hirty-three years later, the present NYIPT child therapy program is the thriving grandchild of the program I organized in 1973 at the New Hope Guild Center using psychoanalytic principles to treat emotionally disturbed children.

The wonderful background of theory and practice in child therapy afforded to us by the great contributors of the 1930’s has remained the solid rock upon which we have been able to continue our work today.

The use of Freudian psychoanalysis for adults was expanded to more specifically treat the problems of the child by Melanie Klein, Anna Freud, Donald Winnicott, Margaret Mahler, Fred Pine and Anni Bergman, among others. It is through their work that we can now apply such theoretical concepts as the primary and secondary process, the early oceanic feeling, the paranoid schizoid and depressive positions, the ego and mechanisms of defense, transitional objects, symbiosis and individuation, and so on. We now work with transference and countertransference and we have come to know the developmental lines to understand special problems from infancy to adolescence. In addition, we have been able to gain the cooperative ego of parents who are seen in monthly collateral visits to supplement the child’s weekly sessions.  

Today we are faced with difficult problems, such as physical and sexual child abuse, drug addiction and mental disturbances in both birth and foster parents, and severely unstable home environments. We can no longer be principally concerned with the child’s psychic stress. In these extreme cases, the reality-unreality balance has tipped toward the soma-psychic response to physical abuse. Projective identification with an internalized  persecutory  object  may still operate  in the psyche, but grounds  for persecutory feelings in abuse cases have a reality base. The post traumatic stress syndrome has a history which cannot be dealt with by a purely psychoanalytic approach.

We are now in a position to re-evaluate the old accepted notions of the relative balance between the psyche and the soma, between the influences of each in these cases and to choose the right road to travel. What are these accepted notions?

It has astonished me to find so many paradoxes involved. For example: there is no dichotomy between mind and body. Post Freudians have found the opposite to be true. The “Existential Paradox” tells us that the mind is symbolic and functions with a psychic awareness of self, whereas the body is creature-like and finite. But before we get to “finite” we have the whole story beginning with Freud’s discovery that in “conversion hysteria” unresolved fantasies could produce a body symptom with no anatomical defect. Other symptoms involved with reality-unreality problems were classified as psychosomatic, and when they appeared in children they were successfully treated by Melitta Sperling. Winncott believed that the tolerance of illusion is necessary for the formation of a transitional object and for a true self to develop. On the other hand, Melanie Klein used only psychoanalytic theory to treat two very young brothers who were sexually acting-out with each other and they were treated by interpreting the sadism and masochism involved.

Further development in areas specifically related to child therapy brings us to an appreciation of Mike Eigen and his understanding of Wilfred Bion whose ideas opened the psychoanalytic door to the unconscious communication between mother and child called “content and container.”

The gist of these paradoxes highlights the reality-unreality problem as a psychoanalytic conundrum and one for psychoanalysts to resolve as it relates to neuroses and psychoses. But what is the relevance for the physically abused child?

The opportunity afforded me as a supervisor of therapists working with today’s abused children, gives me direct access to their history as a presenting problem and how the needs of these patients deviate from the formerly accepted “psychoanalytic treatment” model. How can we use a “band aid” for bruises sustained in abuse cases?

Freud’s hope for a curative therapy for all mankind was “to fuse the copper of suggestion with the gold of psychoanalysis.” But he lived in a world of “Civilization and its Discontents” where all people were considered as living in the civilized mold. We are now living in another world --- that of globalization and its terrors. We recognize child abuse as one of its manifestations. It seems important that we look back now so we can see the huge disparity between “the then and the now,” and its relevance for the new picture of child therapy today. 

In the world of the 1970’s the psychoanalytically based treatment of children was carried out in the expectable environment of a cooperatively oriented parental involvement. It was within this setting that the parent and child therapist could work together so advantageously for the child. A scrutiny of today’s cases reveals that these favorable conditions can no longer prevail. In their place, we have chaos, both in terms of living conditions and parenting.

In many of these cases, the child’s parents were born and raised outside of the United States. They talk about their early years as troublesome and how they had to cope with life in places like Puerto Rico, Jamaica, Trinidad and Mexico. Many have struggled with overwhelming trauma, and psychoanalytic language and concepts are new to them. Disaster, in one form or another has led to their present turmoil. In one recent sexual abuse case, the father is a vagrant living in the street and found to have criminal intentions. The foster mother in another case takes in children as a money-making proposition. It is not uncommon in today’s cases to find parents who are homicidal, suicidal, and/or addicted to alcohol and drugs.  Many parents are unavailable for monthly collateral sessions with the child therapists.

On the other hand, the child coming for treatment is very much like the 70’s child – transferentially interacting and psychoanalytically available. The result is a need for a two–pronged approach; on the one hand, to “fix” the needs of the parents and on the other, to attend to the needs of the child. We have to agree with Freud that a “suggestion” technique might be a fitting adjunct to psychoanalysis in these instances.

Our past experience with psychoanalytic techniques still serves us well where we can effectively use them, but something else has to be introduced to deal with cases where the environment is so chaotic.

What to do can only be worked out with a better understanding of what we are “supposed to be” doing by the parents who bring the children in the first place. Their attitude sometimes suggests that we’re in business here to correct the “naughty child.” We get paid for it – sometimes by them or mostly by the government. It’s purely a business where they’re doing their part by bringing the child, and they say, “now go ahead and do yours.”

Where any indication of an opening into a better self-adjustment in the parent exists, we can hope to work more psychoanalytically with them as we have in the past.

But to deal with damaged bonds experienced by the abused growing child, I have found Mike Eigen’s reference to be helpful in his book on “Damaged Bonds.”  It is not possible to remove the damage to self by removing the “damage” object (e.g. residues of a depressed or psychotic or abusive parent); the damage is done. The only resource that remains for us is a preventive one; to prevent further damage by improving some of the environmental chaos in the here-and–now.

Traditional social work case-intervention certainly would seem to hold promise as our elusive “band aid.” We need the expertise of our traditional case workers to come to grips with deplorable living conditions, with family counseling with any of the home corrections where needed - even in the preservation of life itself where criminal intent is openly displayed and in need of legal mandates.

In view of the foregoing, social work/case work where needed would seem to be a viable new dimension in child therapy today on an equal footing with psychoanalytic technique for those cases where extreme abuse occurs.

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