Nr 18. 2008 sid. 110–124
Vad är ett rum för psykoterapi?
En psykoterapeutisk behandling kan ske under många olika yttre förutsättningar. När vi tänker på faktorer runt och i terapeutens rum är det inte alltid så att det ens finns ett eget rum för terapeuten. En psykoterapeutisk behandling kan ske hemma hos patienten, på sjukhus vid patientens sängkant, via telefonkontakter och på många andra upptänkliga sätt. Det viktigaste är att terapeuten kan skapa en ram för det möte som sedan kommer att ske.
I den här artikeln vill jag fokusera på det psykoterapeutiska rummet i psykoterapier med barn i mycket konkret bemärkelse, dvs. en arbetsplats, där en person (terapeuten) ansvarar för att settingen kan hjälpa den andre (barnet) att finna uttrycksformer för det psykiska lidandet och den bristfälliga utvecklingen.
Många barn pratar gärna, men oftast inte om det som föräldrarna sökt hjälp för. Det är alltför komplext och obegripligt för ett barn att kunna reflektera och i ord förmedla sitt eller familjens dilemma. Hade de redan tillgång till tankar och ord för det som bekymrar dem eller familjen, så hade man i de flesta fall redan kunnat hantera detta inom familjens hägn. De flesta behöver därför andra kanaler och uttrycksmedel för att förmedla och arbeta med sitt psykiska lidande.
Det kan tyckas väl
detaljerat att lyfta fram sådana självklara fenomen som väggar, dörrar
och fönster. Men efter att ha följt många terapeuters stretande med
dessa yttre faktorer kan några ord ändå vara på sin plats.
Dörren är en annan självklarhet, men inte alltid så enkel. Själv arbetade jag under en period i ett rum där dörren inte hade någon tröskel och en glipa som inte var många millimeter kändes som ett Ginungagap – en oändligt stor öppning där ord och andra ljud strömmade både ut och in. Många barn är mycket upptagna av just dörren. Den kan bli en första upplevelse av att barnet själv kan reglera fenomen som släppa in/släppa ut/stänga ute. Markeringar för upptaget (skyltar, ljussignaler etc.) får ofta en mycket stor betydelse, speciellt för dem som har svårigheter med gränser mellan upplevelsen av ett själv och andra.
What is a room for psychotherapy?
Psychotherapy can take place in various settings. When thinking about issues concerning the therapist’s room it might even be the case that no such actual room exits. A psychotherapeutic treatment can take place in the patient’s home, at a hospital by the patient’s bedside, via phone and in many other conceivable ways. The crucial question is how the therapist manages to create an adequate frame for the meeting that is to occur.
In this article I will focus upon the psychotherapeutic room in therapies with children in a very concrete and tangible sense, i.e. a working site where one person (the therapist) is responsible for arranging a setting, where another person (the child) can find ways of expressing his/her psychological suffering and flawed development.
Many children talk a lot, but scarcely about the things for which their parents turn for help. The experiences concerning his/her or the family’s dilemma are far too complex and difficult for a child to contemplate upon and explain to someone else. If these kinds of thoughts about the family’s distress had been accessible to them, this had probably already been taken care of within the family or the closest network surrounding them. Therefore many children need other kinds of channels to convey and work with their psychological pain.
The frames of the therapy room
It might seem far too detailed to point out such obvious phenomena as doors, walls and windows in a therapy room. But having followed the struggle by many child therapists with these kinds of external factors a few words might be appropriate.
The fact that walls preferably should be thick and sound proof enough to let the child and therapist work without disturbance ought to be obvious. In many recently constructed buildings this is however not the case. Ventilation shafts leading sounds from distant rooms right into (and out of) the therapy room are common. This might be of enormous significance when working with children who are hypersensitive to sonar stimulation.
The opinion of how the walls are decorated inside the room differs between therapists. My opinion is that the walls should be as bare as possible. Every picture or other material that is pinned to the walls will make specific sense for each and every patient. So, if the therapist prefers to put up something on the walls, s/he must also take into consideration the reactions and associations of each specific child.
The door is of course another obvious matter to attend to, but not always that easy. Once I worked for some time in a room without a threshold and a gap of only some millimetres seemed like a gorge – an enormous opening where words and other sounds just flooded in and out of the room. Many children are quite preoccupied by doors. A door might become the child’s first experience of a capacity to regulate phenomena like letting in/letting or even out/shutting out something or someone. Different kinds of “occupied” signs linked to the entrance of the room are usually given quite a significance by some children, especially those with difficulties in experiencing boundaries between self and others.
This might seem a very banal idea, but I have often found it useful to have some kind of a curtain in front of the door or two doors with a small gap, where the child can squeeze in between. Many children express a wish to hide/be found and some kind of draping inside the room by the door might fill the purpose of a sound silencer as well as a means of creating a potential space between the door and the curtain where the child might dwell. S/he is neither outside the door, nor inside the room, but somewhere in between, in an area of his/her own where a ”capacity to be alone in the presence of someone else” (Winnicott, 1965) might be formed. Many of the restricted number of children of today for whom psychotherapy is offered are suffering from pervasive behaviour and conduct disorders (often diagnosed according to the DSM-manual system). Various themes concerning closeness/distance will therefore become recurrent aspects of the treatment. A therapy room for children must therefore contain some material that makes it possible for the child to stage experiences of existing and being seen/not seen but still existing.
One aspect, rarely read about in therapies with children, is how they might use windows. But having followed quite a lot of children in therapy I have seen how the windows have become a recurrent and quite essential therapeutic material to some of them. Just standing there looking out of the window might become a way of resting from an overheated relationship – and this without leaving the room or slamming the door in the face of a therapist. But the looking out the window might just as well turn out to be the first interest in the fact that something exists outside the child, s/he can begin to move away from an egocentred world and get interested in something that exists outside his/her world. In the first example, the therapists must pay attention to whether the child actually needs a rest from an overheated relationship and needs to take a breathing space. Or if the therapists should “call in” the child into an interrelational pattern. In the second case, however, when a child starts to show interest in something existing in the outside world, it might be preferable to consider whether the little patient might even exhibit a wish to share his/her experiences with the therapist. Maybe this is the first time s/he invites another human being to a “joint attention” concerning an experience? In cases like these, it might be essential to remain beside the child and just share the watching and perhaps naming what is seen in this joint attention. For a child with pervasive contact disorders such a situation might represent a first attempt to perceive, experience and to get a bit enthusiastic about the fact that other people can be “used” to share emotional experiences with.
A window usually has some kind of curtains/blinds, if not for any other reason than to keep the sun out or let it in. This can also prove to be quite an enriching material for the psychotherapy in progress. This regulation of letting the light in/keeping it out might become a potential development in the child regarding his boundaries between self and others. If the therapist’s room doesn’t have a curtain by the door, or other things to hide behind, a curtain by the window (even the most transparent one!) might be used by the child to form some kind of boundary between the child and the therapist. I guess we are many therapists who have been fascinated by the way some extremely thin threads in a curtain might be used as a “veil” in the interpersonal relationship, even for rather old children.
The interiors of the therapy room
A link of communication between the outside world and the inside of the therapy room is the telephone. For some therapists it feels quite good to work without such a link. I personally prefer to have access to a phone, but blocked from outside calls during the session. There are many means – for those kids who seem to need this – to challenge the limits and boundaries of the therapist’s integrity. My personal belongings and the phone, constitute for me, some kind of frame as to how close the child may get to me. Situations emanating from wishes to use the phone will give rise to numerous therapeutic interventions and in many ways become quite fruitful. The meaning of this potential link to the environment is always a specific question for each child and the ways of meeting over matters concerning the phone can become very useful.
Other aspects of interiors include of course the furniture, the lights, possibly carpets. I prefer as little material in the room as possible, but not to the extent that it may look barren and uninhabited by human beings. Having a table, a sofa and some kind of armchair suits me best. And, while working with children, a good and comfortable place for the therapist to sit is needed, where s/he can be reasonably at an equal level with the place where the child sits. I prefer an ordinary movable desk chair, which can be raised or lowered. To be able to quite swiftly regulate the distance between oneself and the child (here by the means of the rolling wheels of the chair) is quite a useful tool in the interpersonal relationship, in a very concrete, as well as metaphorical way – exploring distance and the closeness.
The sofa can serve many functions for children and adolescents. Some prefer to cuddle up in a corner surrounded by some pillows. Adolescents sometimes want to put their feet up and curl up or snuggle down in other ways on the sofa, all of them a means of protecting their integrity. How a person is sitting on a sofa might give rise to a lot of therapeutic material: is the patient transferring a relaxed way of sitting – even a too floppy or sleepy one? Or is the young one sitting at the edge in quite a stiff position? It is also possible to sit next to a child in a sofa when this might seem an adequate way of reaching out to him/her.
A few years ago I met a little girl who had suffered from extensive crises in her life. She started out by hissing and spitting at me. When therapy proceeded – and there were many exhausting sessions! – she sometimes wanted to cuddle up in the sofa. She really seemed to “sink into” it, and actually asked me to sit next to her. I thought it extremely important not to touch her in any way, which would have been to come too close physically.
We could read a book together which she took out from the shelf containing the few books I keep in the room. And for the first time she managed to take in what I said without spitting out all my comments. Paradoxically, this “sitting-beside-position” – to sit close to each other each on our own sofa cushion – turned into a greater distance than being apart in separate chairs. This position made it possible for us to meet over other themes and eventually even talk about the trauma that had devastated her family. Had we been sitting just opposite each other, each on our own chair, I am sure she would not have been able to take in my words as quickly as she now did. She would most probably have continued spitting them out, even in a very unpleasant concrete way, where the spit globules flew through the room.
Many children get a feeling of “space” in a sofa, a certain space around the body of the child, an area the therapist cannot penetrate. There is usually some space between the place where the child is sitting and the arms of the sofa, a space to stretch out his/her body. Two chairs placed beside one another usually do not provide the same option of obtaining an extended space in the place where the child is sitting, Especially children with difficulties related to closeness and distance, who have been physically or emotionally abused, might need to see in a very concrete way that there still remains some cloth of the sofa before the cushion the child is sitting on ends and another person’s physical closeness exists or later on can be allowed to exist.
Apart from a sofa and some chairs, a table can obviously come in handy on various occasions. Some children need the table as a “barrier” between themselves and the therapist (it is therefore important for the therapists to consider for each little patient where the therapist places him/herself). The table can also be used to put things on. Particularly while working with adolescents and with adults (e.g. a child’s parents), it is important to consider how the position of the table between us, might be used by them. Some need the table as a protection between themselves and the therapist, sometimes in a very concrete way this can, by and by, take on a more metaphorical meaning. Others prefer to sit at an angle to the therapist in order to get a glimpse of his/her whole body. Whatever the reasons might be, we therapists should consider each patient’s possible motives and means of regulating the distance between the ones in the therapy room. Everything will prove to be useful material in the psychotherapeutic process!
I consider it to be of importance that a therapy room for children has some kind of different sections. One might contain e.g. the Erica material (with a sandbox and some toys) or similar materials and some facilities for drawing/painting. Another section of the room might contain a sofa and chairs and a table is useful where the child can sit down and work with other themes or just relax in the presence of the therapist. By the ending of therapy – and this is almost always the case regardless the age of the child – many prefer to sink into the sofa and have some small talk about facts of life. A reflective function and position (Jemerin, 2004) has been formed and thoughts about themselves or others can now be reflected upon. The turmoil, the anxieties or other themes earlier presented in sandtrays, drawings, via games and play and above all in the interpersonal relationship have been worked through and the child is beginning to meet experiences in life like others of the same age. It is not uncommon for the therapist to hear children in the ending phase talk about other “troublesome” children, sometimes accompanied by a question whether that child also might come for treatment.
I have already mentioned the importance of providing the room with some kind of means for a “protective area”, a curtain or some furniture to hide underneath. Perhaps a blanket to pull over one’s head can fill this purpose. The spitting little girl, described above, let me “stay in the room” (these were her words) only if I sat stock still on my chair and she could hide under a blanket. There we were, two persons in a room with a closed door, as it were, without any mutual connections or communication. But nevertheless we remained in the same room and the therapist had survived her assaults – and the spitting and all abusive words ceased, partly due to my way of conveying to her that she was allowed to spit, but that this spitting should not be at my face but in a small bucket that I held in my hands, a technique Gudrun Seitz, (the first Swedish child therapist, in the early 1940’s) described as “affirming” the child’s needs (here to spit it out), but helping the child to channel them.
I think that this little girl had a huge need to defend her integrity. To spit or to hit others, as she did in preschool, as well as to hit me, was not a good way of handling the matter. When she allowed herself to remain in the same room as another person, even if it was under a blanket, and not just to spit her fear and hatred away, this was her first step in creating some kind of lasting relationship. Such concrete “things” as a blanket and a bucket turned out to be the best of therapy “toys” for quite a considerable part of the treatment.
Other kinds of material in the child psychotherapist’s room
It is not a coincidence that I have written so much up to now in this article, about things that may seem externally related and apparently not significant for the therapist’s room. One can easily imagine a therapy room equipped with some toys and other playmaterial.
However, quite an essential part of the therapeutic process takes place between the two persons being in the room and relating, or trying to avoid each other. Some children prefer to work almost exclusively via symbolic exposure or play, e.g. with some toys from the Erica cupboard (Danielson, 1998). I am quite struck by the opportunities the small toys, or the exploration of the sand, can elicit. But most of the children that nowadays are offered psychotherapy within the public services (at least in Sweden) are suffering from pervasive disorders and they are usually unable to use the toys in any kind of symbolic way. This is one of the reasons that these toys are not so frequently used, at least in the beginning of therapy processes. Which of all the toys the child chooses is naturally dependent on the specific psychological pain the unique child is suffering from as well as his/her own preferences.
Many children are totally absorbed by working solely with the sand. The more severely affected the child is in his/her attachment disorder, the more frequently the arena for the psychotherapeutic process will be set within the relationship with the therapist or just using sand and water. Salomon Resnick, who has been working for a long time with children with autism, expressed at the Frances Tustin conference in 2006 that therapy material for children with these kinds of difficulties could be limited – at least at the beginning of therapy – to sand and water. (A report from this conference can be found in volume nr 16 of Mellanrummet)
However, many children can make use of the options the Erica material embraces. For children who can make use of metaphors, symbolic communication with these kinds of toys and drawings is one way of expressing themselves and sharing their inner worlds and cognitive styles with the therapist. Quite an interesting presentation of this can be seen in the session with Linn in this volume of Mellanrummet and Saralea Chazan’s comments on the way this girl is using drawings. When a child is involved and busy with his/her own expression, it becomes possible for the therapist to have the time, at least to a degree, to reflect upon what is going on in the room. Instead of twosomeness (or in worse cases just a child’s solitary preoccupation) it is now possible to discern a triangulation between the child, the ways s/he is expressing the inner world and the therapist. This threesomeness makes it possible for the therapist to remain in the relationship with the little patient and at the same time focus on what is illustrated by the child.
Many children prefer modes of expressing their feelings and thoughts through drawings, working with clay etc. Scissors, some glue and tape are among the most frequently used materials, something many of we therapists have experienced countless times. To be able to cut out something from a background, that remains, might present a huge cognitive and emotional effort for some children. In Mellanrummet vol. nr 4 (as well as in the EFPP clinic book series, 2005), I have described how a child with autism worked with the concept of three-dimensionality by cutting out, and then gluing together paper scraps at one end of the paper, so one paper was fixed upon the other. This looked like a calendar with one paper in front of the other. This action, so simple for most of us, was for this boy a huge effort. This, together with other experiences on a bodily and physically experienced level, was the starting point of his emotionally and cognitively experienced sense of three-dimensionality of relations achieved later, i.e. that other people had an inside with thoughts and feelings of their own. This had been quite unthinkable to him when therapy started.
For many children with sad experiences of unreliable caretaker’s lack of attachment, breaking-up and relating in new family constellations like in foster care or adoption, the gluing, taping and the linking and also the cutting-off, acquires a crucial meaning.
Toys, games and books
Most therapy rooms are, according to my view, far too overloaded with things. Maybe this can be looked upon as the therapist’s uneasiness in just being and remaining in a relationship with a little person, without any kind of external material to facilitate the meeting.
Very few toys, games and books are needed. To have a room equipped with a lockable closet, where the play material is kept, could be one way of keeping the over emphasis on toys and other things at bay. Most children of today are overstimulated by far too many toys, so this is hardly what is lacking in their lives. What is needed is rather someone who will accompany them over time on their pathways of exploration, and eventually a health bringing play. Most children coming to therapy have not had this kind of free play and the power it can provide other kids. Mellanrummet vol. 17 focused on this theme. For the therapist the challenge is more like reflecting upon one’s own availability when a child wants to ”play”. Is the therapist supposed to take part in a play sequence? In that case, how? Are we to focus upon the boundaries between and play and reality? Or are these concepts obvious to the specific child in our room?
A therapy room needs only a very few toys which make it possible to work with themes like:
To “take in”
Joining things and thoughts together can frequently be seen in activities when the child makes use of tape/glue, but also in various kinds of games that can be helpful to the child like sorting, categorising, discovering and exploring sequences in time and space and later in events in their lives.
Many children in therapy want to “bake, cook”, in the sense of using very simple playmaterial, where they can join and mix different “ingredients”. I suppose we are rather many therapists who have witnessed and taken part in cooking and serving of different “dishes”, of more or less appetizing appearance. The way of taking part in these kinds of activities must of course be considered and the therapist’s decision as to how to get involved should be guided by what the specific child expresses and needs. The phenomena in work – and hopefully in progress – is whether, and in that case how, the therapist as “another” person is prepared to “take in“/incorporate the child’s offerings. Obviously our interventions are also affected by what kind of stuff the child is treating us to; sometimes nice, sometimes poisonous and smelling horrible.
Another interesting topic that might arise in therapies with children is, in what manner we as a therapist respond to a child who wants to “enmesh” him/herself with us, sometimes in very confused ways. Drawing together, entering into sequences in play and other kinds of therapeutic material, all entailing an unseparated way of interacting, can be quite a demanding task for the therapist, where his/her skills and capacity for assessment are put to the test. Under certain circumstances, and in some phases in psychotherapy with children who are still quite unseparated, this might be a necessary stance for helping the child on his/her way out into a future separated identity. On other occasions, when the child’s wishes or claims to have the therapist remain as an unseparated part of the child, this might be exactly the therapeutic work that needs to be done in order to facilitate further development.
To get rid of
Testing ones abilities and strength are other themes many children are preoccupied with. Therefore a therapy room for children has to be equipped with some material which enable such efforts. In this article I am concerned with a room where children will enter. Therefore it is important to remember that most of our human efforts and struggles have to be perceived and experienced on a bodily level before some mental representations can be developed. Children are physically active and for us to expect a 4-5 year old child to use only symbolic material (preferably small toys) or just verbal accounts, is not realistic. The kind of material, considered useful by child therapists for the child’s expression of physical and mental representations, varies. Some might prefer a swing or a punch bag, or other kinds of material making it possible to throw things against and towards one another. This might, under certain circumstances, be seen as a means to create a future “potential space”, at first as a physically perceived area between two people. I usually find simple balls to be quite helpful in creating a future “potential space”, where the rolling ball is neither with one person nor the other, but somewhere in between, on its “own” path towards someone/something. This third direction and position can sometimes lead to interesting and shared explorations for a child, who otherwise would have found it far too difficult to interact on a two-person level.
I have already mentioned how many children need to hide, climb into a sofa, stand on their heads etc. So, no big financial investments concerning play material for discovering grossmotor capacities are needed. If a particular child is in need of that kind of equipment, it is probably more appropriate to reconsider the child’s needs and discuss this with the parents and find out what they (or others) can do in the child’s everyday life to attend to these deficiencies.
To experiment with balance
Different kinds of work concerning the balance between the two basic drives in life (to breathe in/to breathe out, to “take in”/get rid of, to incorporate/to externalise are often to be seen in therapies with children. How different parts can find a place, a location, in the little one is actually a rather large question! If we could just start to talk about the problems that are haunting or limiting the child, then we could just go ahead with it. The problem, as I have already mentioned, is that many of the children that nowadays are entitled to some kind of psychotherapeutic help are suffering from pervasive disorders. This implies that their means of perceiving, thinking – not to mention reflecting – are severely damaged or not even yet developed.
Fusion, to bring together different split mental parts in the child’s experience, is seen in almost any therapy. This can be illustrated in very concrete ways, where the child brings together and mixes e.g. dry and wet sand from the two sandtrays in the Erica equipment. This is something (for practical reasons) that is not feasible. But how can the therapist meet a child who in reality lives two separate worlds when his/her parents do not live together (one world with his mum, the other with dad) and he/she is not allowed to mix the two ”worlds” in the sandtrays? Gudrun Seitz (Lantzourakis, Nilsson, Ånstrand, 2003) stressed, as I mentioned earlier, the importance of “affirming the child’s impulses, but channelling them”. With these words she implied that what the child wants/needs/shows might be “right”, but the form/way of expressing/channelling the needs might be very wrong or quite unpractical or inappropriate for others. And in all this the child needs the adult’s help to find more appropriate “channels” and means to express what s/he is struggling with.
To be quite concrete again: the question of mixing sand or other material can lead to most interesting outcomes if the “impulse is affirmed, but channelled”, i.e. it is OK to mix, but perhaps in another bucket and not just pouring lots of wet sand (or lots of paint) into the tray with dry sand (or another colour). Apart from the practical reasons for this, the most important thing is that the child destroys the possibilities for him/herself to return to the dry sand (the colours) since it has been annexed by the wet one. We are many child therapists who have been left with buckets with strange smelling and looking “mixtures”. One little six year old boy I met in therapy said he constructed his own ground (that was his actual expression!). It was to be built up by “concrete”. He mixed wet and dry sand with lots of water, hot and cold. He brought snow from outside (obviously it thawed down to water), scraps of asphalt he had collected on the street outside, small twigs and lots of other stuff. He crowned the whole creation with his own saliva, in a very deliberate way, and then it only remained to stir the “pot”. This “stink bomb” turned into something essential in that part of his therapy process. It was the first time he had ever “created” anything at all, something his parents had been worried about. During this time of his therapy he often entered his sessions by asking if his “mixture” was ready yet, touched it with his fingers and asserted that it needed some more time before it was OK. It is quite obvious that his way of working turned out to be very useful, also at in metaphoric sense, concerning the length of his therapy. When he entered therapy he had very vague appreciation of concepts like time and space. Needless to say that when his “mixture” was “ready” he started to build his house and was able to use other kinds of toys and paint. These mental representations could in that latter part of the therapy process be shared and contemplated in an emotionally and cognitively reflective way.
Other material that might come in handy for exploring and experimenting with issues of balance, midpoint and equilibrium as well as the harmony between different drives are such devices that makes it possible to transform one form into another. A sandmill or sieve which the sand can be poured through and thereby change its form can fill such purposes. The specific toy is obviously not the crucial point, rather the fact that something can work as a means to form and experiment with issues like change and transformation.
To keep games or not in a therapy room for children is a frequent question when a room is to be equipped. This might be a matter of the psychotherapist’s preferences, whether s/he is comfortable with this kind of material. When a child plays a game, as it should be done according to the common rules, one really has to consider whether this is a helpful therapeutic tool for this child or not. In this volume of Mellanrummet we can read about the children Thomas, Peter and Sarah and how they approached the games as medium for their work with various mental and cognitive disorders.
Thomas is using Monopoly, which is, as he calls it, for ”glownups” (in fact it is a version for children) and he is preoccupied with the mere fact that he can move his tokens around and the fact that they are related to one another in different ways and positions. Perhaps he is beginning to discover and explore perceptions and understanding of “prepositions”, i.e. that one object actively and with agency can move and relate to others in the environment? This was one of his difficulties in real life, as we can read more about in the sessions with Thomas. As Anne Alvarez points out in her clinical commentaries, he is also using the printed figure in the centre of the board as something quite different to what the innovator of the game probably ever could have imagined, i.e. a figure alluring the player into prison.
Peter is also using a game, Pick-up-sticks, in a very odd manner, even if he is sticking to the rules of the game. Here, Monica Lanyado in her comments, reflects upon the balance between the sticks and how fragile this equilibrium is. If this is changed just a tiny little bit, the chaos underneath can be seen. For Peter this game might have become a way of forming, visualizing and working with the psychological state he was in (filled with chaos and disintegration where his rigid regulating functions toppled). As a means of not just ”being” and getting stuck in an emotionally overheated relationship, an encounter over a game, like the ones described in the session with Peter, might give him some breathingspace and time to regain a certain amount of stability.
Sarah is also using games, in her case Memory, in an odd way. It seems to be of utmost importance for her that a little toy dog is watching alternatively is taking part of the game, a therapeutic material that might be used by the therapist in his/her relationship with this girl. To be looked upon, regarded and taken into another person’s mental and cognitive sphere is something Antònia Grimalt is reflecting upon in her comments on the sessions. Sarah succeeds in combining her cards and seems to be preoccupied by the fact that she did not peep. From having been busy with finding similar cards she goes on to a similar topic, i.e. to compare two erasers which are similar, but still not the same. Maybe this is an essential theme to continue the therapeutic work from for this specific girl?
In the examples above we can see how the children are using the games that happen to be kept in the therapy rooms, but they all use them according to their own needs and abilities. For a child psychotherapist this way of addressing whatever material there is in the room, can offer options for finding approaches for psychological growth, addressing psychological pain and other issues that can advance the therapeutic work.
Books and magazines are rarely used in psychotherapies with children, but there might be occasions when such materials can be used in an intermediate area and in encounters. For some children with attachment disorders the reading and the words coming from the therapist can be seen as something soothing, and predictable that the child can take in and be filled by. The young traumatized girl I mentioned in the beginning of this article was later on in therapy able to cuddle up in the sofa, expressing a wish that I should sit beside her and read to her. In the beginning of her therapy with all the spitting and rejecting of any human contact this would have been an unthinkable thought. I think, that for this particular child, it made no difference what we read when this started out. The content was of subordinate significance. It was rather the form that became important, being able to sit down in a relaxed way beside another person, like some ”corrective emotional experience”. This made it possible later on to focus on the contents of what was read in a particular book. She had abruptly lost one of her parents in traumatic circumstances. So to be able to just sit down and trust someone simply “coming to her”, and above all giving her something she could take in and keep (here in the shape of a flow of words and intonation from another human being) became a turning point in the treatment. Gradually the contents of the book she preferred “Så funkar Du” (“This is how you function”, in Swedish) came to be essential. She was occupied by the fact that some parts actually did not function so well in some people. But could they function in her? And can one person – or a child – affect another person so parts of that person’s body did not work or were damaged? She was very taken by the pages in the book that described the parts that were affected in her parent who had died.
In an account of a presentation by Anne Alvarez to Mellanrummet’s Friends Association (Blomberg, Mellanrummet nr 4) the differences between form/shape and content are highlighted. This is something a child psychotherapist will find most useful, especially when children play with toys, use games, read or are read to. Very often the main work, with children with pervasive contact and behaviour disorders, is focused on the building up of an “apparatus” – form and structures – which not until later on in treatment can be used for working with psychological contents.
The child’s box and endings
Finally we come to a most crucial point in all therapies with children: their own box. In this they can put their products during the time the therapy is going on. Questions concerning what is to be put there, what can be thrown away and in that case why, is the starting point of many therapeutic interventions.
Some children make their box their own by putting “wall paper” in it, painting the inside or decorating it in various ways. Others just let it remain a box, a container for their products. All these things can be used as starting points in the therapeutic relationship and for comments and discussion on how one is taking care of ones own products.
One recurrent question, when it is time to end therapy, concerns what is left in the box. I have gradually came to stress to the children I meet that it is quite important to look through the material in the box and sort through it. I usually suggest three piles: one for things that could be thrown away, one to take home when therapy ends and one called “I have-not-decided-yet”.
To be able to and be allowed to throw away some parts of the whole production from therapy is a frequently misunderstood prerequisite for psychological growth. Everything does not need be kept! Like dreams, there are some “waste” products the child needs to leave behind. There are often some raw sketches, which later on, have unfolded into something else. These are without doubt things that deserve a better fate than to be exhibited at home and then thrown away. I think it is much better to share the development and growth with the child within the therapeutic context and hear his/her views on what has happened during the time in therapy.
In the boxes there are also drawings and other material expressing hard experiences and emotions that have been worked through during therapy. To be allowed to throw these away – or to let the therapist take care of them – could be an alternative to showing them at home. There is a world of people who have no capacity at all to grasp the full meaning of them, in what context they were created and the emotions involved while producing them. At home they are delivered in quite another context. Some of the child’s difficult or vague emotions, should be allowed to be left behind in a “container”, willing and interested enough to take care of them. It is an important part of the therapist’s professional stance to be a person who can stand firmly enough to receive and endure what the patient needs to leave behind in the relationship with the therapist or at a more concrete level: in the room. Everything is not to be returned. Betty Joseph (1994, 1998) has written some very interesting thoughts about not returning projections and transformed counter transference reactions to the patient until there actually exist some parts in the child which can receive these. The same thing is valid on a more concrete level. Maybe a therapy ends by the child asking the therapist to take care of the products and keep some of it. The most important question is – as always – to contemplate on what makes a certain child do these deeds or express the wishes he does. And what kind of specific interactions this particular child is in need of from the therapist to help him grow and be able to handle his/her psychological pain.
I think that the pile “I have-not-decided-yet” is the most interesting one. When I actively introduce this concept (very few children suggest this as an alternative), my intention is to help the child to reflect, to actively stand the feeling of being a bit ambivalent and to dwell in the process of decisionmaking. Everything does not have to be “in” or out”, some can be left for a while to contemplate upon. This pile has turned out to be quite meaningful and leads to new angles of looking upon what has been going on during therapy and where the child is heading.
I would like to end these thoughts about the child psychotherapist’s room with the statement that the equipment we need is not a financial burden implying costly investments. The most important of all is to supply a room where the psychotherapist can be comfortable enough to meet the child on the path both persons will tread. It is a journey and an exploration that requires some technical support in material form, but above all a person there who is present with a readiness and the skills to meet the child.
Blomberg, B. (2001). Form in unconscious phantasy, thinking and walking. Referat från föreläsning av Anne Alvarez för Mellanrummets vänförening. Mellanrummet nr 4, 53-61.
Blomberg, B. (2005). Time, space and the mind: psychotherapy with children with autism. In Houzel, D. & M. Rhodhe: Invisible boundaries. Psychosis and autism in children and adolescents, 25-42. London: Karnac, EFPP Book series.
Blomberg, B. & Hermansson, J. (2007). Beyond autistic barriers – treating and understanding. Account from 3rd International Conference Frances Tustin Memorial Trust, Mellanrummet nr 16, 172-178.
Danielson, A. (1998) Building your own world. Manual for the Erica method. Stockholm, Psykologiförlaget AB.
Jemerin, J. (2004). Latency and the capacity to reflect on mental states. Psychoanalytic Study of the Child, 59, 211-239.
Joseph, B. (1994). The patient who is difficult to reach. I E. Bott Spillius: Melanie Klein today. Vol 2: Mainly practice. London: Routledge.
Joseph, B. (1998). Thinking about a playroom. Journal of Child Psychotherapy, 24 (3), 359-366.
Lantzourakis, A., Nilsson, W. & Ånstrand, K. (2003). Att möta barnets inre värld. Stockholm: Ericastiftelsen och Mareld.
Winnicott, D.W. (1965). The capacity to be alone. I The maturational processes and the facilitating environment. London: Hogarth Press.
Copyright: Allt material ©