's great that this particular parent has individual support and even without the kids in the room that we can be clear that our work together, that there will be overlap but that our work together is in service of supporting the children and supporting this parent’s relationship with the children.

One clinician described how important parents working on their material can be for the child in addition to the parent. She stated: I try to hear as much as I can and help them tolerate the experience of being reminded of what they went through as they see their child. And I've certainly made referrals for the parent to get their own work and try to help them recognize and appreciate how valuable and important that might be. Not only for themselves but certainly for their child. And in certain circumstances, I've even said the most important thing you can do for your child right now is get into your own treatment. This is important stuff for you and the way that it's affecting you right now is affecting your ability to really be present with your child and help them as much as you can. Or words to that effect. I have said that at various times.

Most clinicians remarked on how influential a parent’s history, particularly of their own parents, is on their parenting and their child’s experience of them. In many

149 cases, clinicians probe for such information and encourage parents to examine these themes in their sessions. One clinician noted how he might raise this topic with a parent: I might say it's not so unusual in my experience that an unexamined past sometimes affects the future and you don't want a future born only of the past.

You want a future with this to do with what happens now. So that tomorrow might be a bit different. And that's what I think I'm asking us to work toward. I say we I see us as parents. I think it's a collaboration. Well, you try.

Another clinician described her thinking about exploring this with parents and how therapeutic it can be as an intervention in itself: The parent's whole experience and history is an important part of their relationship with the child and their child's experience. And just doing that assessment can be almost the really experiential way of doing that sort of psychoed in helping parents understand that. And with a lot of parents it becomes relational because I usually do it pretty early and then they're having feelings in the room and then I get to respond to those and that may be a new experience.

Another clinician noted that to many parents considering a link between their childhood and their parenting can “almost offer a kind of relief. Nobody’s asked about it before.� Another clinician described a similar relief at becoming aware of something that was hitherto not conscious. She stated: What are those issues, what are their concerns and then try to explore what was going on in their lives at the time of the age of their child or if their child has sickness or some trauma if anything like that ever happened to them. So, I'll pretty quickly explore that. And I find that the parents are usually pretty comfortable

150 going there... It's oftentimes something they're not so consciously aware of, it seems. So, you know there'll be pauses and reflection. It wouldn't be like oh yeah, I've been thinking about that. It would be more like, "Oh/Huh" you know. And then I've had some parents that don't like it and then I'll joke with there I go again asking those questions about your childhood, I know you don't like that. But over time I think people get comfortable because they see the relevance.

While exploring a parent’s history was common among participants, some clinicians did note some situations in which the therapist moved too quickly in the exploration or interpretation of a parent’s history and dynamics. One clinician noted the need to be cautious when exploring family history. She stated: So, I start with the child's history and the family history. And that's where it can go too fast because if then something is uncovered and you’ve only met them two times.

Another clinician mentioned: So, I guess it’s always the thing that there are tripwires within all of us and certainly within parents that you don't always know are there. You try to repair if you make a mess… and we need to be as careful as possible I suppose.

There were some instances reported in which a clinician provided an observation or an interpretation about who the child represents in a parents’ mind, which was not received well by the parent. One clinician described attempting to work with a mother on how her child was reminiscent of her experience of her own mother. She stated: I think it always is a matter of trying to appreciate where the parent's limits are at least for the moment with what the parent can tolerate. I'm pretty sure I lost one

151 analytic case kind of early on with a boy, a latency boy, when I moved a little too quickly in the direction of her own relationship with her mother. And I think it frightened her and that crossed the line for her. I soon realized it was too painful, too frightening for her. And then within a couple of weeks they've made the decision to pull him out of treatment.

She described the connection she observed between the mother’s experience of her child and her mother: Well he had, in those days we called it Asperger’s. Yeah. Now we don't call it that. So, he was tough, he was tough to connect with at times and he had interests very detailed interests in things that she had no interest or understanding of. So, she was kind of dismissive of him and kind of kept him at arm's length… There were ways in which she would describe her own mother as kind of distancing from her and keeping her at arm's length and how painful that was for her. And so, as I discerned some more about that, I tried to gently see if there was any way she could work on that and the answer was no. She will not be reflecting on that.

So, I think it was having to do with where they were close and are not close and then protecting themselves. Big difference in relationship. So yeah that was part of it.... And so, I was trying to get over the edge of that probably a little too quickly, it landed the wrong way somehow or other… And she couldn't or didn’t want to think more or feel more about that. There was probably a sense of loss too. She couldn't connect with her son in ways that she probably would have found more satisfying. He didn't like the kinds of things she liked. She didn't like or understand or have any interest. She was very kind of dismissive with him, his

152 interests all the things he loved. He was hard to connect with. I found myself struggling too. It was hard…

Another clinician described a mother’s struggle to make use of an interpretation relating her experience of her child to her experience of her mother. He stated: I think that she understands her mother could not be there for her in any way and that her mother was really only there for herself. But I think it’s very difficult still.

It was very difficult for the mother to see that her child was her mother to her.

That doesn’t work so good for her still. She doesn’t like it. When they’re in the middle of a breakdown and she can be very emotional in these sessions. When everything is working, I don’t know where those feelings are. When it’s not working, sometimes we have enough momentum where she can be like, maybe I’m confusing that it makes me feel the way my mother made me feel. Yeah, but she can’t accept that in the moment.

One clinician remarked on the delicate balance of addressing material related to the parents. She stated: Well you know, but sometimes that’s where the family therapists and their idea of the identified patient, they’re right. The parents want to identify this person as the problem and as soon as you start to get somewhere with the parents being a problem, that can be a treatment destructive resistance. Because as soon as they start to have to look at themselves, they pull their kid. It’s a very delicate balance.

You want to be able to help the kid.

Another clinician discussed parents being more available for work on themselves in individual treatment. She stated:

153 I think they're more available in individual treatment for work on themselves maybe because they haven't identified the problem as the child's problem. It takes a little more work for a parent to be able to recognize that they have a role in their child's problem, unless they say I'm coming for treatment.

One clinician provided an example of this. He described a case in which a woman came to treatment when she was expecting a child. Her mother had been a Holocaust survivor and lost her husband when the woman was a young girl. The clinician noted the woman’s presenting concern, She was afraid of having a girl, she didn’t know how she could ever handle that based on what she went through with her mother.... So, she really wanted to sort of think about who she was and how to manage herself to be the best mom she could be.

Parent guidance.

One of the interventions that was mentioned to some degree in all interviews was providing parents with guidance. This was often referred to as parent guidance, parent education or psychoeducation. Clinicians in the sample often presented themselves as a resource for parents regarding child development, helping parents decipher and respond to the meaning of a child’s behavior as well as to support parents in recognizing, tolerating and responding to a child’s feelings. One clinician noted: I see myself as an advocate for the child primarily and as a translator as you do in couple therapy and also representing what the parent may not know about a child and children’s

154 development because the average parent knows very little, in my opinion.

Psychodynamic clinicians are distinct from behavioral therapists in that the overarching goal is not behavioral change alone. Psychodynamically oriented clinicians note that unconscious determinants of behavior are easily adaptable and may resurface in a different form if one expression is closed. Where this may look like a resolution of the presenting problem, the problem may have simply changed shape and expression, leaving the underlying issue intact and unchanged. Thus, clinicians in this sample had mixed thoughts and reactions to questions of parent guidance. Most clinicians spoke to two guidelines for being effective in supporting parents in this regard. They emphasized the need to focus on the underlying meaning of a given behavior or feeling and being cautious about presenting oneself as an expert educating a parent. One clinician stated: The most important thing is understanding the meaning, intention and desire behind a child’s behavior. The other most important thing is you can’t replace the parent. You have to find a way to have empathy for them even when they’re doing things that you think are not in the child’s best interest. And try to understand why they’re doing that, how they are doing that and help them see their way to some better place in parenting.

Several clinicians expressed the importance of respecting parents’ role and being cautious about overstepping the clinician’s role in supporting the family. One clinician cited pioneers in child analytic work. She stated: I think it’s really important to respect their role. And Mrs. Furman used to say that we’re hired help and we should not be kidnappers. Selma Fraiberg said something similar about parent-infant work. She told her trainees you never hold the baby

155 even if offered. The demonstration that you’re the mother, you’re the father and I’m here to help but I’m not going to take over. I think is always important in any case.

Another clinician added: If you’ve read some of Mrs. Furman’s articles you know you know that one of the things that she would often talk about was the danger of the therapist thinking you could be a better parent.

One clinician explained this phenomenon as a common countertransference in working with parents and how she’s come to manage that in her practice. She stated: It’s almost like the countertransference is I can be a better parent than that parent.

But you can’t. You can’t be the parent. You can never be the parent. You can be a facilitator. So now I think of my role as helping the child have a better relationship with the parent and the parent have a better relationship with the child. It’s not my role to replace or gratify myself by thinking well, I could have done this better. So that means really engaging your empathy for the parent.

This countertransference she suggested at times partly stems from parents’ feelings of inadequacy. She stated: There’s a lot of stress that comes from parenting and when you feel you’re ineffective as a parent. I’ve had a number of people who feel sort of helpless and like a bad mother or a bad father.

Several clinicians remarked on the delicate narcissism of many parents, the responsibility they carry and the feelings of guilt that arise when their children are suffering. One clinician noted:

156 People feel a lot of responsibility in this day and age about how they can screw up their kids. I mean it’s in our culture way more than it was like in the 40s where people just let their kids raise themselves and they didn’t take a lot of responsibility. If you had a bad kid, you had a bad kid. It was like they were born that way or something. But now I think many parents would think that it was their fault or be embarrassed.

She added: I think there is a piece of parenting work for me that has to do with helping parents be okay with their kids’ different moods and without feeling guilty because that’s the other thing, they’re going to feel they feel guilty if they’re kid’s not OK… And so you have to help them move away from self-blame. And that’s where I think maybe a non-blaming therapist is really healing for the parents because I’m not going to frame anything as you did this or you should do that.

Another clinician also noted parents’ concern about whether they are doing a good job as parents: The other thing I’ve learned through the years, it took me a long time to learn, is parents can be easily narcissistically wounded and you want to make parents feel important and valued and like they’re doing a good job.... Sometimes parents don’t feel confident. I want to help parents feel like they’re doing a good job as parents.

Some clinicians expressed reservations about quickly responding to a parent’s request for practical suggestions or advice. One clinician emphasized how challenging it can be to provide education or guidance in the context of therapy. She stated:

157 So, I don’t know if it’s a parent education, I don’t know what that would look like… What I find difficult with that is again back to the delicate narcissism of parents. I, unfortunately feel like I stepped in it too many times, where you’re gently offering suggestions and it’s heard as I am fucking up. I think if a parent is prepared to hear some suggestions like that, you know, it’s such a delicate area where some parents could totally take that and use it.... I’ve seen situations with parents who are so overly identified with their child that they want to be different than their own parent who is abusive, it’s such a sticky area. I get what it is, but I see it can be super sticky. And I think that it’s hard to know when that would come up. Would it be a parenting class? I’ve done groups where I was a participant in the group where we would talk about what we struggle with as parents and try to help each other. I like that idea. But I think the idea of parent education is hard. I think it’s a tricky thing in the context of therapy. Even if a parent asks for advice, the latent question is still sort of am I doing a good job or am I ok. It’s very tricky and challenging.

Another clinician explained her approach of trying to maintain focus on parents claiming their own competence by inquiring about their thoughts and approaches. She notes providing some strategies if it seems called for, but much of her work surrounds understanding the request. She stated: I try and figure out if I can how much they really need it. Are they asking me, you know, what should I do? Often if you tell them, they do the opposite or don’t follow your advice anyway so it’s not always such a productive thing to do. And I think to do it on the one hand can give the message that I don’t think they can

158 figure it out, so I will ask what you have tried. What seems to work, what doesn’t.

But if they sincerely need some strategies or something like that, I’ll offer them. I don’t usually say you should read this book or that book. If they’re reading something and they ask me what I thin, again, I’ll try to figure out what they think and support their response to whatever it is that they’re reading. I don’t give a lot of advice, but I don’t withhold advice. I just try to match what the particular need is as it comes up.

Regardless of clinicians’ reservations, the request for concrete suggestions surfaced extensively in cases of working with parents. Clinicians demonstrated and deliberately expressed humility when providing solutions and routinely sought to solicit feedback from parents about what they thought about the suggestion and how it went if they tried it. One clinician noted: There’s something that Fred Pine said that I really like which is ‘I may be going out on a limb here and let me know if you think this is really inappropriate or crazy, but I have an idea or a hypothesis.’ It suits my personality because I don’t feel I’m always questioning how much of an authority I am, I don’t want to come across that way. So, I have that, that’s my tendency.

She said separately: So I consider myself pretty gentle and I feel like if I if I make a mistake or I feel like I haven’t listened enough or whatever, I will go back in the next session and say you know I rethought something or I feel like I made a recommendation to you and I’m wondering, were you comfortable with it or not?

159 Another clinician noted: You can say to people, well look you don’t have to take what I say as true. Just think about it. Let me know if any of it resonates or if it’s having an effect pro or con.

Another clinician explained how she contextualizes direct support in the context of parent work: I’m really careful with that. I don’t bombard them… I do a lot of listening in proportion to giving suggestions. I do mostly listening. The suggestions usually come after I feel I have a very solid relationship. And I say you might want to try this. And sometimes I say I know that it works. Like if your child is doing well in school it’s probably because he or she knows what to expect. There are clear limits and boundaries. There is a schedule and that helps children function and lowers their anxiety. I often tell parents that it raises their children’s anxiety to have too much power and control in the family. And so, they don’t have to worry about hurting their child by setting limits that it actually makes a child feel more secure. And I talk about the scale of harsh to permissive and that we know that somewhere in the middle is more optimal. And I have them talk about what it was like for you when your mother yelled at you. I hated it. I couldn’t stand it. But I didn’t know any other way. And then I might make a suggestion and I always say we’re still smarter than they are thank goodness. And so, you know we have resources that we can use and give it a try. Let me know how it goes. And then I try to get their feedback. Did you try it? How did it go? How does it feel to you?

160 One clinician described her approach of helping a parent integrate regulating strategies in the course of their work. She stated: It’s one thing for us to talk after something has happened and think about here’s something that you could do or say. And of course it’s harder to think through those situations on the spot where just being in that situation is incredibly painful for you. So, kind of making clear that I’m not in offering developmental guidance or responding to helping the parent think through what they would like to be able to do, trying to be clear that I’m not having an expectation that they’re going to get it right every time. Or that they don’t need to do that, but that having the reflective space and time not in the moment with kids can help over time with practice. I’m not expecting you to go back from the session and do it perfectly every time for the next week. But that stepping out of it and reflecting is a way to sort of build some mental and emotional habits so that over time you can start to have a different awareness and respond differently in the moment.

Some clinicians noted that many behavioral solutions used with children tend not to be effective in an ongoing way. One clinician remarked: All these behavioral things like punishments and rewards, they just don’t work over the long haul. And so, then people think well I’m doing everything I thought I should do and they’re still having tantrums or they’re still whatever because no one’s bothered to figure out what’s this kid is actually worried about.

Another clinician noted: Also, I would never just give a behavior chart. I don’t like stickers and charts and rewards and all of that stuff. One mother decided to make a jar with pom poms in

161 it. I think they do it in his school and every time somebody does something positive, they put a pom-pom in it. And she includes herself because she’s working on her yelling. And when the jar gets full, they get some kind of like a pizza dinner or something very modest. They are very low key this family. But if they come up with something behavioral like that, sticker chart or whatever, I tell them often that that fades and that our goal is to get the child to have the inner control and I give them alternatives. But I say by all means if you want to try it let’s see what happens.

Rather, clinicians tended to focus on the meaning of the child’s behavior and supporting the parents in trying to understand what the child is experiencing. One clinician said she might ask parents, “What else might be going on that the child behaves these ways?” She described “helping parents to think a little bit differently about their child’s behavior.” She explained: I think what I’m trying to do is to help them understand that what’s much more important is the intention behind that behavior. What is that behavior communicating? What is going on inside the child that gives rise to that behavior?

Because that’s way more important in helping the child than controlling or containing the behavior.

One clinician described a case in which the child was having enuresis problems.

She described her efforts to respond to the parents’ desperation for behavioral change/symptom relief toward understanding what is happening for the child. She stated: I’ve got a girl who’s just started is doing a lot of having a lot of trouble with enuresis. That’s a big problem. And you know they’re actually relieved to begin

162 to think how is this more deeply related. We’ve done all the medical tests we’ve done all the exams there’s no physical problem. We understand it’s psychological.

Let’s dig in. Let’s understand. Let’s help with this because for one it’s driving us crazy and two, she can’t live like this. We can’t live like this and she can’t live like this. So, in that case there’s sort of a desperation about the symptom. Well it’s interesting. What is the investment in the symptom? And funny thing about that is as we’ve been getting started, I’ve said don’t tell her she’s coming to see someone who’s going to help her stop having accidents. That may not be what she’s wanting. Let’s not cast this in any particular way. So, I’m just trying to open up possibilities within your minds about what the meaning of everything is. How can we understand the meaning of it and add to our understanding?

Another clinician described the importance of seeing the meaning in a child’s behavior: So, this idea that behavior has meaning, it was like a mantra... and it would really be what we would try to talk with all the parents about. And help them understand it’s like decoding you know Morse code or something. We have to figure out what the message is here that we just haven’t really understood sufficiently. And sometimes the child didn’t even know what the meaning was. You just knew that there was a drivenness to behave in a way to communicate something.

Many clinicians working with children in early childhood described situations of providing more direct guidance to parents than clinicians that primarily worked with older children and adolescents. Clinicians providing developmental guidance and behavioral support in these situations maintained an interest in the child’s emotional

163 experience and what the behavior was expressing, but also provided solutions that were designed to provide more structure in the home, reduce anxiety for the child and parents, and cultivate agency and mastery in the child and parents. One clinician remarked: But if parents could understand that something had occurred that they just didn’t appreciate how frightening it had been for the child. But if they could go back and help the child gain some mastery over that, that helped them feel very empowered and very relieved to think that there was something they could do.

He further noted some concrete suggestions that were often given to parents: We were always focusing on helping the parents appreciate how for a child who had really been overwhelmed and traumatized, they could do things within the home environment to work against further occurrences of complex traumatic kind of situations. One simple thing would be to really carefully prepare children for anything. Any change that was in the offing… and to not overwhelm them with surprise parties or movies they weren’t ready for or just the kinds of things that children are often kind of a bit overwhelmed by.

Another clinician described some of her efforts to help a mother who was raised in an alcoholic family. She emphasized helping the mother provide more structure in her home, understand her child’s anxiety and feel more masterful in being able to provide for her child’s needs. She stated: Those strategies, I think first of all they were a relief because she understood her daughter better. Understood what anxiety she might have. And then how to help her with those. With some specific strategies. You know, picture schedule, calendar, things like that. But that was kind of thinking about her own

164 development and background… And meals weren’t very regular. She didn’t know how to make a schedule in the house. So, we were attuned to her needs in a way that perhaps she hadn’t experienced before.

Another clinician provided some examples of how she focuses her guidance work with parents of young children. She described providing guidance to parents of a child who has wetting accidents and her efforts to help the parents develop more control over her body: So, this is a child who also has wetting accidents. I also work with the parents.

Now I gave a suggestion that they didn’t take but some other suggestions they’ve taken to manage the enuresis during the day. We’re not even addressing the nighttime yet so much because there seems to be a familial factor to that. (The suggestion they didn’t take was) when his bedding is wet in the morning that he put the sheets in the laundry basket and I say that to the parents, this is not punitive. This is taking responsibility and realizing that he can have ultimately control over his body and control over other things that are appropriate. A phrase I use a lot with parents is whether this is a grownups’ decision or a you decision, a four-year-old decision or a child’s decision.

She described other interventions for various problems parents face with young children: I talk a lot about how my in my history of working with children yelling is something that children talk a lot about and that’s very hard for them. And so, I give alternatives. I give alternatives to help a child feel like they’re controlling the situation. I always say to parents, we are still smarter than they are, and we can

165 figure out ways to help them feel like they’re in control of the situation without yelling and screaming and then I give them examples depending on what it is. I might suggest a timer rather than the parents standing over the child. For example, they’re not getting dressed on time. I suggest consequences such as if bedtime is difficult that the parents say, when you show me that you’re in bed and ready for a story I’ll come in and do your story. But it has to be by a certain time. And then if that doesn’t happen, I suggest to the parent to go in and say it looks like you chose not to be ready tonight. So, we’ll try again tomorrow night. So, you’re saying to the child you made a choice not I can’t stand this anymore and you never listen to me. Which is a go to for a lot of parents and they stand behind the child and push them. And I tell them you know a four-year-old’s capable of getting themselves into their pajamas getting to the bathroom. You might have to monitor their tooth brushing still. So, I sort of give them norms by which to manage and have expectations of the child. A child who’s typically this age and take yourself out of the control battle by using a timer. That kind of thing.... I also sometimes suggest to parents that if a child has a tantrum or whatever. There are a few things I do around tantrums with parents. I help them change from time out which feels punitive and isolated to what I call a calm down corner or there is a mindfulness teacher who works with children who calls it a peace corner and we’ve implemented these in most of the classrooms where I work. And the calm down corner is not in an isolated place, it’s in a place where the child can see the parent. When the child is calm, I go over with them, I make the suggestion that they together talk about we’re going to make a place calm down corner for you

166 when things feel like you’re getting upset or you are very upset and you make it together you put some cushions in it. You put a little maybe a basket of cuddle toys or the child gets to choose a few things that would comfort them. And you rehearse it. At first you go and sit with them and practice it and then sometimes you can say to the child when you see they’re getting upset, do you think you need some time in your calm down corner? Again, that’s aimed at locus of control, not isolating the child... My philosophy with parents is you want to join your child and helping them control their behavior. And you want them to know you’re on their side and you always want to use those words. I’m going to help you with this.

Another clinician provided an example of using developmental guidance approaches with a mother who has a separate individual therapist and how the clinician focuses her work with the mother. She stated: She’s really coming in and describing specific situations that are coming up with the kids. And it’s really the sort of sudden and total absence of the father is the presenting concern for the kids and how the kids are responding to that. The parent has really been able to kind of come in and say you know this is what I noticed my child doing. And sometimes it’s saying and sometimes it’s doing, the kids are really little in these situations. And here’s how I responded. And I don’t know if that was the right thing to do. And so, then you know there’s a developmental guidance piece of sort of checking out her understanding and correcting a little bit or filling in gaps about what is likely about her kids’ experience and understanding and needs at the developmental stages that they’re

167 at. And then also the sort of checking out and talking about what you should do at those times, but let’s not skip over just how it felt for you. That I’m making space to acknowledge that even though this particular parent is in individual treatment.

Talking in a lot of detail or thinking about really specific strategies for how to take care of yourself in those moments when something that your kids say or do is really painful for you to kind of bear witness to, that would be a really great thing to talk about with your individual therapist who’s already been working with you.

But then you can also bring that back and talk to me about it so I understand how you’re dealing with that in parenting situations.

168

Chapter V

Discussion of Findings The Absence of Clinicians Who Do Not Work with Parents In the review of the literature on working with parents in psychodynamic psychotherapy, there was a strand of theoretical concern about working with parents in the formative years of child analysis. The concern largely centered upon translating adult psychoanalytic technique to work with children. In these early approaches, some analysts (Anthony 1960, Klein 1932, 1961) considered minimizing parental involvement between a child analyst and the child’s parents in order to maintain analytic purity and to reduce the frequency of parameters (Weiss 1964) in child analysis. Within this study, all clinicians interviewed do work with parents and see that as a valuable and needed aspect of providing psychodynamic treatment for children. Several clinicians mentioned this history and stated matter-of-factly that it was not sensible to them to not be involved with parents. A few clinicians mentioned an awareness of colleagues who do practice in this manner. However, no clinicians who practice without parental involvement volunteered to participate in the study. This may subtly have been affected by the recruitment procedure, in which participants were sought to be interviewed about how they conceptualize their role and conduct their work with parents of children in treatment. It was not explicitly stated that the researcher was also interested in interviewing individuals who considered parental involvement inadvisable. This possibly signaled to

169 those practicing in a modality that excluded or minimized parental involvement that they would have little to offer this study. Being that some clinicians mentioned awareness of colleagues who practice in this manner, it follows that this report only speaks to the methodology and thoughts of clinicians who do consider parental involvement a critical aspect of their psychodynamic work with children.

Parent Work Is Individualized on a Case-By-Case Basis Within the sample, all clinicians work regularly with parents of children in treatment and often expressed that this work was critically important to successful treatment. Many clinicians noted that cases in which the parents were minimally involved were often unsuccessful or less successful than they would have been if parents were more involved. Beyond the uniform support for doing parent work, each of the clinicians described a highly varied and individualized approach to working with parents. Every clinician in the sample mentioned that their work with parents depends on the particulars of a given case. The question of how each clinician works with parents was routinely met with the response, it depends. This response relates to an important consideration in working with parents. Throughout the literature, authors (Hirshfeld 2001, Mishne 1983, Siskind 1997) have emphasized the need for child therapists to individualize work with parents on a case by case basis. While there are similarities among cases, clinicians in this study regarded the manner of working with any child and his/her parents as conditioned by the nature of the problem and its constituent factors as well as the clinician’s orientation to clinical work. This corroborates Hirshfeld’s (2001) similar observation about the participants’ approach in her study on parent work. She stated:

170 Therapists prefer having regular, ongoing contact with parents. This contact differs from case to case, and therapists continually assess and intervene according to each situation. This also implies a certain amount of flexibility concerning the therapeutic frame. That is, therapists tailor the frequency of meetings and the modality of work to the specific circumstances of each case, which depends mostly on the age of the child and the presenting problems. (p.

112) This observation about the lack of fixed procedure is noted in Hirshfeld’s study but is not emphasized as an organizing feature to the extent that it is in the present study. Clinicians in this study routinely positioned themselves in a responsive and investigative role.

Parents contact therapists in search of some form of support when their children are struggling. Psychodynamic psychotherapy is built upon psychoanalysis, which in all its manifestations presents a theory of mind that suggests varying levels of consciousness and motivation. Thus, the need for an inquiry into what a parental request for therapeutic services means is assumed by all practitioners. Further, what distinguishes a psychodynamic practitioner from a strictly behavioral practitioner is that the objective of treatment is not amelioration of the presenting symptom alone, but rather to embed this amelioration of the symptom in a full apprehension of the conditions which gave rise to the expression and the rightful meaning that the symptom had in the individual or family’s situation. In many circumstances detailed in the cases portrayed in this study, clinicians described being at odds with parents due to possessing differing views of the objective of the encounter (Slade 2008a). In general, this was a parental desire for a quick fix and a therapist’s view that the problem is more complex than the immediate parental

171 concern. For example, one clinician described a case in which a child was refusing to go to school and the parents were pressuring the therapist to get the child to go to school.

This symptom was the outgrowth of a highly motivated desire to not develop into a version of his abusive father and to perpetuate the gratifications of maintaining an enmeshed relationship with his mother. The goal from the clinician’s perspective was not simply to help the child overcome the hurdle of his resistance to attend school, but to address the underlying forces that were culminating in this expression of developmental arrest.

Siskind (1997) states: Our training...reminds us to view all aspects of this situation as we view all the material presented by our adult patients in psychoanalysis and psychoanalytic psychotherapy - as grist for the mill. It reminds us that complex questions can only be answered by an approach that respects rather than reduces the complexity of human development. (p. 19) The heart of the complexity of parent work resides in the ongoing investigation as to what the presenting problem represents and what in the course of treatment is to be done to work toward a resolution. In order to proceed to the finer workings of any given individual or family and to be of commensurate therapeutic value and influence, psychodynamic clinicians set the stage for such work by treating each case as a unique instance requiring individualized responsiveness and understandings. Thus, as one clinician in the sample remarked, “There are just approaches and trying to regard the parents as essential.� The foundational findings in this study are that parents are essential and that each case needs to be treated in an individualized manner.

172

The Assessment Process & Definition of the Patient All clinicians conduct an initial assessment of the presenting problem and make decisions related to who or what is going to be the object of the treatment. There are a few background factors that influence setting the stage for the initial encounter and the assessment process. The clinician’s setting, practice norms and the nature of the referral all have an impact on how the clinician receives the initial contact and steps they will take to proceed with each case. The majority of participants in this study currently work in private practice, while some exclusively or partially work in agencies or schools. Most clinicians had experience working in a variety of settings prior to being in private practice. Clinicians in private practice had the maximum freedom to individualize their treatment procedures. Clinicians working in a school setting typically did not have an initial contact with the parents and at times elected to not engage the parents at all due to the limited nature of the supportive work they played with the child in the school setting.

Clinicians working in agency settings had some demands placed upon them to collect certain kinds of data. At times their role in the family’s treatment was designated for them by a supervisor or treatment team as opposed to the result of their own assessment and recommendations. Additionally, some agencies require parents to be involved therapeutically in order for their child to receive services.

In the majority of cases described in this study, clinicians were in a position to engage with the parents as they saw fit. Each clinician was unique in their manner of applying psychodynamic principles to psychotherapeutic work. The assessment and treatment approaches were largely influenced by each clinician’s background, training,

173 current practice norms, and their understanding of the nature of the presenting problem.

There was variation in how each clinician described what areas they typically assess with parents. Some clinicians spoke deliberately to not having a preset agenda or set of questions when engaging with parents initially. They were inclined to respond to the parental request for therapeutic support by listening to the parents and asking whatever felt relevant to the situation. Others had a definite set of questions or ideas, which they routinely found relevant to pursue or useful in the process. There were others working in agency settings, where more formal interview questionnaires and measures were used as a matter of course.

Generally, clinicians sought to have an initial meeting with parents in order to develop an understanding of the problem and to assess the parents. For adolescent patients, clinicians at times assessed in the initial phone call with the parents whether meeting with the parents first would be counterproductive in establishing an alliance with the child. In these cases, clinicians typically suggested a follow-up conversation or meeting after the clinician had met with the child and established a relationship that safely allowed for parent consultation. In the majority of cases described in the study, clinicians had at least one initial meeting with the parents prior to meeting with the child.

Several clinicians spoke to setting up the initial meetings with the parents in an open-ended fashion without defined limits or a prescribed ending. This approach has been suggested in the literature (Novick & Novick 2005, Siskind 1997) in order to develop a thorough understanding of the problem and environmental conditions as well as to build a working relationship with the parents. Siskind (1997) adds the need to

174 extend the evaluation to ensure clarity about who/what in the family is to be treated. She stated: In child treatment it is essential to extend the evaluation process until we have gathered sufficient information to know who and what in the family needs to be treated. Just because we have been consulted about a child does not mean that the child must become the patient. (p. 15) In some circumstances, particularly for those working through a treatment via the parent model (Furman 1957, 1969, 1995), clinicians sought to affect therapeutic change through the parents first and only when that proved ineffective or it became clear that individual work with the child would be beneficial would the child be brought into treatment. The Novicks (2005) describe the application of this approach to child cases in general as a means of situating the recommendation for therapy with parents. They state: The evaluation is not only to assess or diagnose the child, but first to assess the parents and to develop a working relationship with them. This turns parents into partners who can work with the therapist to see how far they can go in helping the child. Together, parents and analyst may reach a point where it is clear to all concerned that there are underlying problems, that there is more to the child’s story. Then a recommendation for therapy or analysis makes sense, as the goal of analytic treatment is to understand what is behind the symptoms. (p. 23) It was quite common in this study, however, that many clinicians were inclined to meet with parents once/twice in the beginning of treatment before meeting the child.

Clinicians that worked in this manner still sought to understand the problem and develop an alliance with the parents but found it unnecessary to have a prolonged introductory

175 period with the parents. Some clinicians described wanting to have more meetings with parents but noted that it was a challenge to enlist parental engagement in a prolonged fashion in many cases. The reasons for this varied. In most cases, the parents were convinced that the problem was located in the child and wanted external support for the child with minimal contact on their behalf. Clinicians who assessed in their initial meetings with parents that the problem was more complexly interwoven with the parents and sought to target their interventions with the parents generally ran the risk of parents choosing to end the treatment.

Clinicians described the primary tasks of the initial meetings with the parents to be understanding the presenting problem and to developing a working relationship with the parents. Each clinician offered various topics that they might deliberately assess during introductory meetings with parents and several clinicians described how they used the assessment process as a relationship building experience for both therapeutic and practical aims. Clinicians tended to approach the assessment in two distinct ways. In one method, clinicians inquired about a number of topics in order to develop a composite picture of the child’s symptoms in context of his/her development and the family’s history. In the other method, clinicians invited the parents to discuss what brought them to consult about their child and then proceeded to delve into areas that seemed pertinent to the discussion.

In general, the areas clinicians found relevant to consider were consistent with recommendations found in the literature (Mishne 1983, Glenn, Sabot & Bernstein 1992, Lieberman & Van Horn 2005, 2013, Novick et. al. 2005, Siskind 1997). The areas clinicians commonly pursued with parents were:

176 

Description of the presenting problem



History of the presenting problem



Child’s developmental history



Medical history



Trauma history



Loss history



Treatment history



Child’s current functioning



Child’s performance/conduct at school and other settings



Child’s interests, skills and positive qualities



Parent’s manner of describing the child



Parent’s relationship with one another



Pregnancy



Parent’s reactions and responses to child’s behavior and feelings



Parent’s degree of psychological mindedness and empathic ability



Parent’s experience of childhood



Parent’s experience of their parents



Family history



Genogram

Mishne (1983) pointed out that some parents are wary of a therapist asking personal and historical questions about them when they have consulted the therapist about their child. She noted that informing parents that the information is being sought in order to help understand the child diagnostically often eased parents’ concerns. Clinicians

177 in this sample also positioned their inquiries into the parents’ lives as related to understanding the child, but at the same time considered parents analytically and diagnostically. Clinicians remained open in the beginning stages as to who was to be the focus of the treatment. In much of the literature, parents are referred to as not being patients (Glenn et. al. 1992, Hirshfeld 2001, Mishne 1983, Novick et.al. 2005). This classification of parents’ status is a means of conveying that the object of the treatment is the child and that the parent’s psychology is relevant, but not worked with holistically as it would be in individual treatment for the parent. Siskind (1997) takes a stance on determining a parent’s patient status in a manner that is consistent with how clinicians in this study approached this formulation. She suggests that sufficient assessment of the parents and the situation on a whole is needed to determine who the patient is. Some clinicians directly spoke to the need to regard parents as patients even when the clinician was largely working with the child. Several clinicians regard the family or the parentchild relationship as the patient. Other clinicians did not speak to this distinction but approached their casework in a manner that left open the possibility of working with the parents therapeutically.

Parent Work is Rooted in a Developmental Framework Clinicians in this sample relied upon a developmental understanding of parents and children in order to evaluate the nature of the problem and to frame their interventions. Psychoanalysis and psychodynamic theory are inherently developmental.

They assume a lifelong developmental process, which progresses and builds in an accumulative and recapitulative sequence. Thus, it is not surprising to find that

178 psychodynamic child therapists approach their work from a developmental point of view.

However, the influential significance of developmental ideas is so pervasive in the collective approach that it amounts to an organizing feature of psychodynamic child therapy and work with parents. This developmental orientation and its influence on conceptualizing work with parents presents itself among the sample in a few overarching areas. The age and developmental level of the child and the parent’s developmental level and status in the phase of parenthood are both taken into account and various similarities in approaches are taken based on the assessment of these aspects and their interrelation in the presenting problem. Additionally, treatment is organized in a developmental fashion and follows a developmental trajectory of its own.

Clinicians in the sample worked with children from infancy (and parents when they were expecting) through young adults. There were subsets of clinicians in the sample that specialized in various developmental stages including early childhood, latency and adolescence. Many similarities among these practitioners were observed when considered in terms of the developmental stage of the child. In general, clinicians tended to be more involved with parents of children in earlier developmental stages and progressively less involved as children aged. The rationale for this methodological tendency is rooted in a psychodynamic understanding of child development. The fundamental understanding of child development is that there is a gradual progression from existing in a highly interwoven psychological relationship with primary objects in early life toward developing a relatively independent psychological structure that persists in an internally organizing manner. While theorists have stressed different processes and emphasized unique views of this developmental process, there is a unified sensibility that

179 such a developmental progression occurs in human development. In the earlier stages of a child’s life, a child is continuously influenced by the parents in the process of shaping an independent sense of self. This continues into later developmental stages, but the foundation of the child’s psychology is most significantly impacted in early life.

Parenthood as a developmental phase (Benedek 1959, Furman 1969) is a developmental concept referenced by several clinicians in the sample that organized treatments around these developmental processes. In the original formulation (Benedek 1959) described the unique nature of parental investment in the child and the parallel revisiting of the parents’ own earlier lives along with their child’s progression through developmental stages. Within the sample, clinicians often made two primary points about parenthood as a developmental phase. First, parenthood and parenting exist in a distinct manner from the rest of the individual parent’s psychology. While this is naturally formed by the individual parent’s character and personal history, it is foremost seen as a developmental phase and mental orientation unto itself. Clinicians stated as an example that a parent may be highly functional and adaptive in one area and troubled in parenting and vice versa. This indicated a sectioning off of the parental area of a parent’s personality. Furman (1969) discusses this idea by positing that this is the area of the parent’s personality that is addressed by the clinician, the part of the parent that is engaged in the act of raising a child and is thereby brought into special contact with their own relevant history related to the task and relationship at hand.

The second point clinicians made in regard to parenthood as a developmental phase was that parents’ experience of their own parents is evoked in the raising of their children. This can be the reemergence of hitherto unconscious aspects of their lives, often

180 aspects which have been profoundly influential in shaping their personalities. Also, parents recall their own parents and how they were parented (Benedek 1959, Furman 1969) in order to use these identifications within the role of being a parent, for better or worse. It is the implicit model they carry of how to parent. This is further elaborated by their earlier fantasies of being a parent and subsequent influential relationships which have acted on these themes. Parenthood offers parents an opportunity to rework challenging and unresolved aspects of their upbringing anew. Furman (1969) highlights the unconscious flexibility parents experience in the early years of being parents and the possibility for psychic transformation that is otherwise less accessible. One of the most common notions clinicians cited parents saying in regard to how they approach their parenting was that they did not want to do to their child what was done to them. Most clinicians in the sample also pointed out the importance of inquiring with parents about their experiences in childhood at the age of their child’s difficulties. Repetitions were noted to be common. Theoretically, at each successive moment and stage of development, parents are potentially placed in closer affective and mental contact with their own experience of being at this particular point in development. In areas where there are difficulties in the parental background, particularly in instances in which this difficulty was incompletely or inadequately worked through, parents are vulnerable to reexperience the original troubling affects and memories and have a greater likelihood of being impaired in seeing their child’s issue clearly or responding to it without conflict. In more severe cases of this sort of repetition are parents who are so compromised by the reemergence of repressed affects from their early childhood that they lose their capacity to parent. These are Fraiberg’s (1975) ghosts in the nursery.

181 Within Benedek’s (1959) original statement on parenthood as a developmental phase, she described the typical development of an intimate reciprocal relationship between a child and his/her parents. She traced it from a symbiotic form of relating in pregnancy to the early stages to a more differentiated manner as development proceeded.

This developmental line within the parent, the child and the parent-child relationship had great significance in the approaches taken among the sample to working with children and parents. It accounted for the rationale of clinicians to focus more emphasis on working with parents in earlier developmental stages and presented various complexities in treatments at all developmental stages.

Benedek (1959) described the state of the infant’s absolute dependence upon the mother and the mother’s symbiotic experiencing of this powerful relationship. One clinician in the sample gave an overview of a parent’s narcissistic investment in the child and how it organically wanes and is replaced by an objective investment in the child. He stated: Yeah, positive narcissism. In fact, one of her (Furman’s) points was that in the first weeks after birth, you know a woman who had carried the baby within her still felt the baby now on the outside to be literally an extension of her own body.

And it would be a gradual declining process of that feeling gradually subsiding but never really completely disappearing. And then conversely the ability to have an objective investment in the child would gradually increase and the child could truly then be seen as someone with a mind of his own, a person in his own right.

So, she would talk about this you know this crisscrossing kind of graph of narcissistic investment waning and an object investment waxing as the child grew.

182 Thus, clinicians in the sample found that in earlier developmental stages when the child was still so intrapsychically linked with parents that it made sense to provide psychotherapeutic support to the parent in the service of aiding in the child’s formation.

At times, this was exclusively regarded as the focus with parents of young children. Some clinicians in the sample discussed working with Erna Furman’s (1957, 1969, 1992) model of treatment via the parent, wherein the clinician would work exclusively with the parents in order to create therapeutic change. In other cases, clinicians conceptualized this as treating the parent-child relationship (Chethik 2000, Lieberman 1992, Lieberman & Van Horn 2005, 2008, Stern 1995), seeing the child’s symptoms or developmental struggles as one part of a dyad or family in need of support and thereby working directly with the parent(s) and child together. In each of these models focused on work with parents of children in early childhood, clinicians remarked upon the parents’ intrapsychic closeness to the child as a key variable to both understanding the child and providing interventions that would influence the parents to develop improved parental ability and thus care of the child outside of the limited hours of treatment. Many clinicians in the sample highlighted the limited nature of therapeutic contact and emphasized that parents have a much larger influence on the child than the clinician does. They noted that due to this and the extent of formation occurring in child development that in earlier periods of development it was more efficacious to intervene with parents alone or with parents and child together. As the child developed a more internalized and differentiated sense of self, the focus of treatment could shift to more individual work with the child. Parents remain an influential force in their children’s lives, but the advanced development of the child makes the child more amenable to external input.

183 The data showed further that more significant intervention or involvement with parents in later developmental stages as well as situations in which parents tried to work with the therapist more extensively on their own material that there were problems regarding the separation/individuation process. In each case where clinicians described such an issue, they also described the phenomenon as having roots in the parents’ experience of their own parents. Often, there was trauma, mistreatment, or neglect in the parent’s history, which was considered to be an influential factor in the child’s symptoms as well as the parents’ emotional reaction to the child and therapist. In these cases, some clinicians found it prudent, and at times unavoidable, to work with both the parent and the child simultaneously. This is consistent with the literature’s reports on the typical constituting factors in which simultaneous treatment (Chazan 1995) or tripartite therapy (Berlin 2002, 2005, 2008, Siskind 1997) is indicated.

In latency and adolescence, clinicians maintained a developmental orientation to their work with parents and children. Clinicians commonly met with parents of latency and adolescent children for an initial consultation and determined the appropriate means of therapeutic treatment. In general, clinicians offered the same range of supportive services to parents if desired and appropriate. No clinicians in the sample had a precondition that parents be extensively involved prior to commencing therapy with a child in latency or adolescence unless there were clear indications from the initial encounters with the parents. At the same time, all clinicians emphasized the importance of developing a working relationship with the parents to support the child’s treatment.

One clinician in the sample rooted parental motivation to support the child’s work in parents’ useable guilt and the wish for their child to do/be well. Furman (1969) describes

184 the common reaction parents have to their child having difficulties as guilt, which implies a sense of responsibility and empathy for the child stemming from the narcissistic and objective investment the parent has in the child. The Novicks (2005) incorporate Furman’s concept of useable guilt by emphasizing transforming guilt to useable concern as one of their aims of parental work. They highlight a key feature of this and other transformations as the parents’ “capacity to see the child as a separate person” (p. 24).

The capacity to desire and take responsibility for the welfare of one’s child is described as one of the hallmarks of being in the phase of parenthood. Where these capacities are lacking or compromised, one task of the clinician is to work toward the development of these capacities. At times, resistances stemming from deficits or conflicts in these areas in the parents do not surface until a child’s treatment is underway.

The Novicks (2005) have organized their therapeutic alliance tasks in a manner that demonstrates their support of the parents’ development of these capacities and promoting a healthy psychological separation between the parents and child. They identify parents as having the overarching tasks of “allowing the child to ‘be with’ another adult,… allowing the child to work together privately with another person,... and validating the child’s progression” (p. 20) in the course of the child’s treatment. These aspects were shown to be highly salient in the process of individual treatment with latency aged children and adolescents within the data. Clinicians described various issues in regard to these themes in conducting individual treatments. In many stages of development, parents at times struggled with the nature of confidentiality of the child’s treatment. This was one reason clinicians gave for needing to be actively and regularly involved with parents in the course of their child’s therapy. Siskind (1997) points out

185 “that children have a right to confidentiality and parents of young children have the right to have contact with their child’s therapist and to get both feedback and help” (p. 227).

Clinicians in the sample were consistently conscientious of both needs in the course of their work. Some clinicians emphasized their approach of developing an understanding of what the parents were needing in their request for information about the child’s treatment and finding ways to meet those needs without compromising the child’s confidentiality.

In early childhood and latency, clinicians described a frequent need to explain to parents the importance of a child’s play and how this it is useful therapeutically. They noted that many parents have an expectation that children conduct therapy in a verbal manner that is out of sync with their developmental level and place pressure on the therapist to either conduct treatment in that manner or justify the method of play therapy. Clinicians generally took this as an opportunity to work with the parents in a manner that assuages their anxiety by helping them understand their child’s means of communication through play and the ways a therapist might use that material.

A noteworthy shift occurred in some reports in the practice of individual treatment with adolescents in respect to confidentiality. Some clinicians did not automatically meet with parents before beginning a treatment with an adolescent. Rather, they would screen with the parents what impact meeting with them first might have on the child’s experience of the clinician and therapy. Some clinicians in some cases decided to meet with the adolescent first and involve parents after discussing it with the adolescent. Others had the initial consultation with the parents and the adolescent together in order to have full transparency and to explain the guidelines of confidentiality to all parties at once. Again, these approaches are informed by a developmental

186 understanding of the needs of an adolescent who is in the process of forging their own identity (Erikson 1950). These clinicians maintain a mindfulness about the child’s level of separation/individuation and assess for this in their interactions with the adolescent and his/her parents.

Finally, there were a couple of developmental patterns that were highlighted in the overarching process of working with parents in a child's treatment. Both demonstrate a corollary to typical development in that there is much more significant involvement between a parent and child in the earlier phases of life and this gradually shifts to lesser intensity and active engagement. Clinicians in the sample mirrored this developmental process in their conceptualization of the frequency of parent contact along with a treatment. Also, in most cases, parental involvement was more frequent in the earlier stages of treatment itself and progressively diminished as child treatments went on. In this respect, the level of a clinician’s involvement with parents followed the developmental progression of the child, with the parent’s needs and work with the therapist being subsumed under that overall aim. Additionally, clinicians were more intensively involved with parents of children that were seen with greater frequency. For example, the common practice cited by analysts treating children in 4-5 day per week treatment was to meet with parents weekly or biweekly. Whereas clinicians providing weekly or less frequent treatment, noted working with parents monthly to quarterly.

187 Parent Work is Focused on the Child, the Parental Aspect of the Parent and the Parent-Child Relationship Clinicians working with children and parents have a developmental framework for understanding child behavior, human development, and parent-child relations. Within this developmental framework, clinicians also have a conceptualization of parenthood as a developmental phase, with unique attributes that distinguish it from other embodiments of adult development. Working from these developmental theories and practice wisdom, clinicians have developed techniques which enable understanding and treating psychological, social, behavioral, emotional and relational problems as they present in the development of the child and within the parent-child relationship. Within this orientation, clinicians have distinct interventions at their disposal depending on the developmental status of the child, parents or both. Due to the complexity of serving in an individual clinical capacity for more than one member of a family, clinicians in general have developed an approach to working with parents that is limited in its scope of work with parents individually and is focused upon resolving difficulties in the child’s development, supporting the parental aspect of the parent and improving the parent-child relationship.

This limited scope and focus is consistent with the aims of child and adolescent work that the Novicks (2005) describe: 

Restoration of the child to the path of progressive development.



Restoration of the parent-child relationship to a lifelong positive resource for both. (p. 17)

In each of the approaches to working with parents described in this study, clinicians viewed their role as helping parents understand their child, supporting parents in their

188 parental function and improving the parent-child relationship. This is consistent with Hirshfeld’s (2001) findings as well as the foci of parental work outlined in the majority of literature on the subject (Chethik 1976, 2000, Cooper & Wanerman 1977, Furman 1957, 1969, 1992, 1995, Glenn, Sabot & Bernstein 1992, Mishne 1983, Novick & Novick 2005, 2013, Siskind 1997). In Hirshfeld’s (2001) study as well as some of the literature (Cooper et. al. 1977, Glenn et. al. 1992, Novick et. al. 2005, Siskind 1997), parents are referred to as not being patients in the traditional sense. They are not presenting themselves to the child therapist in a manner that seeks relief and change through a method of working individually on anything that may be relevant and troubling in their personal lives and psychologies. Rather, parents are consulting a child therapist in order to address problems that are occurring with their child. Thus, clinicians in the sample organized their approach to working with parents in a limited and specific fashion of attending to the parents with the focus being on the child and aspects of the parent that are in relation to or affecting the child. For a majority of the clinicians in the sample, if a parent’s needs extended beyond matters that involved or affected the child, this was treated as an indication that the parent should be referred for individual treatment.

This focus significantly influenced the manner in which clinicians in the sample assessed and worked with parental history in the context of a child’s treatment. Clinicians explored a parent’s history in a manner that was explicitly stated as pertaining to understanding the child’s symptoms, the parent’s challenges in responding to the child, and the nature of the disruption in the parent-child relationship. Parental history was regarded as an influential determinant of parental behavior and affective experiences in raising a child. Several clinicians noted that parents often experienced relief at becoming

189 aware of the links between their childhood experiences and their current experience of raising their child. In positive experiences of this, parents used the insight to develop empathy for themselves and their child and a more empowered point of departure for making choices in their responses to their child. In some circumstances, clinicians described situations that led to heightened resistance in the parents, at times resulting in parents choosing to end the treatment. These latter circumstances highlight the delicacy of the boundaries of parent work. While it may be highly relevant to the child’s condition, parents vary in their ability to make use of an interpretation that links their past and the present situation.

A psychodynamic child therapist’s concern in working with a child is foremost to develop an understanding of the meaning of a child’s behavior, affects and thoughts/fantasies. Clinicians in the sample highlighted their dedicated view that behavior has meaning. For many parents who consult a therapist, a child’s behavior may not be regarded as such. Rather, parents may, for many reasons, view the behavior simply as a problem to be eradicated and appeal to the therapist to support them in this endeavor.

Toward this end, many clinicians in the sample described the need to help parents recognize and incorporate the meaning behind behavior into their relationship with their child. They also noted the need to help parents bolster or develop means of tolerating, regulating and symbolizing affective states. In general, this can be seen as the development of reflective functioning (Slade 2008a, 2008b) and mentalizing (Fonagy 1993, 1996, 2002) in parents.

Clinicians in the sample routinely emphasized needing to approach any form of parent guidance or parent education with empathy and awareness of how delicate parental

190 narcissism may be. Many clinicians in the sample did discuss providing parents with information about typical child development and at times advised on how parents might intervene with or respond to their child. However, most clinicians were exceptionally cautious in providing such information to parents and maintained an analytic curiosity about the nature of the parental request or the clinician’s impulse to advise the parent.

This is consistent with the cautions advocated for in the literature on parent guidance (Chethik 2000, Cooper et. al. 1973, Glenn et. al. 1992). Several clinicians remarked on the importance of respecting a parent’s role in working with parents in all situations and particularly when providing guidance. One clinician remarked: The other most important thing is you can’t replace the parent. You have to find a way to have empathy for them even when they’re doing things you think are not in the child’s best interest. And try to understand why they’re doing that, how they are doing that and help them see their way to some better place in parenting.

Rescue fantasies and muddled identifications were noted as common pitfalls, transferences and countertransferences in working with children and parents as has been noted in the literature (Siskind 1997, Novick et.al. 2005). The clinician emphasized it here to suggest a grounding antidote to these situations and to point to another guiding principle that pervaded clinicians’ approach to working with parents. Namely, a fundamental respect for the parent’s role as the parents was considered an essential component of the clinician’s work with parents.

191 Implications for Future Research Within this study, all clinicians viewed working with parents as an essential component of child treatment. However, they did mention an awareness of colleagues who choose not to involve parents extensively. In future studies on the topic of parental involvement in child treatment, it would be important to add the perspectives of individuals operating from a psychodynamic perspective and do not involve parents in treatment.

The sample in this study was relatively homogenous. All individuals in the sample were white and worked predominantly in relatively affluent settings. Some clinicians in the sample worked in social service agencies and others provided treatment to a diverse clientele in terms of socioeconomic status and race/ethnicity. However, for the most part, the findings in this research reflect current practices among psychodynamic practitioners working in private practice with a clientele that was also largely comprised of educated and financially comfortable individuals. While the thinking and general concepts outlined in this study seem likely to be inclusive of individuals from varying backgrounds, it also is plausible that working with individuals with greater economic hardship, less education and facing various forms of social dynamics not highlighted here would present other considerations to be factored into a comprehensive understanding of working with parents in child psychotherapy.

Toward this end, several participants in this study discussed some theoretical and practical challenges in working with parents of children whose gender identity is other than consistent with their natal sex, particularly children and families who are considering gender reassignment medical procedures in early developmental stages.

192 Clinicians in the study noted a need for updated literature on the subject and various complexities such a dynamic introduces into the treatment. Specifically, within the findings outlined here, clinicians being sought for parent guidance in these situations is particularly high and the potential meanings of the child’s identity could be manifold in the family system. And while the general attitudes and established professional approaches would approach such a situation as any other that was presented for consultation, clinicians in the sample seemed less sure-footed about how to appropriately work with children and families in this area. Thus, some dedicated consideration for working with parents in these circumstances is a needed area of future exploration.

Several clinicians raised the topic of neuroscience and expressed the need for the literature in this area to be more descriptive and applicable to clinical practice. Some clinicians described using some concepts drawn from neuroscience in discussing a child’s difficulties as relating to or stemming from innate biological factors. Clinicians found these types of explanations to be useful to parents in that it allowed parents to create some emotional distance from the child’s difficulty and to view and respond to the child with greater clarity and understanding. So, while there is not a direct link between neuroscience literature and working with parents, clinicians who do reference body and brain-based phenomena in their work with parents would benefit from more studies being done on the use of such information in context of parent work.

Insofar as work with parents is individualized on a case-by-case basis, certain concepts within psychodynamic theories are not simply applied in general.

Intergenerational transmission of disturbance, transference, separation/individuation and resistance are all intricately contextualized phenomena that are likely best observed in the

193 analysis of individual cases. Thus, subsequent studies may be conducted doing in-depth analyses of individual cases to demonstrate the function of these dynamics in particular cases in order to portray how these phenomena are worked with clinically and to examine the points of therapeutic action. Furthermore, the greater the intensity of treatment and parental involvement, the more potential the clinician has to observe these dynamics and make therapeutic use of them. While most clinicians in this study referenced each of these topics, clinicians providing therapy once/week and having less frequent contact with parents tended to emphasize the finer workings of these dynamics less than clinicians who treated children multiple times per week or in psychoanalysis. This was in part attributable to the general nature of the research question and what particular clinicians chose to emphasize in their responses. Thus, it would be useful to specifically study how these significant concepts are observed and worked with in weekly psychotherapy.

Finally, several cases were presented in this study in which psychodynamic treatment led to significant improvement in children who were seen initially to be on the autism spectrum or otherwise atypically developing. Due to the clear indication that this form of treatment can lead to progressive development in these children and that without it they may continue to develop in a more autistic manner or further relying upon autistic defenses, it would be useful for studies to be conducted on this topic to demonstrate psychodynamic psychotherapy’s efficacy in this area.

194

Appendix A Recruitment Letter

195

David A. Sisk, LCSW 588 Lincoln Avenue Suite 200 Winnetka, IL 60093

Date Agency/Individual Name Title Company Address City, State, Zip Code To Whom It May Concern: My name is David Sisk. I am a doctoral candidate at the Institute for Clinical Social Work. I am looking for participants for a research study I am conducting for my dissertation. The name of my study is Working With Parents of Children in Psychodynamic Psychotherapy. I am looking to interview practicing clinicians in regard to how they conceptualize and conduct their work with parents.

Within this study, I will interview 10-15 psychodynamically oriented clinicians providing child treatment. Each interview will last 45-60 minutes. Each participant will be offered a $25 gift card to Amazon in gratitude for his or her participation.

If you or someone you know is a psychodynamic psychotherapist with at least 5 years post-graduate experience is interested in participating in this study, please contact me at (773)732-5073 or david.sisk@gmail.com

Sincerely,

David A. Sisk, LCSW

196

Appendix B Consent Form

197

Leave box empty - For office use only

Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research [Insert Study Title] I, , acting for myself, , agree to take part in the research entitled Working With Parents of Children in Psychodynamic Psychotherapy.

This work will be carried out by David A. Sisk, LCSW (Principal Researcher) under the supervision of Joan DiLeonardi, PhD (Dissertation Chair or Sponsoring Faculty) This work is conducted under the auspices of the Institute for Clinical Social Work; At Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; (312) 935-4232.

Purpose (Include short paragraph stating that the study involves research, the purpose of the work, what use may be made of the result) The purpose of this study is to explore how practicing psychodynamically oriented clinicians conceptualize and conduct their work with parents of children in treatment. The aim is to discover the critical factors that inform the therapist’s decision-making and treatment planning. Within current theoretical and clinical literature on the subject, authors are arguing for the need to include parents more in child therapy and for scholars and researchers to investigate and delineate this area of practice. This study seeks to add to this emerging literature by interviewing practicing clinicians and aggregating these findings into a basic theoretical

198 framework that can be used to inform clinical practice, serve as the basis for further investigation and provide education to clinicians in training.

Procedures used in the study and duration Short paragraph describing the protocol, measures, duration and payment (if any).

Participants in this study will undergo a one-hour in-depth individual interview.

Participants will be asked to share their thoughts on the topic of working with parents in treatment, to provide examples from their practice that illustrate their methods, discuss how they were trained and what they draw upon to inform their decisions, and to convey areas of this practice that they feel are not well documented, understood or consistent with existing literature and common practices. Participants will be provided a $25 amazon gift card in gratitude for their participation.

Benefits Describe the direct benefits to the subject for participation in the study. Payment is not considered a benefit. If no benefits accrue directly to the subject, state that clearly.

Include general benefits to society, knowledge here.

This study aims to add to the existing literature on working with parents.

Participants will benefit by having an opportunity to contribute their thoughts and experience to the ongoing dialogue in the field about this area of practice. The interview will also provide a dedicated time to think critically about working with parents and allowing participants to reflect on their professional practices.

Costs Describe any monetary costs to the participants (for travel, tests, etc.). If the costs are being covered by a sponsor or by the researcher, state that. If there are no costs associated with participation, state that explicitly.

The only cost associated with participation is the one-hour time commitment to undergo the interview. To the extent that it is possible participants will be interviewed in their offices. The researcher will travel to the participant. In a case where a participant is not able or interested in conducting the interview in their office, the researcher will offer to meet in his office. In this case, the cost will be of time in transit to the researcher’s office.

Possible Risks and/or Side Effects List any known risks, including inconveniences or negative emotional responses that may as a result of participation. State what measures will be taken to minimize discomfort/hazard and what reimbursement/treatment will be given should possible risks materialize. If you cannot predict the risks because there is no body of knowledge concerning a procedure like the one you are using, state that the risks cannot be predicted.

The nature of this discussion is an inquiry into the professional practices and thinking of a licensed mental health professional. Working with parents, children and families can be an emotionally challenging form of psychotherapy. Thus, participants

199 may be revisiting cases that were strenuous, stressful, disheartening or confusing. This is unlikely to cause any significant distress to a practicing clinician. In the event that discussing their thoughts and case material significantly overwhelms a participant, the researcher will offer to terminate the interview and provide a referral for professional consultation or psychotherapy.

Privacy and Confidentiality Define clearly how the participant’s privacy and the confidentiality of the data will be protected. Outline the procedures for keeping identifiable data separate from rest of research data and describe how the data will be disposed of.

Each participant will be assigned a research code. The convention will be research participant gender (M/F/O) number participant in the study. For example, F1, M7, 09. A list of the corresponding participants names and contact information to this list will be held on an encrypted hard drive and will be deleted upon completion of the project. The reason for maintaining an identifiable list is that the researcher may need to contact the participant with a follow-up or clarifying question. Participants will be encouraged to share confidential data of their treatment cases and professional practices. Participants will be notified that their examples may be used in the final report of this study.

Participants will be asked to conceal the identity of their patients/clients in a manner that is consistent with professional practices in writing about patients. These methods may include: using an alias for the patient, changing the gender, age and other identifying information in a manner that does not compromise the clinical utility of the communication. In situations where there is concern about the use of patient confidentiality, this will be discussed directly with the participant. All transcripts and working documents will be stored on an encrypted hard drive. All personal notes of the researcher and printed documents will be stored either on an encrypted hard drive or in a locked file cabinet.

Subject Assurances The following is the format that should be followed in creating the assurances: By signing this consent form, I agree to take part in this study. I have not given up any of my rights (my child’s rights) or released this institution from responsibility for carelessness.

I may cancel my consent and refuse to continue in this study (or take my child out of this study) at any time without penalty or loss of benefits. My relationship with the staff of the ICSW will not be affected in any way, now or in the future, if I (or my child) refuse to take part, or if I begin the study and then withdraw.

If I have any questions about the research methods, I can contact David A. Sisk, LCSW (Principal Researcher) at (773)732-5073 or Joan DiLeonardi, PhD (Dissertation Chair/Sponsoring Faculty), at (847)824-0892 on weekdays (day), Between 9 am and 7 pm (evening).

200 If I have any questions about my rights – or my child’s rights – as a research subject, I may contact Dr. John Ridings, Chair of Institutional Review Board; ICSW; At Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; irbchair@icsw.edu.

Signatures [All consent forms must be signed and dated. They must be explained to the participants and witnessed by the person who is explaining the procedure.]

I have read this consent form and I agree to take part in this study as it is explained in this consent form.

Signature of Participant

Date

I certify that I have explained the research to (Name of subject) and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward.

Signature of Researcher Revised 14 Oct, 2015

Date

201

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