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Clinical commentary by Debbie Hindle, a child and adolescent psychotherapist working in Glasgow and organizing tutor of the clinical training at the Scottish Institute of Human Relations From a research perspective In the background to the clinical material, the therapist identies these sessions as a turning point in the work. So I thought I would begin by considering the research on turning point sessions in child psychotherapy before thinking about the complex issues that this young child and her therapist were grappling with together. Carlberg (1997: 331) dened a turning point session as
a session where the therapist notices that something qualitatively new may be identied concerning the behaviour of the child or the childs way of showing his/ her inner world, or where something new enters the interplay between the child and the therapist.

Carlbergs small qualitative study is fascinating to read, as he was able to identify common features, as well as a range of themes that emerged in the cases reported over a two-year period. In relation to the clinical material described in this commentary, I was struck by the directness of Graces communication to her therapist, and the way in which they came together to create a narrative, with the therapist giving voice to Graces feelings. These moments also captured by Graces words and actions seem to exemplify what Carlberg (1997: 345) described as a key principle behind these kinds of changes a moment of emotional meeting underlying the turning point. That is, it is in the context of the relationship and the emotional quality of the interplay between child and therapist that seems to pave the way for such changes. Carlberg (1997: 342) also noted that there is often an extended signicant process preceding the turning. In the therapists background information, we hear that in the initial period of the therapy, Grace was often silent or spoke only in whispers . . . or was hidden in corners of the room or under the blanket. She describes how sessions appeared more like infant observations, with only fragments of play discernible. I found myself wondering if the therapists observation skills, her capacity to accurately and attentively observe, as evidenced by her detailed recordings of the sessions given, provided an important context for the work we see emerging in these sessions. There have been numerous publications about the importance of infant observation and its implications for clinical work. In particular, it is worth noting Sternbergs (2005) study of infant observation and its inuence on clinical training in psychotherapy. Through her interviews with clinicians, she was able to demonstrate how the experience of infant observation initiates or at times catalyses processes of development in its participants (p. 226), opening the door to a deeper understanding of unconscious processes, the countertransference and a capacity to tolerate uncertainty. In the clinical sessions given, I would hypothesise that the therapists emotional availability, gained through her experience of infant observation, enabled her to gather even the smallest fragment of play and to begin to imbue these fragments with meaning. The therapeutic relationship seems to have provided a much-needed containing environment, which facilitated the emergence of this young girls play.

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Defensive structures and primitive anxieties At the start of the rst session, the therapist describes Grace as petite and swamped by her school uniform, almost immediately alerting us to her prematurity. Later in the same session, the therapist notes that when Grace (as a cat) slowly emerges from underneath the blanket she is in charge of how much light and sound she lets in, as if needing to regulate sensory experience. Cohen (2003) gives a stark and vivid account of a neonatal intensive care unit and how premature babies may experience their world. We can only imagine how this may have aected Grace, seen in her diculties in establishing feeding and in settling at night. The fact that her mother was largely unsupported no doubt contributed to Grace and her mother not getting o to a good start. This sense of things not coming together is beautifully illustrated towards the end of the second session when the therapist was able to talk to Grace about things not happening at the right time . . . or coming to her in the wrong way at the wrong time. What emerges is how this early experience seems to have coalesced into a defensive structure. From the rst miaow, a story unfolds. We learn that the cat is stuck up a tree . . . it is night time and the therapist ventures that the cat might be feeling frightened and alone. Similar to the owl in the cage in the second session, both images allude to the position she nds herself in high up or caged in, unable to access the help and comfort she needs. Like being silent or under the blanket in the initial sessions, this state of mind may have aorded her some protection, but also left her in an isolated and vulnerable position. With the birth of her sister when she was two years old, unresolved issues became centred on the developmental task of toilet training. By the time she was referred to the CAMHS service at four-and-a-half years of age, she was refusing to use the toilet and was troubled by constipation, requiring medical interventions. Her parents understanding of Graces presenting problem as a symptom of a wider problem seems to have set the scene for positive engagement with the clinic and with the process of therapy. But what do we make of her presenting problem? Barrows (1996) reviewed the literature on soiling in children and reected on three cases in which the children were constipated or showed retentive functions. He suggested that in each case the symptom was indicative of a particular type of object relationship characterized by an excessive need to exercise omnipotent control over the object (p. 240). He linked this defensive function with diculties in the child fully accepting the psychic reality of the Oedipal couple. But at the end of this thoughtful paper, he also notes Boston (personal communication) in which she says that
the same symptom can also be an expression of a defence against very primitive terrors such as those described by Bick and Tustin, as well as a fear of losing all the body contents along with the faeces (p. 259).

Although we cannot know denitively, I found myself wondering about the primitive anxieties that may have beset this young girl as an infant anxieties that so disrupted her relationship to the breast and to all those aspects of her earliest relationship with her mother which could have provided comfort and security. The psychoanalytic process In reading the process notes, I envisaged myself reading a musical score with each movement or communication by the child eliciting a nely tuned response from her therapist, followed by developments in the childs play.

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In the rst session, I thought there were two signicant points. The rst was when the therapist linked what the cat might be feeling directly to Grace.
I said I wondered if Grace sometimes shared the cats feelings, of darting o quickly, wanting to be the highest and the rst and then feeling quite worried about things.

This soon leads to a surprising rescue when Mummy and Daddy arrive with a ladder to help the cat and the other children down from their position high up in the tree. Clearly, active intervention was needed, similar to what Alvarez (1992) describes as reclaiming. Grace has not been able to get down or to overcome her more encapsulated position on her own, but has needed the help of her parents and therapy. Only then, as a cat, does she sleep and then drink and eat hungrily. Keeping her comments in the context of the play, the therapist notes the importance of the cat needing time to recover. Slowly as Grace emerges from under the blanket, a bit at a time the therapist acknowledges how upset the cat has been. It is this sensitivity to the childs need for time to communicate that sets the tone of the session. Nothing seems rushed or intrusive; rather the material unfolds, leading to a tender moment when Grace says It likes stroking you know, which in turn is armed by the therapist saying that it needs to be close and comforted. I thought this was the second signicant point in the session. Only at this point does Grace say that the cat is a girl kitten, her voice become stronger and a family is introduced. Although at rst she portrays an idyllic scene, this is soon shattered by conict between the children. The oldest kitten feels pushed out, but also removes herself to what the therapist describes as a cold hard place, all alone. Only gradually does she return, and with the parents introduction of the idea that the children could take turns, the possibility of a second chance enters the frame. Like the initial rescue of the cat, this stands as another resolution in the session. In musical terms, resolution refers to the process by which dissonant elements in intervals move to consonant ones to ensure satisfactory closure and completion (Latham, 2002: 1051). This seems an apt metaphor for what was being conveyed. I thought the session beautifully conveyed the tension between being alone and being part of a family, and also the problem of having to wait for her session, feeling shut out, alone and displaced by other children. In a sense, the session also represents the childs struggle in nding an analytic home. In the second session, Grace again draws attention to an inside space a cocoon and an egg which the therapist says for both one just has to wait. In the story that develops, the mother has died and the owl is being looked after by neighbours. She is in a cage to protect her, but the cage is problematic because it also restricts the owl. The therapist identies that the poor owl, it feels so misunderstood. What is striking is the childs response when these issues are taken up in the transference. Almost immediately, the owl is said to need a bigger cage and is given the name Fluy. It was as if this transference interpretation opened the door to exploring complexity the familys frustration at never being able to get things right for her and the owls reluctance to come out. The session ends with the emergence of two ideas: that the owl has been inside so long that it doesnt want to come out; and that the second baby fed easily and grew quickly. This acknowledgement of her diculties, and an awareness that her sister had not struggled in the same way, seemed a remarkable end to the session.

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At dierent points in these two sessions, there is a tension between Grace being outside the reach of the family, her perceived rejection by them (You go to a dierent home) and her longing to be part of a family where Grace (as a kitten) is given a second chance. I thought this therapy was also providing Grace with a second chance and a dierent sort of medicine than that which she plays out as tasting bad and spoiling her food. In these sessions, she seems to be oered something in the right way and at the right time, and also by her mother, who generously waits for her and warmly relinquishes and receives her at the beginning and end of the sessions. I was particularly struck by Graces use of the image of the owl. Many years ago, I was seeing a latency aged boy with many debilitating anxieties in intensive therapy. At one point in our work together, he brought Jill Tomlinsons book (1968), The Owl who was Afraid of the Dark from home and we read and re-read this in the sessions over many weeks. The baby barn owl in the book Plop is wide-eyed, helpless and totally dependent on his parents for food. Like the little cat in Graces rst session he is high up in a tree and like her use of the blanket, he takes refuge in his nest. But because he is afraid of the dark, he cannot join his exasperated parents in their nightly hunts or learn to feed himself. In the story, he cannot be persuaded or cajoled to relinquish his fears, but must explore the problem by talking to a series of other people he encounters in the day and come to his own realization and resolution. The links with psychotherapy seem evident here in that the process involved in overcoming his fears takes time and involves learning about himself and others and seeing the world from dierent perspectives. It is only after this that Plop is able to use his parents patient help. In the Introduction to The Psychoanalytic Process, Meltzer (1967: xii) briey denes analytic activity as a search for truth. I think we see this at the end of the second session, when Grace approaches what Bion would refer to as K the knowledge of her own resistance and the dierence between her and her sister. But in The Apprehension of Beauty, Meltzer and Harris Williams (1988) further describe the way the K-link overrides yearning for gratication and control over the object, making it possible, even essential, to give the object its freedom (p. 27). One wonders in this case whether such a shift in this young girls position might also enable her symptom and its unconscious link with omnipotent control of internal objects to resolve. In reading this clinical material, I was time and again struck by the beauty of the analytic method, its resonance, tone and rhythm which brought to life the very essence of emotional engagement and reciprocity in the context of a therapeutic setting.

References
ALVAREZ, A. (1992) Live Company: Psychoanalytic Psychotherapy with Autistic, Borderline, Deprived and Abused Children. London: Routledge. BARROWS, P. (1996) Soiling children: the Oedipal conguration. Journal of Child Psychotherapy, 22 (2): 24060. CARLBERG, G. (1997) Laughter opens the door: turning points in child psychotherapy. Journal of Child Psychotherapy, 23 (3): 33149. COHEN, M. (2003) Sent Before My Time: A Child Psychotherapists View of Life on a Neonatal Intensive Care Unit. London: Karnac. LATHAM, A. (ed.) (2002) The Oxford Companion to Music. Oxford: Oxford University Press. MELTZER, D. (1967) The Psychoanalytic Process. Strath Tay: Clunie Press.

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MELTZER, D. and HARRIS WILLIAMS, M. (1988) The Apprehension of Beauty. Strath Tay: Clunie Press. STERNBERG, J. (2005) Infant Observation at the Heart of Training. London: Karnac. TOMLINSON, J. (1968) The Owl who was Afraid of the Dark. Methuen and Co Ltd.

Debbie Hindle Scottish Institute of Human Relations 172 Leith Walk Edinburgh EH6 5EA UK Email: Debbie@sihr.org.uk