Social Reality and a Child‘s Wish for Psychotherapy[1]

By I. Berns

Abstract: 

It is a widespread view that doing psychotherapy with patients upon whom therapy is imposed by a third party is questionable. However, this is nearly always the fact when doing psychotherapy with children. The present article demonstrates how to use the psychoanalytic method of free association to grasp unconscious meaning, especially unconscious commentaries by children regarding the motivation to do therapy. Those who undertake child therapy have to take into account such unconscious commentaries by children as well as the given social realities - that is, that children rely on the adults to whom they relate - and that psychotherapy cannot be carried out without the adults‘ consent. Six examples are offered.

 

Social Reality and a Child‘s Wish for Psychotherapy 

By I. Berns

 

It is not usual for a child to ask for psychotherapy. Usually  parents, teachers, physicians, or guardians bring a child to a psychotherapist. In my 20 years of professional work, on only two occasions was it the child who originally wanted therapy. These two children pressed their parents to contact me. In both cases the children knew something about psychotherapy and the possibility of getting help with psychological problems. In all other cases caring adults introduced the idea of psychotherapy to the children.  

This requires considerable frame modification when working with children in psychotherapy, and it deserves our full attention. The deviations refer to the frame components of intimacy, confidentiality, abstinence, and neutrality, and struggles with the ethical principles of autonomy.

The situation is comparable to those with patients upon whom psychotherapy is imposed by a third party,  e.g., offenders with judicial sanction, students in training analyses, psychotherapists after judicial decision. 

It is a widespread view that patient motivation represents an indispensable basis for psychotherapeutic work. Nevertheless it is strange that on one hand psychotherapists agree that judicially arranged therapy is not meaningful. Yet on the other hand, training analyses with prescribed frequency and duration, are not regarded as problematic. Likewise undisguised, but thematically related, is undertaking a child‘s psychotherapy.

Articles regarding this subject are rare. The phenomenon is noted but rather defined as a hurdle whose overcoming is regarded as a particular challenge. Thus, Anna Freud (1927) described how she tried to get her young patients‘ confidence by  making herself interesting and useful to them. This would create a child‘s attachment to her and would hinder their withdrawal from her. After this she fostered a working alliance with the child on a manifest level. 

Melanie Klein (1930) assumed that a child would express him- or herself, and that she would be able to understand the child from the beginning. Interestingly, she did not try to get a child‘s consent on a conscious level. She visited children whose parents had contacted her, in their home, without asking for the children‘s permission, listened to and watched them and offered explanatory interventions with great casualness.

 How do contemporary psychotherapists deal with this topic? 

Behavior therapists (Reiter-Theil, et al.) react to the ethical aspect - a respect for the autonomy of the child-patient by opening with a clearing-up phase before starting formal therapy. They inform children about their right to say „No“ - telling them that therapy is not going to be easy and asking for their agreement. After having received such „informed consent“ they consistently work with the agreed-upon frame. 

The French psychoanalyst Francoise Dolto and her successor Caroline Eliacheff established the symbolic payment as a specific test of the child‘s motivation. They ask for a symbolic fee - individually defined for each child, e.g., a stone, a small coin, a picture, a used ticket stub. If the child does not bring the object, it would be analyzed as an expression of not wanting to come. Dolto also reports of situations where she congratulated a child for having expressed this, and therefore did what seemed right to her, that is, she discontinued the session or terminated the therapy. 

Regarding the authorization to do therapy with children, Vesna Bonac (2000) points out that children have the same rights as adults, and that caring adults accordingly have a duty to use their real power to provide for them on their behalf. This is her answer to Thomas Szasz (1965), who regards psychotherapeutic work with children as incompatible with the principles of psychoanalytic ethics

One may appreciate the engagement and imaginativeness of the interventions of A. Freud, Klein and Dolto/Eliacheff. And I share Bonac‘s view that offering psychotherapy is a most adequate intervention for a child needing psychological help. Though I also respect Szasz‘s consistently radical analysis, nevertheless, I do not share his conclusions. 

In my opinion the specific psychoanalytic possibilities are not made use of in the concepts of the above mentioned authors. However, here is a chance for psychoanalysts to make use of their specific method regarding this issue, that is, the understanding of unconscious psychological contents and processes, dissolving the discrepancies between conscious and unconscious attitudes. 

I assume that children are able to make autonomous responses to a therapist‘s offer of psychotherapy, and I assume further that they will react to this offer consciously, as well as unconsciously.

I invite you to follow my process in searching for an attitude to harmonize theoretical considerations and clinical experience. Six examples illustrate this trial.

* * *

First, I will try to analyze the manifest clinical situation. Before parents decide to contact a child psychotherapist they usually have gone through a longer process recognizing in the end that their child behaves in a manner that signals the need for psychological help. Often the parents also state that their own efforts to help the child were not successful.

From a social point of view, the act of parents bringing their child to therapy is usually one of utmost responsibility. It belongs to the task of parenting, looking after the health of their children, not waiting for blatant symptoms before taking adequate steps to help them. So, the question arises whether one and the same act done by parents, can be assessed as good care taking, yet still not make sense from a psychoanalytic therapy point of view. Even good care taking can imply interference in the sovereignty of the child and thus contradict basic principles of psychoanalysis regarding the autonomy of patients. 

The process concerning a child‘s motivation for psychotherapy is always associated with interpersonal issues. All developments with children are thus accompanied by interaction with others.  On the basis of clinical experience I take for granted that children note acts by care taking adults both consciously and unconsciously. I also take for granted that they communicate, on an unconscious level as well, in everyday life, with those persons to whom they so relate. It must also be added, but according to experience it is highly unlikely and very rare that children decide to ask for therapy on their own, at the same time as their parents do. 

According to clinical experience I assume such processes are evaluated unconsciously and are expressed derivatively. Consequently, one can assume that a child, whose parents bring him or her to a psychotherapist, and do this in the above mentioned responsible way has had an unconscious dialogue with his or her parents which leads to this decision. If parents are correct in their conclusion that psychotherapy would be helpful to the child, one can expect the child to rate this action of the parents and the psychotherapy offer unconsciously as beneficial - and express this derivatively. 

Example 1: 5 year old boy, first session

At first I met the parents of this child. They told me that their son would not be interested in changing anything. I invited the child to a separate session without his parents and told him that I had heard from his parents that they were looking for assistance in managing his outbursts of rage. I mentioned that his parents and I had decided together to offer him my help in not becoming so furious. The boy answered that he did not want anything from me. If I could talk to his parents and tell them to do everything in the way he wanted them to, everything would be fine, there would be no difficulties. While he was talking, he moved to the sand box and began to pile some sand into a large mountain in the rear of the box and two smaller mountains on both sides and in front of it. He had taken four play figures from a board: two tall ones, and two small ones, and tried to place them on the top of the mountains: the two small ones on the top of the large mountain, each of the tall ones on top of the small mountains. The figures did not have enough stability in the dry sand. They fell which made him angry. He grumbled violently and pressed down on the tops of the mountains, to flatten them and make them more stable. The dolls fell again and again, and his grumbling and furious acts pressing the sand became more and more hectic. Finally there was one single surface of sand where the four dolls played together cheerfully. 

Comment: The patient in this example primarily reacted on the level of secondary processing, by responding directly to my offer of therapy, saying that he wanted nothing from me. Simultaneously he accepts the offer unconsciously, creating a narrative taking a derivative position to his symptoms and to the therapeutic offer. The narrative tells a story other than what was expressed manifestly. I think he unconsciously expresses that such an unbalanced relationship as he enacts with his parents, and manifestly requested to be confirmed by me, was not at all that delightful. Rather he seems to say that if everyone met at the same level they could be happy together. Since he expressed all this to me in reaction to my offer of therapy, I understood this also as unconsciously approving my offer. Implicitly the act of his parents in initiating the contact is approved. It is likely that these parents reacted correctly to the derivatives of their child. Thus, the above mentioned hypothesis received validation.

Likewise one can expect that a child whose parents misjudge the therapeutic need, will express this. 

Example 2: In a first contact I saw a mother and her 9 year old daughter, about whose unreliability and attention-deficits the mother complained. The mother was convinced of the girl‘s laziness. She did not complete her tasks for school and had already received poor grades. The mother worried about the child‘s school career. The child listened to her mother attentively, with guilty nodding supporting her mother‘s explanations. Before the mother left me alone with her child, she informed me of the dates the girl would be able to come to therapy, and again the child confirmed that she wanted to come. When her mother left, the girl took a doll and brought it to a doctor, that is she got the doctor‘s case, opened it and examined the doll with stethoscope and reflex hammer. Then she announced that nothing was wrong with the doll. Nevertheless the doctor would give an injection and stick on a plaster, thus allowing her to go outside to play. With these hints of hers, I interpreted her dilemma that although nothing was wrong with her, she nonetheless was ready to consent to therapy to soothe her mother and assumed that I would join in this plan. I then told her that it didn‘t seem right for me to take part. Her response was: „If you do not have any more plaster my mother would buy some and I could bring it along.“ In the end I worked with the mother and offered her my help in accepting a girl who did not fit her wishes for an eagerly learning child.

These two examples demonstrate that it is possible to receive a basic statement regarding the therapeutic plan by a child. Nevertheless this is not enough when working with children. Psychotherapy as a profession takes place in a social framework which can be put into question by insights coming from the clinical work whose validity is not nullified. In working with children this means that therapy can only be carried out with the agreement of the child‘s parents. This emphasizes the fact that children are existentially dependent on the adults caring for them in ways other than is true for adults. 

Psychotherapists who decide to offer therapy to a child have to take into account the conscious and unconscious motivational status of child and parents. This is an act of basic ethical responsibility. 

My first two examples point out a discrepancy between conscious and unconscious statements by the child. As a psychoanalyst I always try to inform myself as to what the child tells me unconsciously and thus informs my decision to offer my help. It is a fact, however, that in the case of a child‘s psychotherapy there are usually three persons involved, each for him- or herself, providing conscious and unconscious, healthy and pathogenic views, concerning the therapeutic plan.  Often these views do not match. Also, their unconscious healthy and pathogenic statements do not match. It makes sense to look at whether there are conditions under which psychotherapeutic work with a child should not be offered.

In the worst case it means that a therapist might not treat a child despite the unconsciously expressed need for therapy by the child. The clearest example is where a psychological reorganization of the child endangers his or her parents. To survive, a child needs parents more than therapist. 

Example 3: Involves a 10 year old boy with whom I had already worked quite successfully for approximately 50 sessions. His mother was pleased with his progress. Yet after my vacation - during which the boy made a trip with some children - this being seen as progress - he began to devastate the therapy room and make it unusable. He held his ears shut when I addressed him, or produced loud tones which out-shouted my words. I tried to offer him stability by locking the cupboards and thus reduce the extent of possibilities to devastate the room. This intervention made him stop. He cried desperately, and said, „Nothing makes any sense“. „Yes,“ I answered, „you showed me for some time that everything gets broken. Something must have happened for you to conclude that there is no sense in our cooperating any longer.“ At this point he built in the doll's house a scene with three dolls. Two of them, each for itself, left the house, leaving the third one alone. While both outside dolls seemed to be enjoying themselves, the one who remained at home devastated the house, and fell out of the window when looking for the others to come back. In fact she fell directly in front of one returning doll. This one stumbled over the fallen doll, and thus kicked it back into the house. Helplessly, furiously and silently the returning started to restore order so as to see it immediately destroyed again. This brought the mother doll back on her feet. She shouted at the child, asking for the reasons for making such a mess. 

I knew that his mother was being treated by a psychiatrist and had tried to commit suicide several times, one of which had directly preceded the beginning of the boy‘s therapy. I understood that he had perceived that his reorganization was experienced by his mother as threatening. He assumed she was suicidal in connection with his good development and that he suspected that worrying about him was necessary to keep her alive. He seemed to believe that he provided her with the sorrow she needed to stay alive. I interpreted this. While I was speaking he tidied up the doll's house and then left without saying another word. It was approximately 7 minutes before the end of the session. When he did not appear at the scheduled sessions twice, I dialed his telephone number at the time of the session and got his mother. I heard her call him and tell him that I wanted to speak to him. I heard him answer, „Tell her I will not come any longer“, and the mother said, „He asked me to tell you that he will not come any longer. Perhaps it‘s o.k., since I am in therapy now.“ 

I do not seriously expect that he will be back, given that his mother has since gone through a number of therapies. 

Experiences like this one are a great burden for the therapist and harder to bear than the case when all say <No> on a derivative level. In such cases the necessary work is restricted to solving the discrepancies between unconsciously healthy and unconsciously pathogenic attitudes, and subsequent manifest attitudes. 

This afore mentioned example involved unfavorable conditions. But what kind of conditions are favorable? An unconsciously healthy „Yes“ by the child seems to be indispensable, that is a „Yes“ expressed derivatively, after the therapist has made a specific offer to help the child with his-or-her problems. Equally indispensable is an unconsciously healthy „Yes“ from parents, maybe a story about an uncle, who understood them better than their own parents when they were children, or a spontaneous narrative of having finally generated up the courage to talk to a colleague who then proved to be trustworthy. Receiving such unconsciously healthy communications from parents will probably occur when the psychotherapist listens for them in exactly the same way as to the child. This means however that the therapist does not provide for the frame components privacy and confidentiality and thus an atmosphere of safety (Schafer1983, in: Smith 1991), and consequently children will express this implication. I shall give two examples.

The following example (No. 4), dates from the time I had just begun to work with the communicative approach and a trigger-orientation. I was already busy with here-and-now questions and in following the plan of not setting preconditions during the first telephone contact, to make an appointment for a first session, but not to specific whom I wanted to see in the first contact, but leave it to the patient or parents to decide who would come to the first session. If the parents came first I talked to them and arranged a meeting between their child and me with them. At the beginning of such a meeting I would give a summary to the child of what I came to know from his-or-her parents about them. 

Example 4:  What follows is a sequence from the first session with a 10 year old boy. Prior to this I had contact with the boy‘s father who told me that the boy was adopted as a baby. I started the session telling the boy something of what his father had informed me of his symptoms and his life history. I noticed that I was saddened by his situation. 

Therapist: You probably think it was not correct to decide on the adoption since you were such a young child. 

Patient: Yes, I was really very young at that time. 

Therapist: So young that you now think this cannot have been a correct adoption, because you were such an infant and could not express your wishes. But now you can do it, and you do it now. 

Patient: You mean when I moan? 

Therapist: Yes, and when you lock yourself in your room, and when you want to run away. (I knew this from the father, not from the boy.) 

Patient: Yes, nobody can tell me anything at all. (After a pause) ...For example, if there was a kingdom, a quite large one, and there is a king who issues all the laws and the realm is quite large. Then there is this small village where only a few people are living who make their own laws, and those are also good... oh, now I have forgotten what I wanted to say ...

Therapist: You are telling me your history, of your father the king, who is a clever man and issues good laws, and then the village, this is you..., and you also have good ideas for laws... Patient: Yes, now I remember... if then the king sets up supervising cameras in the whole country, insisting that his laws are obeyed, even in the village. Then one must buy all the chewing gum one can find, chew it and stick it on the cameras and microphones.

Comment: Obviously the boy makes attempts at helping me to do a good job. In my view, he tells me it is no good starting my contact with him using an image of him based on information obtained from his father; it is no good listening to his father, thinking I could get meaningful information concerning the boy; it is no good trusting this information over what he tells me. 

Simultaneously he offers me a chance to become therapeutically active on his behalf. He demands that I not use information gotten from his father and that he would like to do something to make it impossible. Does he simultaneously say that it was not correct that I accepted an arrangement involving any contact with his father? Or is his criticism limited to my listening to the father and my passing on of information to him, and my use of these information acting as if I already know something about him? 

Derivatives of this type stimulated me to look for methods which might enable me to decode the unconsciously healthy motivations of parents and children, and at the same time to prove myself to be trustworthy to all involved. I assumed that my attempts at grasping their unconscious motivations might be evaluated as good by both parents and child. On the basis of considerations that this result might be principally relevant for all involved, I developed the hypothesis that primarily and indispensably I needed an unconsciously based agreement with parents. Only if this is granted does it make sense to meet the child and to inform him or her that I will fulfill the wish of the parents to offer my therapeutic help. This is the only relevant, but indispensably necessary information, children should get regarding the contact of their therapist with their parents.  

Here is a further example of my professional development: 

Example 5: Again it is a first contact. The patient, an 11 year old boy, sat down and looked at me full of expectation. I said, „Your mother told me that you would like to do psychotherapy.“ He nodded and murmured something that seemed to be approving. I waited until he said, „I don‘t know how to begin.“ I answered, „It would be fine, if you tell me whatever comes to your mind.“ Now we were both silent for about 1 - 2 minutes, then he said, „In earlier times I got on with my father very well. But now this is lost, because my father raped my sister in a most brutal way.“ He was silent for a short time, then he went on, „My mother has a neighbor. My father called her by telephone. He probably wanted to find out what we knew, and what my mother intended to do. Thank God the neighbor was clever enough to tell my father nothing, but she came to my mother and told her everything.“ (Pause). „When my sister informed my mother of what my father had done, my mother didn‘t talk to my father about the topic for a long time. She always put him off and told him my sister was ill, or my sister and I could not visit him for different reasons.“ He was silent again, then continued, „I do not know whether it is correct, but I believe my sister.“ 

Comment: Without noting each detail, we can see that the patient speaks about the implications and difficult-to-understand consequences following indirect communication, implications like talking behind someone‘s back, sounding out, manipulating, obtaining information from and giving them to third parties who may use them in their own interest. Simultaneously he states that passing on a message is good when enabling the mother (here also the therapist) to help the child. He is somewhat unsure („I don‘t know, what is correct“), nevertheless, he wants to dare it („but I believe my sister“). 

This is one of the two children who initiated contact with me via his mother. He does not say that she should not have done it, and he mentions that one can handle this if done with care. However, there are no derivatives saying that it was wrong to have agreed to the initiative of his mother. And there is no hint that the neighbor should have hung up the telephone on his father. 

* * *

Comparing the examples you may notice that my interventions introducing myself to the children differ from each other. The first sentence in example 5 says,  „Your mother told me that you would like to do psychotherapy.“  The first sentence in example 1 was „I have heard from your parents that they want my help in coping with your outbursts of rage. Your parents and I have decided together to offer you my help in not becoming so furious, too.“ Still different were my first words in example 4 regarding the adopted boy and the supervising cameras. You are becoming witness to my development regarding  this issue. 

Evaluating lots of patients‘ derivatives responding to differently formulated interventions of mine, I conclude that children do value the initiative taken by parents in contacting a psychotherapist and the participation of the therapist in this act unconsciously, as good and correct. Often it is not mentioned derivatively - like in example 1. If the therapist says more than, „I heard from your parents that they want help in dealing with you, and I proposed to offer my help to you, too. They agreed, and thus I offer my help to you, proposing that we two meet in my office and I listen to you“. If the therapist says more than this, derivatives will follow as described above in Examples 4 and 5. 

After having talked to the parents I only offer a proposal to meet a child if I got the impression a) that an offer for therapy is adequate, b) the parents consented derivatively, and c) I have the time to carry out the therapy. Is the child younger than six years I arrange a date with the parents and give my offer to the child when he or she comes. Children who are able to read will get a letter of mine noting the above-mentioned and proposing a date.

This intervention is quite unusual. I decided to act this way after evaluating the possible implications and the real alternatives. My two years experience is that each child to whom I wrote decided to come. My offer which is formulated neutrally and does not express any obligation, received validation on a manifest level. Obviously children react to the implicit respect for their autonomy. However, until now I did not address a child who was not in need of therapy, that is, until now all children consented derivatively to the therapy plan.

By this way a child gets an offer explaining by itself. In Principal, it provides the possibility for parents to reduce their initiative to the first contact and to leave it to the child to decide to accept my offer or not. Such a letter of mine supplies the child with as much information as an adult will get by the first telephone contact. 

Of course my intervention will not exclude that parents talk with their child about their contact with me, and I have no influence on what happens with the letter. It may be opened and read by other people and can be used for different purposes. Such possibilities are given implicitly but it is not me who is responsible for such things. I put up with them, so to say.

In principal, given the realities of a child‘s social situation this intervention of writing a letter seems to maintain utmost autonomy of child patients and respects the responsibility of parents. Simultaneously it helps me to organize my office and offer therapy to a child in need at a moment when I am able to carry out the plan.

It may happen that my conclusion out of my communication with a child‘s parents is wrong. This would mean that my offer addresses a child who is not in need for therapy. If he or she does not react to my offer I think this is disadvantageous just for me: The session remains vacant. I take the risk, and I do not think that my offer harms the patient.

The initiative by parents and the participation of the psychotherapist concerning this issue of referral, often implies that the psychotherapist and the parents are perceived by the child as allies. I assume that this possible implication is more often perceived by those children who have experienced this sort of complicity by adults, possibly on the part of their parents. Depending on what kind of pathogenic solution they already have found, the therapist will be requested to take part in such a compliance (like in Example 2 about the girl with the doll), or those children will not cooperate; this can mean the therapist will not receive derivative hints, which requires adequate psychotherapeutic interventions. 

Let me illustrate with Example 6: A 12 year old boy came to a first session. I invited him by a letter, as explained above. I had already talked to his mother who told me she assessed him as suicidal. I got the impression that she tried to manipulate me and that she perceived my decision to offer my help to her son as a victory for herself. Nevertheless I took for granted that she wanted my help for her son, since she told a spontaneous narrative about a trainer who had good ideas about promoting the boy‘s integration into a group doing sports. 

I started the session with the boy as described above and he kept silent. I made two or three attempts to persuade him to communicate and noted that I could also listen to his silence and understand it as an indicator that he did not want to talk to me. I formulated an interpretation and got his response. He said, „Exactly. You‘ve got it... Can I go now?“ I will not depict my actual response to his question, but would rather show my present understanding. By giving him a correct interpretation I proved myself to be someone who understood him and thus was acceptable as a therapist, at least in principle. His question implied an offer of complicity: manifestly he asks me to confirm his neurotic attitude - at the same time there is an indirect request to prove myself as a therapist. If I could use this to formulate a therapeutic intervention, it would support the original offer to him and provide an example of how one can remain autonomous when complicity is offered. For example, I could have said: „Obviously I did understand you when you were silent. Now you ask a question, and I will try to understand you again. At first I conclude from your question that you would like not to be here, nevertheless you came. And that you think you can only leave with my permission. Obviously I did not manage to let you know who I am and what I offer to you. What I want to say first is that I will not answer your question with a yes or a no.“

* * *

With these 6 examples I have tried to demonstrate a specific task for psychotherapists in their work with children, that is, to look for the unconscious motivation of child and parents. But it is not only the attitudes of those directly concerned that makes this process so complex. Practices in every day life, which were developed jointly and have reached legal status, provide further complexity. Practices like this are usually not analyzed but just applied. There is a specific situation in Germany. The community provides that psychotherapies with children are paid for, and include the parents, that is appointments are arranged with parents, too, with the same therapist. This practice is a constituent of psychotherapy with a child. In the course of time people have developed a conscious attitude that this procedure is an appropriate one. This means if there are psychological problems with a child, parents bring them to a psychotherapist and they themselves receive an offer for consultation. For parents and psychotherapists this practice provides financial advantages. It implies a strong seduction to complicity in diagnosing the child as being ill. 

Given this background, I often see children who might make themselves accomplices of their parents - like in Example 2, the girl with the doll who consciously said „Yes“ and unconsciously said „No“ to the offer of psychotherapy. It is possible, however, that a child who complies with parents and/or therapists is really in need of psychotherapy. To find out whether this is so, is the specific task for child therapists. They must understand which part of the therapist‘s offer gets validation and which does not. 

Child therapists may follow these derivative hints and adapt their offer just as one might when working with adults. It is very likely that they will get negative evaluations regarding the frame components of confidentiality and privacy (like in Example 4, the boy with the microphones). It may be that these components cannot be corrected or that correction results in a discontinuing of therapy. Recognition of such realities, as well as accepting its specific consequences, are basic psychoanalytic propositions.

To withhold children from psychotherapy because some, even important, frame components cannot be realized, means to throw out the baby with the bathwater. As I have indicated, children do validate an offer of therapy if it fits their therapeutic need. I think that we owe adequate recognition of this fact, even as we strive for ideal conditions. 

References:

Bonac, V. A. (2000). Communicative Psychoanalysis with Children. London: Whurr.

Dolto, F. (1989). Fallstudien zur Kinderanalyse. Stuttgart.

Eliacheff, C. (1997). Das Kind, das eine Katze sein wollte. dtv TB 35135.

Freud, A. (1927). Die Einleitung der Kinderanalyse. In: Einführung in die Technik der Kinderanalyse. München: Kindler TB.

Klein, M: (1930). Die psychoanalytische Spieltechnik: ihre Geschichte und Bedeutung. In: Das Seelenleben des Kleinkindes. Reinbek: Rowohlt TB.

Langs, R. (1992). A Clinical Workbook for Psychotherapists. London: Karnac.

Smith, D. L. (1991). Hidden Conversations: An Introduction to Communicative Psychoanalysis. New York: Routledge.

Szasz, T. (1965). The Ethics of Psychoanalysis. New York: Reprint 1988.

1] This article is reprinted from the International Journal of Communicative Psychoanalysis and Psychotherapy, Vol. 15, Nos. 1-2. The ideas contained in this article have first been presented at the conference of the International Society of Communicative Psychoanalysis and Psychotherapy in New York City, 26 – 28 October 2001.

The author of this article can be reached by E-mail:
<UBerns@aol.com>