Reading Klein

Klein wrote three papers explicitly on this topic, relating to work with young children, latency children and adolescents. These gather together the practice implied in many others of the clinical examples included in almost all her writings and spell out the rationale for her approach. Much later she also wrote a series of as-yet unpublished lectures on technique in adult analysis which are likely soon to be available in book form. The three papers on child analysis were all included as chapters in her first book, The Psycho-Analysis of Children, published in 1932 and dedicated to Karl Abraham. The completion of this book was a significant achievement and represents the clinical and theoretical conclusions she drew from her extensive work as a child analyst. It is also full of down-to-earth descriptions of the setting required for child analysis and this suggests that Klein viewed the book as one which could guide future generations of child analysts in practical ways, as well as inspire them with the desire to practise her craft. In 1932 this was still a very new field, though one which had attracted the support and keen interest of very senior psychoanalytic figures, including Freud. The book was surely intended to be read as an authoritative statement of the approach to child analysis which Klein had developed in Berlin (Frank, 2009) – and was continuing to develop in London – and which she intended to serve as a foundational text in this new field. Her enthusiastic reception in London, where child patients were referred on her arrival, must have seemed like good evidence of a space waiting to be filled. Klein’s foreword to the first English edition was full of hope. At this point she was surrounded by generous intellectual and professional support at the highest level.

In this chapter we shall review these three papers, but it is appropriate to begin by quoting the vigorous opening lines of this book:

Psycho-analysis has led to the creation of a new child psychology. Psycho-analytic observations have taught us that even in their earliest years, children experience not only sexual impulses and anxiety, but also great disappointments. Along with the belief in the asexuality of the child has gone the belief in the ‘Paradise of Childhood’. These are the conclusions which were gained from both analysis of adults and direct observation of children, and which are confirmed and supplemented by the analysis of small children.

p.42

(The Psycho-Analysis of Children, 1932; p. 3)

It is absolutely characteristic of Klein’s thinking that she immediately turns to clinical detail to demonstrate her view that children’s deep anxieties are linked to strong feelings of guilt, arising from aggressive phantasies originating in Oedipal preoccupations, and also important to note that her first example is a child she began to see at age 2¾. At once therefore she is claiming that the Oedipal complex begins very early in a child’s life, an important divergence from Freud’s initial view. She also spells out at the outset the psychoanalytic roots of her technique:

The very differences between the infantile mind and the grown-up one showed me, in the first instance, the way to get at the associations of the child and to understand its unconscious. These special characteristics of the child’s psychology have furnished the basis of the technique of play analysis which I have been able to work out. The child expresses its phantasies, its wishes and its actual experiences in a symbolic way through play and games. In doing so, it makes use of the same archaic and phylogenetically acquired mode of expression, the same language, as it were, that we are familiar with in dreams; and we can only fully understand this language if we approach it in the way Freud has taught us to approach the language of dreams. Symbolism is only a part of it. If we wish to understand the child’s play correctly in relation to its whole behaviour during the analytic session we must not be content to pick out the meaning of the separate symbols in the play, striking as they often are, but must take into consideration all the mechanisms and methods of representation employed by the dream-work, never losing sight of the relation of each factor to the situation as a whole. Early analysis of children has shown again and again how many different meanings a single toy or a single bit of play can have, and that we can only infer and interpret their meaning when we consider their wider connections and the whole analytic situation in which they are set . . .

. . . For play is the child’s most important medium of expression. If we make use of this play technique we soon find that the child brings as many associations to the separate elements of its play as adults do to the separate elements of their dreams. These separate play-elements are indications to the trained observer; and as it plays, the child talks as well, and says all sorts of things which have the value of genuine associations.

(pp. 7–8)

In conclusion I should like to sum up briefly what has been said in this chapter. The more primitive nature of the child’s mind makes it necessary to find an analytic technique especially adapted to the child, and this we find in play analysis. By means of play analysis we gain access to the child’s most deeply repressed experiences and fixations and are thus able to exert a radical influence on its development. The difference between this method of analysis and that of adult analysis, however, is purely one of technique and not of principle. The analysis of the transference-situation and of the resistance, the removal of the early infantile amnesia and of the effects of repression, as well as the uncovering of the primal scene – all these things play analysis does. It can be seen that all criteria of the psycho-analytic method apply to this technique too. Play analysis leads to the same results as the adult technique, with only one difference, namely, that the technical procedure is adapted to the mind of the child.

p.43

(pp. 14–15)

How is this to be achieved with young children? Klein gives us a lively glimpse of what it might have been like to have been taken to see her:

On a low table in my analytic room there are laid out a number of small and simple toys – little wooden men and women, carts, carriages, motor-cars, trains, animals, bricks and houses, as well as paper, scissors and pencils. Even a child that is usually inhibited in its play will at least glance at the toys or touch them, and will soon give me a first glimpse into its complexes by the way in which it begins to play with them or lays them aside, or by its general attitude towards them.

(p. 16)

As the chapter progresses we read of all sorts of vital practical things the child analyst has to sort out – to find out in the initial consultations with parents the child’s words for body parts, urine, faeces and so on, and any special private family words which may be relevant; to have in mind how to deal with the situation if the child is too anxious to come alone to the consulting room; to decide whether the child may need help when going to the lavatory. Descriptions of several child patients’ play then set out the ground for discussion of her technique. The outstanding point is her conviction about the place and pace of interpretation, and this usually comes as a shock to her readers since she does not hold back. Here is her justification for this bold approach:

I have brought forward the above examples in order to support my view, based on empiric observation, that the analyst should not shy away from making a deep interpretation even at the start of the analysis, since the material belonging to a deeper layer of the mind will come back again later and be worked through. As I have said before, the function of deep-going interpretation is simply to open the door to the unconscious, to diminish the anxiety that has been stirred up and thus to prepare the way for analytic work.

I have repeatedly laid emphasis upon the child’s capacity for making a spontaneous transference.

(p. 24)

Klein therefore uses her immediate observation of the child’s behaviour and puts into words the response to herself and the whole situation, relating it to the feelings towards the parental figures in the child’s life. The point is, she argues, to see the mobilisation of the central anxiety which the analytic setting unleashes and to take hold of it, thus offering the child the feeling of being understood and invited to recognise that his analyst is someone available to help with what upsets him.

How one gets this across to the child is spelt out in a number of examples. There is a particularly interesting description of the initial work with Ruth, aged 4¼, whose extreme anxiety demanded a flexible approach from Klein, since she refused to come into the consulting room on her own. As her older sister had been brought along, Klein invited her to join Ruth, and her presence, as Klein had hoped, allowed Ruth to begin to play. But one day a few weeks later the sister was unwell. Klein judged that she could now take the risk of a session with Ruth alone. Here is what happened:

With her parents’ consent I took the second course. The nurse handed the little girl over to me outside my room and went away in spite of her tears and screams. In this very painful situation I again began by trying to soothe the child in a non-analytical, motherly way, as any ordinary person would. I tried to comfort her and cheer her up and make her play with me, but in vain. When she saw herself alone with me, she just managed to follow me into my room, but once there I could do nothing with her. She went quite white, and screamed, and showed all the signs of a severe attack of anxiety. Meanwhile I sat down at the toy-table and began to play by myself, all the while describing what I was doing to the terrified child, who was now sitting in a corner. Following a sudden inspiration, I took as the subject of my game the material which she herself had produced in the previous session. At the end of it she had played round the wash-basin and had fed her dolls and given them huge jugfuls of milk, etc. I now did the same kind of thing. I put a doll to sleep and told Ruth I was going to give it something to eat and asked her what it should be. She interrupted her screams to answer ‘milk’, and I noticed that she made a movement towards her mouth with her two fingers (which she had a habit of sucking before going to sleep) but quickly took them away. I asked her whether she wanted to suck them and she said: ‘Yes, but properly.’ I recognized that she wanted to reconstitute the situation as it happened at home every evening, so I laid her down on the sofa and, at her request, put a rug over her. Thereupon she began to suck her fingers. She was still very pale and her eyes were shut, but she was visibly calmer and had stopped crying. Meanwhile I went on playing with the dolls, repeating her game of the session before . . .

All the while I began by applying my interpretations to the doll – showing her as I played with it that it was afraid and screaming, and telling her the reason – and then I proceeded to repeat the interpretations which I had given for the doll by applying them to her own person. In this way I established the analytical situation in its entirety. While I was doing this Ruth grew visibly quieter, opened her eyes and let me bring the table on which I was playing to the sofa and continue my game and my interpretations close beside her. Gradually she sat up and watched the course of the play with growing interest, and even began to take an active part in it herself.

(pp. 27–28)

As is evident in this example, Klein used the technique of ‘displacement’ when talking to Ruth, attributing the child’s terrible worries to the doll, as a first step, and explaining gently what it was that made the doll so frightened. She is very attentive not only to the pace at which children can cope with facing their fears but also to the form of words which are appropriate. ‘I take the way in which the children think and speak using their own images as my model’ (p. 32). She noted, for example, that a little boy said of the toy swing, ‘look how it dangles and bumps’ and then utilised his word ‘bump’ in talking to him about parental intercourse, and found that this made immediate sense to him.

The playroom Klein advises for the analysis of young children has to provide other opportunities for play in addition to the small toys she gave them. She suggests it should have a small basin and running water, and items for water play (beakers, sponge, cloth, etc.) and describes how all the furniture of the room will be pressed into use at times and needs to be serviceable for such purposes. She also gave children material for making things as well as drawing – paper, card, pencils, scissors, string, bits of wood, even a knife (!) – and was tolerant of children choosing to bring their own toys. The search is for a way in which the child will be able to express himself as freely as possible. On the whole Klein’s patients were inhibited in play rather than wild and difficult to control, which would be more often an issue with the patients seen in contemporary psychotherapy with children, but what comes alive is her sense of freedom in finding out what will work with a particular chid, and her willingness to experiment.

Once the child patient is a little older, games of make-believe often come to the fore, as in the case history of Erna, a very depressed 6-year-old girl with severe sleeping difficulties and obsessional thumb sucking and masturbation. Klein found she needed to play the parts assigned to her by Erna in many scenarios, in which the child’s intense rivalry with her, representing mother, was at the heart of every game. The ferocity of Erna’s phantasies and play was extreme, and in her work with this severely ill child Klein did have to place severe limits on her behaviour, making it plain that she was not to attack her analyst physically, although she was permitted to express her destructive rage freely in other ways. Klein formulates the appropriate technique for dealing with emotional outbursts as having three elements: the child is only required to control expression of his feeling in so far as there is a necessity in reality (e.g. not to flood the whole room, not to injure the analyst); expression of destructive messy impulses within the room is accepted; the analyst’s task is to interpret the meaning of the child’s abusive and violent behaviour in the session in the context of earlier developmental difficulties, and to tolerate the child’s destructiveness meanwhile.

Moving on to discuss analysis in the latency period Klein first describes the marked change in children’s relationship to themselves and others as the passions of early childhood recede, though we may note here that the notion of ‘latency’ has undergone considerable revision in the light of today’s children’s earlier development, a sexualised and generally uninhibited cultural context and changed family and educational mores.

The analysis of children in the latency period presents special difficulties. Unlike the small child, whose lively imagination and acute anxiety enables us to gain access to and contact with its unconscious more easily, children in the latency period have a very limited imaginative life, in accordance with the strong tendency to repression which is characteristic of their age; while, in comparison with the grown-up person, their ego is still undeveloped, and they neither have insight into their illness nor a desire to be cured, so that they have no incentive to start analysis and no encouragement to go on with it . . .

p.46

. . . children of this age group do not play like small children nor give verbal associations like adults. Nevertheless I have found it possible to establish the analytic situation without delay if I approach their unconscious from a point of departure that corresponds to the nature of the older child. The small child is still under the immediate and powerful influence of its instinctual experiences and phantasies and puts them in front of us straight away; it is therefore appropriate, as I found in early analyses, to interpret, even in the first sessions, the small child’s representations of coitus and its sadistic phantasies; whereas the child in the latency period has already desexualized those experiences and phantasies much more completely and worked them over in a different form.

(p. 58)

Children’s games in this later phase of childhood tend to be much more connected with everyday reality and there is more repression in evidence, as in Klein’s description of Inge’s play:

For a considerable time she played an office game with me, in which she was the manager who gave orders of every sort and dictated letters and wrote them, in contrast to her own severe inhibitions in learning and writing. In this her desires to be a man were clearly recognizable. One day she gave up this game and began to play at school with me. It is to be noted that she not only found her lessons difficult and unpleasant but had a great dislike for school itself. She now played at school with me for quite a long time, by taking the part of the mistress while I represented the pupil; the kind of mistakes she made me make gave me important clues to the reasons for her own failure at school. Inge, as a youngest child, had, in spite of all appearances to the contrary, found the superiority of her elder brothers and sisters very hard to put up with, and when she went to school she had felt that the old situation was being reproduced. As the details of the lessons which she gave in the role of a mistress revealed, in the last resort and at a very early age, her own desire for knowledge had not been satisfied and was repressed . . .

(pp. 61–62)

While Inge was a failure in reality, in imagination she played every role. Thus in the game I have described, in which she played the part of office-manager, she represented her successes in the role of father; as the school mistress she had numerous children, and at the same time exchanged her role of the youngest child for that of the oldest and most intelligent; while in the game of being a seller of toys and food, admittedly by a double displacement of roles, she reversed the oral frustrations.

p.47

(p. 63)

We can note here Klein’s emphasis on the damaging impact of the blocking of Inge’s desire to find things out. Instead of being able to express her longing to understand the world and to feel enabled to explore reality, she has turned to a phantasy of already being in possession of all knowledge.

Sometimes children of this age are able to bring dreams to their analysis, but their associations are more likely to be expressed through simultaneous physical or play activity rather than in verbal form. The developmental maturation of the child is of course considerably supported by the analytic work and in latency children the transition from action-based communication through play into more purely verbal expression can often be observed.

This boy [a nine-year-old], who behaved in many respects like an adult obsessional and in whom morbid brooding was a marked symptom, also suffered from severe anxiety which was, however, chiefly exhibited in great irritability and in fits of rage. A great part of this analysis was carried on by means of toys and with the help of drawing. I was obliged to sit beside him at the play-table and to play with him even to a greater extent than I usually have to with most small children. Sometimes I had even to carry out the actions involved in the game alone by myself under his direction. For instance, I had to build up the bricks, move the carts about and so on, while he merely supervised my actions. The reason he gave for this was that his hands sometimes trembled very much, so that he could not put the toys in their places or might upset or damage them. This trembling was a sign of the onset of an anxiety attack. I could in most cases cut the attacks short by carrying out the game as he wanted it, at the same time interpreting, in connection with his anxiety, the meaning of the actions (in the game). His fear of his own aggressiveness and his disbelief in his capacity to love had made him lose all hope of restoring the parents and brothers and sisters, whom, in his phantasy, he had attacked. Hence his fear that he might accidentally knock down the bricks and things which had already been put up. This distrust of his own constructive tendencies and of his ability to make restitution was one of the causes of his severe inhibition in learning and playing.

After his anxiety had been resolved to a large extent, Werner played his games without assistance from me. He did a great many drawings and gave abundant associations to them. In the last part of his analysis he produced his material chiefly in the form of free associations. Lying on the couch – a position in which he, like Kenneth, preferred to give his associations – he would narrate continuous phantasies of adventure in which apparatus, mechanical contrivances and so on played a large part. In these stories the material that had before been represented in his drawings appeared again, but enriched in many details.

(pp. 66–67)

The vast range of cases on which Klein draws in this chapter is remarkable, and testifies to the extent of her clinical experience. The number of examples also serves to demonstrate the imaginative flexibility in her techniques. When writing about one very cut-off 9½-year-old boy, whose play was profoundly monotonous, she described how not only did she need to play with him as one might with a very small child and follow his rarely verbalised instructions, but she also realised that in order to establish rapport and avoid replicating the behaviour of his intrusive father she had to remain silent herself. To offer interpretations, she surmised, would have provoked further retreat. This boy’s inhibition in speaking persisted for a long time, but in due course he began to be able to send her messages in writing, and then to whisper things to her as long as she too used a low voice, thus protecting them from the persecutors which she realised he believed had been ever present.

In this chapter Klein also tackles the question of the child analyst’s relationship to her patient’s parents. She puts it like this:

I refer to the analyst’s dealings with the parents of his patients. In order for him to be able to do his work there must be a certain relation of confidence between himself and the child’s parents. The child is dependent on them and so they are included in the field of the analysis; yet it is not they who are being analysed and they can therefore only be influenced by ordinary psychological means. The relationship of the parents to their child’s analyst entails difficulties of a peculiar kind, since it touches closely upon their own complexes. Their child’s neurosis weighs very heavily upon the parents’ sense of guilt, and at the same time as they turn to analysis for help, they regard the necessity of it as a proof of their guilt with regard to their child’s illness. It is, moreover, very trying for them to have the details of their family life revealed to the analyst. To this must be added, particularly in the case of the mother, jealousy of the confidence which is established between the child and its (woman) analyst.

(p. 75)

A couple of pages later, however, she writes of the potentially benign effect of a child’s analysis on family relationships:

The removal or lessening of a child’s neurosis has a good effect upon its parents. As the mother’s difficulties in dealing with her child diminish, her sense of guilt diminishes too, and this improves her attitude towards the child.

(p. 78)

Yet she is cautious in considering what can be achieved in the direct contact between a child’s analyst and his parents:

Nevertheless, I do not, in the light of my own experiences, put much faith in the possibility of affecting the child’s environment. It is better to rely upon the results achieved in the child itself, for these will enable it to make a better adaptation even to a difficult environment and will put it in a better position to meet any strains which that environment may lay upon it.

p.49

(p. 78)

These suggestions arise from a context in which the parents seeking help for their child from Klein were often quite well informed about psychoanalysis and indeed committed to it intellectually. Although a number of the case histories she reports involve a child’s treatment being ended prematurely from a psychoanalytic perspective, this was usually due not to a breakdown of support from the parents, suggesting how well Klein was able to calibrate the kinds of links she made with them, but to external factors such as a family move. Making space in children’s lives for several sessions a week did not seem to pose great difficulties, and many families had nannies who could bring the children to their sessions. Few of the mothers were themselves working outside the home. All of this is a far cry from contemporary life, but it is also the case that, while Klein found she could work successfully on the basis of quite limited meetings between herself and her patients’ parents, child analysts and psychotherapists now most often find that some separate arrangements for regular parental consultation in addition to review meetings with the child’s therapist prove necessary. The complexity of professional networks which do not appear in Klein’s account of her work also tend to require a good deal of liaison. However, the stance Klein takes with regard to the privacy of the child’s sessions remains fundamental, and she offers a wise reminder of the primary duty of the child analyst in her reflections on the way that parents (and one might add, other adults significant in the child’s life) can often find it difficult to keep track of the child’s behaviour and relationships during the course of his treatment:

I think we shall be well content to forgo our full due of recognition from that quarter [parents] so long as we bear in mind that the foremost aim of our work is to secure the well-being of the child and not the gratitude of its mother and father.

(p. 79)

Such a prescription sits rather uncomfortably with the contemporary emphasis in public health provision on tracking outcome closely, and judging this in major part by the views of parents and teachers. Klein is by no means uninterested in how the children she has treated develop and she quite often includes information about their later trajectory when she has been able to ascertain details. She is committed to helping her patients to relate to the demands of external reality, and is clearly satisfied when this is brought about, but she is primarily concerned to protect the child’s private space within the analysis, which is needed if the problems of his inner world are to be given proper attention.

In the third of the chapters on technique Klein tackles the changes ushered in by the child’s experience of puberty. The cases she presents range in age from 12 to 15, so as the age of puberty has moved forward over the last 80 years, it is probably helpful to think of her technical recommendations as applying to the early years of adolescence somewhat more broadly.

Typical analyses at the age of puberty differ in many essentials from analyses in the latency period. The instinctual impulses of the child are more powerful, the activity of his phantasy greater, and his ego has other aims and a different relation to reality. On the other hand there are points of similarity with the analysis of the small child, owing to the fact that at the age of puberty, we once again meet with a greater dominance of the instinctual impulses and the unconscious, and a much richer phantasy life. Moreover, in puberty manifestations of anxiety and affect are very much more acute than in the latency period, and are a kind of recrudescence of anxiety which is so characteristic of small children.

Warding off and modifying anxiety, which is also an essential function of the ego in the case of the small child is, however, carried out with greater success by the more developed ego of the adolescent. For he has developed his various interests and activities (sports and so on) to a great extent with the object of mastering that anxiety, of over-compensating for it and of masking it from himself and from others. He achieves this in part by assuming the attitude of defiance and rebelliousness that is characteristic of puberty. This provides a great technical difficulty in analysis at puberty; for unless we very quickly gain access to the patient’s affects – strong as they are at this age – which he principally manifests in a defiant transference, it may very well happen that the analysis will suddenly be broken off.

(p. 80)

She goes on to note the continuity in many respects in the presentation of young adolescents with the preoccupations visible in the play of small children:

The material of the adolescent closely resembles that presented by the small child. At the ages of puberty and pre-puberty boys busy themselves in their phantasy with people and things in the same way as small children play with toys. What Peter, aged three years and nine months, expressed by means of little carts and trains and motors, the fourteen-year-old Ludwig expressed in long discourses, lasting for months, on the constructional differences between various kinds of motors, bicycles, motor-cycles, and so on. Where Peter pushed along carts and compared them with one another, Ludwig would be passionately interested in the question of which cars and which drivers would win some race; and whereas Peter paid a tribute of admiration to the toy man’s skill in driving and made him perform all sorts of feats, Ludwig for his part, was never tired of singing the praises of his idols of the sporting world.

(p. 81)

While the more normal adolescent will tend to display a vivid conflictful world peopled by admired heroes (sporting heroes in Klein’s cases, perhaps figures from popular culture too, nowadays) in contrast to the scornful dismissal of teachers, relatives, the ‘uncool’, more inhibited characters maintain a retreat from disturbing feelings more akin to what is ordinary during the latency years. Klein suggests that when latency sets in too soon or continues too long, that is, occupies an extended period of years, it is an indication of a severe developmental disturbance. This grounding of her observations in an understanding of normal patterns of child development is most important, and it is a feature of the way she introduces us to the many children whose material she presents that she makes quite a clear assessment of their degree of disturbance. Some are described as fundamentally normal children who could nonetheless benefit from analysis in terms of the development of character and the lifting of subtle restrictions in their relationships. Others are children whose neurotic difficulties were all too obvious, whose lives were blighted by their anxieties and whose problems made them a source of deep concern for their parents.

In discussing her technique with adolescents, Klein presents several cases in which guilt and anxiety about sexual activities, either past or present, are a central feature. Here is an example:

In the analysis of the fourteen-year-old Ludwig . . . I was able to discover . . . the reason for his strong feelings of guilt about his younger brother. When, for instance, Ludwig spoke about his steam-engine being in need of repair, he at once went on to give associations about his brother’s engine which would never be any good again. His resistance in connection with this and his wish that the session would soon come to an end turned out to be caused by his fear of his mother, who might discover the sexual relations which had existed between him and his younger brother and which he partly remembered. These relations had left behind them severe unconscious feelings of guilt in him, for he, as the elder and stronger, had at times forced his brother into them. Since then he had felt responsible for the defective development of his brother, who was seriously neurotic.

(pp. 83–84)

The centrality of anxiety about masturbation, sexual fantasy and sexual activity with other children is quite striking. This feature perhaps has its origins in the relatively repressive upbringing of children in the early twentieth century with respect to sexual knowledge and also to auto-erotic activity, but it meant that in order to help these patients Klein had to think deeply about the sexual development of the boy and girl, and this led her to revise aspects of Freudian theory. Here is her approach to the pubertal girl:

I now turn to the analysis of girls at the age of puberty. The onset of menstruation arouses strong anxiety in the girl. In addition to the various other meanings which it has and with which we are familiar, it is, in the last resort, the outward and visible sign that the interior of her body and the children contained there have been totally destroyed. For this reason the development of a complete feminine attitude in the girl takes longer and is beset by more difficulties than is the case with the boy in establishing his masculine position. This greater difficulty in the woman’s development results in a reinforcement of the masculine component of the girl at puberty. In other cases only a partial development, mostly on the intellectual side, sets in at that time, while her sexual life and personality remain in a protracted latency which in many cases may last beyond the age of puberty . . .

p.52

. . . Even girls in whom the feminine position predominates have anxiety during puberty which is more severe and more acute in its expression than in the adult woman.

(pp. 85–86)

Klein goes on to give a long account of her work with Ilse, aged 12 at the start of her treatment. After realising that Ilse was a most reluctant patient, quite unable to talk with any freedom, Klein suggested that she might like to draw.

During the months that followed, Ilse’s associations consisted in the main of drawing – apparently without any phantasy – done with compasses, according to exact measurements. These measurements and calculations of parts of things was the main activity, and the compulsive nature of this occupation became increasingly clear. After much slow and patient work it emerged that the various forms and colours of these parts represented different people. Her compulsion to measure and count proved to be derived from the impulse, which had become obsessive, to find out for certain about the inside of her mother’s body and the number of children there, the differences between the sexes, and so forth. In this case, too, the inhibition of her whole personality and intellectual growth had arisen from a very early repression of her powerful instinct for knowledge, which had changed into a defiant rejection of all knowledge. With the help of this drawing, measuring and counting we made considerable progress and Ilse’s anxiety became less acute.

(p. 88)

Ilse became able to talk about her despair over her failure at school and her tormenting belief that her clothes were all wrong and that she never looked right. The account continues:

As Ilse’s difficulties in learning continued to diminish, a very great change took place in her whole nature. She became capable of social adaptation, made friends with other girls and got on much better with her parents and her brothers and sisters. One could now call her a normal girl and her interests now approximated to what was adequate to her age; and as she was now good at school, a favourite with her mistresses and had become an almost too-obedient daughter, her family were completely satisfied with the success of her analysis and saw no reason for its continuance. But I did not share their opinion. It was obvious that at this point, when she was thirteen and physical puberty had already begun, Ilse had psychically only just accomplished a really successful transition to the latency period. By means of resolving anxiety quantities and reducing her sense of guilt, the analysis had enabled her to adapt herself socially, and to progress psychically to the latency period. However gratifying these changes might be, the person I saw before me was still a rather dependent child who was still excessively fixated to her mother. Though her circle of interests was greatly widening she was still hardly capable of having any ideas of her own. She usually prefaced her expressions with such words as ‘Mother thinks’. Her wish to please, the great care that she now took of her appearance in contrast to her former total indifference to it, her need for love and recognition – all these sprang predominantly from her desire to please her mother and her mistresses; the same purpose served her desire to do better than her schoolmates. Her homosexual attitude was predominant and there were as yet scarcely any heterosexual impulses visible in her.

p.53

The continuation of the analysis, which now proceeded in a normal fashion, led to far-reaching changes not only in this respect, but in the whole development of Ilse’s personality. In this she was very much helped by the fact that we were able to analyse the anxiety which menstruation aroused in her . . . . It was only now that her psychological puberty really set in. Before this, she had not been in a position to criticize her mother and form her own opinions, because this would have signified making a violent sadistic attack upon her mother. The analysis of this sadism enabled Ilse – in keeping with her age – to achieve a greater self-reliance which became visible in her way of thinking and acting.

(pp. 90–91)

In this case, we see how the girl’s failure to work over her over-strong sense of guilt was able to disturb not only her transition to the latency period but the whole course of her development. Her affects, which found an outlet in outbursts of rage, had been displaced; the modification of her anxiety went wrong. Ilse, who had the appearance of an unhappy and discontented individual, was not aware of her own anxiety nor of her dissatisfaction with herself. It was a great advance in her analysis when I was able to make her understand that she was unhappy and to show her that she felt inferior and unloved and that she was in despair about it and, in her hopelessness, would make no attempt to gain the love of others.

(p. 91)

She goes on to suggest that the analysis of pubertal children requires an understanding of the technique of adult analysis, that is, the use of free association and the couch. Indeed, she argues that training in adult psychoanalysis is a prerequisite for the ‘more difficult field of child analysis’. This expectation remains the practice in some psychoanalytic societies but has been subject to sustained challenge over the last 60 years, during which child psychoanalytic training has successfully established itself as an independent pathway. Given Klein’s own theoretical advances in understanding that the roots of our psychological difficulties go back to our very early lives, it can certainly be cogently argued that the psychoanalytic study of the child’s mind is an excellent point of departure. It is also the case that some children do show themselves to be very responsive to the psychoanalytic method, getting to the emotional heart of the matter more readily than some adult patients. What child analysis does tend to protect is the combination of the centrality of clinical observation and a psychoanalytic theory attuned to development, and such attention to the potential growth of the mind is a useful counterbalance to a focus on pathology.

Klein follows up the chapters on technique with some observations on indications for treatment in children which are extraordinarily wide-ranging. The difficulties she mentions include eating disorders (‘derangements in eating’, she calls them); sleep disturbances; phobias and excessive timidity; inhibitions in play and/or a capacity for physical expression; self-harm and accident-proneness; hyperactivity (‘overliveliness and fidgetiness’ are her words); tics; inhibitions in learning; over-reliance on material possessions and gifts; and unusual vulnerability to physical illness. This list attests to both her enormous range of experience and to the unifying power of her model of the role of early anxiety and guilt in shaping the mind. It is also remarkably prescient in terms of the difficulties presented to contemporary child and adolescent mental health services.

She also offers some considered comments on normality, pathology and health in children. First, a reminder as to what is specific to child analysis:

Finally I would like to draw attention to the technique employed in the treatment of this case. In the first part of it I used the technique belonging to the latency period, and in the second that belonging to puberty. I have repeatedly referred to the connecting links between the various forms of psycho-analytic technique appropriate to different stages. Let me emphasize that I regard the technique of early analysis as the basis of the technique applicable to children of every age. In the last chapter I have said that my method of analysing children of the latency period was based on the play technique I had worked out for small children. But as the cases discussed in the present chapter show, the technique of early analysis is indispensable for many patients at the age of puberty as well; for we shall fail with many of these often very difficult cases if we do not sufficiently take into account the adolescent’s need for action and for expression of phantasy and are not careful to regulate the amount of anxiety liberated and, in general, do not adopt an exceedingly elastic technique.

(pp. 92–93)

Comparison with the neuroses of adults cannot serve as a yard-stick, since the child who most approximates to a non-neurotic adult is by no means the child who is least neurotic. Thus, for instance, a small child which fulfils all the requirements of its upbringing and does not let itself be dominated by its life of phantasy and instinct, which is in fact, to all appearances completely adapted to reality and, moreover, shows little sign of anxiety – such a child would assuredly not only be precocious and quite devoid of charm, but would be abnormal in the fullest sense of the word. If this picture is completed by the extensive repression of phantasy which is a necessary pre-condition of such a development, we should certainly have cause to regard that child’s future with concern. A child whose development has been of this kind suffers, not from a quantitatively minor neurosis but from a symptomless neurosis; and as we know from the analysis of adults, such a neurosis is usually a serious one.

p.55

(p. 101)

The question now to be considered is: how does a child show that it is fairly well adapted internally? It is a favourable sign if it enjoys playing and gives free rein to its phantasy in doing so, being at the same time, as can be recognized from certain definite indications, sufficiently adapted to reality, and if it has really good – not over-affectionate – relations to its objects. Another good sign is if, together with this, it shows a relatively undisturbed development of its instinct for knowledge, which freely turns in a number of different directions, yet without having that character of compulsion and intensity which is typical of an obsessional neurosis. The emergence of a certain amount of affect and anxiety is also, I think, a pre-condition of a favourable development. These and other indications of a favourable prognosis have in my experience, however, only a relative value and are no absolute guarantee of the future; for it often depends on the unforeseeable external realities, favourable or unfavourable, which the child encounters as it grows up whether its neurosis of the child will reappear in the life of the adult or not.

(p. 103)

The adult individual may succumb to a neurosis, to characterological defects, to disturbances of his capacity for sublimation or to disorders of his sexual life. An infantile neurosis can be detected at an early age, as I have endeavoured to show, by various slight but characteristic signs; the cure of the infantile neurosis is the best prophylaxis against the neurosis of the adult. Later characterological defects and difficulties are best prevented by being eliminated in childhood. The play of children, which enables us to penetrate so deeply into their minds, gives us a clear indication when their analysis can be considered as being completed in respect of their future capacity for sublimation. Before we can consider the analysis of a small child as completed, its inhibitions in playing must have been largely reduced. This has been accomplished when its interest in play appropriate to its age has become not only deeper and more stable but has also been extended in various directions.

When, as a result of the analytic work, a child who starts with a single obsessive interest in play gains an ever-widening interest in games, this process is equivalent to the expansion of interests and the increase of capacity for sublimation which is the aim of the analysis of an adult. In this way, by understanding the play of children we can estimate their capacity for sublimation in future years; and we can also tell when an analysis has sufficiently guarded against future inhibitions of their capacity to learn and to work.

p.56

Finally, the development of the child’s interest in play, and the variations in quantity and kind which they show, also permit reliable conclusions about its future sexual development.

(pp. 104–105)

Klein’s technique, usually represented as seeking to make contact with a child’s deeper anxieties as soon as possible, can easily be overstated. As documented in this chapter, she took sensitive account of children’s individual ways of holding anxieties at bay and would try out different ways of enabling them to begin to trust her. Nonetheless, debate on matters of technique and underlying theory was intense, and in The Freud–Klein Controversies 1941–45 (King and Steiner, 1991) are recorded the divergent views of Klein and her co-workers and the group led by Anna Freud in the form of papers presented to the British Psychoanalytical Society in a long series of meetings between October 1942 and February 1944.

There have been significant developments in psychoanalytic technique in subsequent years. Of central relevance in these changes is the theory of the early shaping of the mind developed by W.R. Bion and the new understanding of the relationship between the minds of mother and baby, and by analogy, analyst and patient. The model of containment of infantile anxiety through maternal receptiveness and reverie opened up the potential understanding of very early unintegrated forms of experience, and also of broken-down psychotic states in which mental structure and an awareness of reality have become unavailable. Analysts began to recognise how important was the function of containment with respect to these fragmented forms of experience. Before interpretation could be useful to the patient, the unthinkable-about experiences had to become recognised, known to a mind capable of bearing them and transformed through the thinking activity of the analyst.

This expanded understanding of early forms of human communication was particularly relevant for child analysis, and more so in the light of changes in the population of children being referred for analytic help. The by-and-large stable families in which Klein’s patients grew up are now often replaced by very troubled backgrounds, high levels of trauma, loss and deprivation. The growing complexity of the contemporary globalised world has been accompanied by a sharply increased incidence of mental health problems among children and adolescents, including very serious levels of difficulty.¹

A second major theoretical discovery impinging on technique was the revised understanding of countertransference. Heimann’s suggestion (1950), that the analyst’s countertransference sometimes reflected not the continuing personal problems of the analyst, as Freud and Klein had believed, but an unconscious response to an aspect of the patient, has been very influential. In fact, Klein’s own theory of projective identification (see Chapter 6) was vital in making this new perspective possible.

Technique in analytic work with children and adolescents has changed in the light of these ideas. The gathering in of the anxieties evoked by the analytic setting remains the starting point, but what and when to interpret to the child are less clear-cut. Exploring the distinction between deficit and disturbance (Alvarez, 1992) is one aspect of this development. Allowing for the idea that the analyst’s feelings in the session provide vital clues to the child’s deeper emotional state, particularly when the levels of mental pain are very high, is another (Hoxter, 1983). ‘Kleinian’ technique now encompasses a considerable range, though the focus on the centrality of anxiety and on the importance of finding words to describe emotion and the inner world remains central.

1 It is only in recent decades that reliable epidemiological data has become available in the UK. This indicates that the incidence of serious mental ill health among children and young people doubled between 1974 and 1999. For boys aged 15–16, the proportions of young people reporting frequent feelings of depression or anxiety increased from 1 in 30 to 2 in 30; for girls from 1 in 20 to 2 in 20. In 2004, one in ten children and young people (10 per cent) aged 5–16 had a clinically diagnosed mental disorder. See http://www.hscic.gov.uk/catalogue/PUB06116/ment-heal-chil-youn-peop-gb-2004-rep2.pdf, and Green et al. (2005). Data gathered in 2009 suggests that this increase levelled off after 1999, although worsening economic prospects on a European scale, particularly for young people’s employment, may lead to renewal of this upward trend. On this, see http://www.nuffieldfoundation.org/time-trends-adolescent-well-being and Hagell (2012).