CPPNJ - The Center for Psychoanalysis and Psychotherapy of New Jersey


The Capacity to Be Alone: A Treatment of a Latency Age Boy

By Charles J. Most, Psy.D.

With the fall coming and the advent of another school year for children about to start, I think back to the excitement of wearing new clothes, seeing friends that you hadn’t seen over the summer and the opportunity to learn more. Many children are not so positive about starting school and some outright dread the thought of facing what in their inner reality is a terrifying separation from their mothers and real or imagined persecution from bullies or teachers. External and internal anxieties on the paranoid-schizoid level abound for the child that dreads returning to school. This article will address the beginning of my clinical work with Richard, an 11 year old boy who did not want to return to school or leave his mother, and feared many things in his life.

Winnicott’s (1958) article on the developing capacity to be alone arises, in part, from Klein’s (1946) work on the paranoid and depressive positions. The early onset of object relations and the manner that the young child manages fears of annihilation, persecution and the fear of loss offer us clues to the treatment of children who are struggling with the development of the capacity to be alone. The capacity to be alone is founded on the repetitive experience of being alone in the presence of a “good-enough” someone, first in external reality and then with the introjections of the “good” internal object representation. Ego immaturity is balanced through the ego support of the mother and the child is more and more able to be alone and to enjoy being alone. This developing capacity is vital for the management of anxieties both paranoid-schizoid and depressive that we must confront later in life. A feature of the paranoid-schizoid position is the ego’s struggle to maintain its own integrity in the face of painful experiences that threaten annihilation. It was due to Richard’s inability to manage such anxieties that his parents sought a consultation with me.

Richard’s mother explained that her 11 year old son “had worries.”. Richard could not go outside without being able to physically see an adult present. He refused to attend school, clubs and sometimes sports, while complaining that other boys were picking on him. He would not sleep over at anyone’s home, spent more time with his friends’ mothers than the friends if he were to visit, still urinated the bed nightly and was filled with fears that his parents would die. After a series of consultations before I I actually met with Richard, both mother and father expressed anger and resentment toward their son. Father was enraged that his son was a “sissy” and that he and his wife could not enjoy their marital relationship. Mother demanded that all bedroom doors be left open and that Richard use the parents’ bathroom, rather than mess up “another” bathroom. They ended their final consultation by letting me know that they had previously worked with a cognitive-behavioral psychologist who “had written an article” on OCD and that he “told us what to do.”They related that they were “disappointed” with the results of that treatment. I told the parents that we could think together and find our own answers. Their last question to me as I was escorting them to the door was “and how long will this take?” When treating children, the child analyst must approach and address the child and all his internal objects as well as the parents and their internal objects. A delicate balance and the ability to manage both the child’s and the parents’ envy, rage and ambivalence is always on the mind of the child analyst.

My initial consultation with Richard was eventful. And as Betty Joseph (1985) writes, it is helpful to think of the total transference as everything the patient brings into the relationship with us. I am certain that the total transference was created before Richard even entered my door and in part was a carryover from an unsuccessful treatment in the recent past. In his first session, Richard’s mother stood in front of me with this tall, skinny and scared boy, and then said “tell Dr. Most how camp went.” He promptly turned and ran like a bat out of hell outside and down my driveway, and stood in the busy street as I attempted to keep this boyfrom running out into traffic. Never mind interpretation, the first rule of psychoanalysis is: keep the patient and analyst alive!

Thus, I was first introduced to the terror Richard was experiencing. The total transference included the terror of being killed, the uncomfortable nature of this public/exposed event (what would my neighbors think?) and the pressure of this seemingly uncontrollable event. I remember thinking to myself, “okay smarty pants, what are you to do now”? Many sessions followed with him running away, with me talking to him with a privacy fence in between us, meeting in his mother’s automobile, talking on the street or in a parking lot and even with me having to physically hold him so that he wouldn’t hit me or his mother. After one difficult session, later in the evening at the dinner table, my daughter told my wife that she never “never knew how hard Daddy worked…I saw this little boy run through the shrubs with Daddy following behind him.” I thought to myself, “Did Melanie, Anna, Donald or Martin ever do this?” Thus the beginning of Richard’s treatment began with him letting me know just how scared he really was and testing my determination to engage with him and contain his worries. The total transference and the projections immediately began and I had to become an effective container, as Bion encouraged us to be, for Richard’s treatment to proceed.

Richard eventually developed over time the capacity to be in the consultation room with me and view me less as a persecutory object and more of an understanding adult who could listen, hear and see beyond his manifest complaints. I worked monthly with the parents to understand and support Richard’s therapy and tolerate their ambivalences toward their son and me. The parents expressed conflicting themes: from the mother it was: “ Help Richard grow up, but not too fast;” and from the father, “Get my wife back to me and make this kid grow up.”

I take you to the beginning of the second year of treatment following the mother wanting me to “get Richard ready for the school year” and in the same breath reducing his sessions over the summer. It had been two weeks since our last session due to a holiday and the mother “forgot” to bring him to his previous appointment. I heard a ruckus outside my door and then mother came into my office in an exasperated state telling me that she had wanted to drop Richard off ten minutes early so that she could go to Shoprite, saying “I can’t believe this is going on after a year’s therapy.” I allowed mother and son to play out their enactment, and I absorbed the mother’s contempt toward both of us. Richard came into the room and sat on the end of the couch with his back toward me. After a period of silence Isaid to Richard that he is here and not here. He turned around and yelled at me, “I hate to be alone and I was sure that you weren’t here!” He acknowledged that “in my head you weren’t here” and we discussed how since he wasn’t here last week and knew that I “was alone” he thought that I would not be here for him. I said, “so then we were both alone and wondering where each of us was”. We acknowledged how important it was for him to be here and he thought that I would punish him for his mother not bringing him last session. We spoke about feeling alone and him not having an image of me in his head of being in my seat waiting for him. He spoke of bullies at camp accusing him of wanting to squeeze their penises. We spoke of his great anxieties and how they seem never to pass, and that he must learn to tolerate such a painful state before we can think and understand them and then act in the best manner.

The following session Richard came in with a large ice cream cone and sat on the couch looking at my reaction; an “I have something and you don’t” look on his face. After some time, l comment of the size of his ice cream cone on such a hot summer’s day. He told me it was a prize for winning the “most courageous camper” award at camp. He then explained that he told the camp counselor’s about the boys teasing him about wanting to squeeze their penises. I let him know I understood how much courage it took to tell a counselor and not just stop going to camp. After speaking about camp and the bullies he asked if we could play one of my CD’s. He took out David Bowie’s “Changes” and we spoke about all the changes he dreamed of and I remembered with him all the changes he had made and hoped to make. He looked through my music collection; related that his father had many of the same CD’s and then asked if I had any children and that if I did he would give them his small-children’s guitar that he had when he was little. He explained he has a “big” guitar now but wanted a better one. I commented on how he would like to be part of my family and have his own big guitar just like Dr. Most. Richard was developing the capacity to be alone in the presence of someone through the internalization of a loving object. He has yet to fully internalize the good object but as we plan for school he is much less anxious this year than in past years. As O’Shaughnessy (1982) explains, mutative interpretations are not by themselves the agency of psychic change. They put the patient in the position to change. He himself must do the active, mutative working through in his own words and efforts. As we work on reducing the more primitive anxieties of the paranoid-schizoid position, Richard is more able to enter and stay for longer times in the depressive position. The event we are working on presently is past the first day of school; it is the 7th grade overnight trip where he must master the capacity to be alone, be with persons other than his parents, not wet the bed and be more independent.

Richard’s treatment has steadfastly progressed, particularly in his ability to remain in the room with me and align himself with me as “two detectives that figure things out”. He is more open to speaking about other boys who “tease and scare” him and how angry his father gets. He is proud that he can stay “dry” in his bed for many more consecutive nights. Just this past week as we in the consultation room together my phone rang. He looked up and told me my phone rang; I commented on his having a reaction to it. He said “What’s if it’s your mother and she’s having a heart attack and she only had one call and called you?” The work continues each session with a plethora of opportunities to make contact. I must admit his projection was so unnerving that I did check the phone to see if it were my mother...

Innumerable thanks to Dr. Martin Silverman, my supervisor on Richard’s case.