The best books on Child Psychotherapy

How would you introduce the subject of child psychotherapy?

It’s well known that Sigmund Freud discovered the child in the adult, while his patients practised free association on the couch. Melanie Klein then went on to excavate the infant embedded in the child, starting off the profession of what became known as psychoanalytic child and adolescent psychotherapy. This evolved from her first analyses of her own and her friends’ children (not something which would be acceptable in our more advanced understanding now of how treatment works) to become one of the major treatments in the British National Health Service for unhappy, deprived and traumatised children, as well as those with serious psychotic illnesses.

Is this done in the same way as one would psychoanalyse an adult?

The couch, of course, is not an option with a small child. Klein introduced a box of toys into the playroom, and willingly took on the roles and rules her small patients assigned to her in their play: the naughty dog, the disobedient child, the monster mummy. Parents were transformed in the children’s minds into tyrants, children into saints and sinners. Klein soon realised that play was the child’s royal road to the unconscious, and that little children’s worlds, like those of adults, were battlegrounds of love and hate: the wish to love and preserve being undermined by the wish to possess and destroy, from the beginning, and from the first bodily experiences of satisfaction or frustration. It’s only gradually, she argued, that these two warring aspects can be brought together into some kind of integration. Whether we ever achieve this fully is doubtful, but we can try. This is a potent conflict and explains in part why children (and adults) were so gripped by the Star Wars series of films – what Klein laid bare were the internal world wars at the heart of every ordinary child’s mind. She and Freud’s daughter Anna were the first major child practitioners, with Klein working privately (and her teachings later became the foundation of thinking at the Tavistock Clinic – an internationally renowned training centre) while Anna Freud established first the Hampstead War nurseries [which provided foster care for orphans], and later the Hampstead Clinic which was renamed the Anna Freud Clinic after her death, and is now a world-renowned centre of research.

Were Klein and Anna Freud friends?

There were differences and difficulties between them from the beginning, a conflict which you could see in a broad sense as being their struggle for the honour of being Freud’s true daughter. In personality they could hardly have been more dissimilar: Anna Freud was a quiet, shy woman, while Melanie Klein, as her biographer Phyllis Grosskurth averred, was ‘absolutely never shy’. After several skirmishes along the way, their theoretical differences resulted in a head-to-head confrontation called ‘The Controversial Discussions’ from 1941-5, where the two women and their respective followers battled about theory and technique. It was a prolonged and rather damaging conflict, which resulted in the formation of three psychoanalytic schools, the Freudians, the Kleinians and the Independents.

In Narrative of a Child Analysis Klein describes her work during the war with a 10-year-old school-refusing child, Richard, when they were both evacuated to Pitlochry. Unsurprisingly, Richard co-opts Hitler and the opposing armies and navies into his own private internal war, his Empire of Mum, as he called it, giving Klein the opportunity to show in detail day by day the unconscious conflicts and rivalries which had produced such profound anxiety in the boy. Richard wanted to be sole possessor of his mother’s love, to the exclusion of his father and brother. Here was Freud’s original notion of the Oedipus complex writ large.

  Is this different from Anna Freud’s technique?

While Klein exposed a word full of phantasied people or ‘objects’, dramas played out on an internal stage, Anna Freud developed her ideas about the mind full of powerful impulses needing to be managed by the ego’s reality sense and the superego’s moral sense. Klein remains best known for her work with very young children, but Anna Freud’s work centred more on the school-age child. The interpretation of the raging id, that seething cauldron full of unacceptable and uncivilised urges, was, she thought, ‘only a means to an end’ and she saw the ego as ‘the proper field of observations. It is, so to speak, the medium through which we try to get a picture of the two other institutions’. She was much more open to the notion of the power of environmental influences, and the primary significance of the parents (which meant she rejected Klein’s idea of a child having a transference to the analyst from the beginning). The Psycho-Analytic Treatment of Children, written in 1927, sums up her views, her theoretical framework and her profound criticisms of Melanie Klein. Later she wrote persuasively about adolescence, and all her work was collected and published in 1974.

Tell me about Winnicott’s Playing and Reality.

Donald Winnicott can be seen in a sense to link the points of view the two women represented, and of all these pioneers he is perhaps best known today, with catchphrases such as ‘the good enough mother’ being in general currency. While there may sometimes be a misperception around about his being too ‘fluffy’ and ignoring of aggression, this was the man who wrote the paper ‘Hate in the Counter-Transference’, following his experiences of giving shelter to a disturbed adolescent during the war years. How much weight do you give to the personality of each child? How much is to do with the environment and the impact of experience? Winnicott worked with Klein when she was researching and writing about the importance of primary splitting in the early infant mind: that at the beginning the baby needs to have a very strong sense of what feels ‘bad’ – the ‘bad object’ – and what feels ‘good’ – the ‘good object’. He gained a huge amount of understanding through her theory and technique, but more and more realised the paramount importance of the early environment, and his developing views, based on many years of work as a pediatrician, meant that the two drifted apart. He was in a real sense ‘the people’s psychoanalyst’, and he gave countless radio broadcasts, talks and interviews as well as writing academic papers. One of Winnicott’s other well-known sayings remains ‘there’s no such thing as a baby; only a baby with someone’ – in other words, the personality unfolds, grows and matures in relationship, first with the primary caretaker and immediate family, and then this template forms the basis for future relationships. So, far from being, as some popular thinking would have it, antithetical to a Kleinian object relations perspective, the two pioneers (pace Klein) are complementary, as Klein always maintained that the baby is person-related from birth. Both of these views have been amply confirmed by subsequent infant development researchers, who have charted both in the laboratory and in the home the micro-analytic ‘dance’ which occurs between mothers and infants. These actually show us, with film and video, the very beginnings of the development of the personality which is a two-person concern from the start, indicating the complementarity of Winnicottian and Kleinian views.

Winnicott’s Playing and Reality, not published till after his death, is a fine and illuminating collection of his major thinking, important not only because of the work with children (just pick any page and there is something to ponder, such as the therapeutic use of string, for instance, or why a teddy bear may be alternately loved and abused by its child owner) but because of the way he shows how the ‘transitional space’ which develops as the baby separates from the primary caretaker will later become ‘the location for cultural experience’. This is the space where creativity flowers in adult life, and he makes a convincing and heartfelt case for this adult play to be respected in all its aspects ‘for we are poor indeed if we are only sane’.

And Live Company, Anne Alvarez?

My last two choices represent some of the finest and most influential work currently available in a continually evolving field. First of all, Live Company by Anne Alvarez remains a seminal choice both for experienced clinicians and those starting out in the practitioner field. Alvarez, whose early thinking was based on many years of working with a particular autistic patient, is characteristically honest about how we all develop through our mistakes rather than our successes. She addresses, among many other essential topics, the importance of differentiating potency from omnipotence, and idealisation as a development rather than a defence in the treatment of children whose lives may then emerge from the despair generated by early experience. How can one go about reclaiming a mind? Alvarez’s work is always underpinned by clinical examples, and offers different and thought-provoking takes on ‘classic’ ideas, such as the meaning of play as seen by Freud and Klein, in a chapter called ‘Beyond the Unpleasure Principle’. The title of her book is a reflection not only of what the baby needs to grow, but of what we all need in order to take our thinking forward in a way which makes sense, and which works, in the company of our own ‘good objects’.

Lastly, the Lanyado and Horne book, A Question of Technique.

Monica Lanyado and Anne Horne’s A Question of Technique also represents years of work, where two Independent practitioners have brought together a collection of excellent papers from colleagues about what actually happens in the therapy room, how you deal with pressures and make decisions which need to be taken on a daily basis. While Anne Alvarez could be thought of as an ‘independent Kleinian’, the contributors to this second book work out of the tradition of Winnicott. There is much here on the adolescent as well as the looked-after child, brief consultations as well as longer-term work – the book as a whole is full of what Anne Horne calls ‘interesting things to say’ and ponder on. In one of the final chapters Horne describes how she sat in the car with an adolescent with gender identity difficulties when he refused to come into the clinic, and how they laughed together when they were both then trapped by the child lock, just as he decided he could indeed get himself in to the consulting room. Was it ‘right’ to get in the car? Was it ‘right’ to laugh? Can psychotherapy sometimes be playful? Can we carry on discussing such issues as innovations rather than deviations? Together, these books represent the sort of grounded wisdom which drives theory and practice forward, in a discipline which continues to evolve. Its premises have been borne out by complementary research in child development and neuroscience, as the exploration continues into the ‘music’ of what happens, in life and in the consulting room.