Application of Horney theory in the treatment of a traumatized child

APPLICATION OF HORNEY THEORY IN THE TREATMENT OF A TRAUMATIZED CHILD

Meryl Brown

This paper will review the history and treatment of a 10-year-old girl referred to the Karen Homey Clinic after the violent murder of her mother. The paper will focus on how the child works through two parallel developments. One development is the child's bereavement reaction to trauma, and the other involves the intrapsychic conflicts aroused in the child by the trauma. The case will be analyzed using Karen Horney's theory of neurotic and constructive development. A theoretical emphasis will be placed on the concepts of basic anxiety, basic conflict, and the child's early attempt for psychic unity. Using Horney theory, I will formulate and apply my beliefs about the process of constructive and pathological identification in the bereaved child. Finally I will discuss what aspects of the therapeutic relationship influenced the growth process of a traumatized and deprived young girl.

Josie is a 10-year-old girl whose mother was brutally murdered by Josie's stepfather. At the time of the murder Josie was locked in her room with her half-sister. She was aware of the fighting in the next room, but did not wit- ness the actual shooting. Several hours after the incident, the stepfather unlocked the door to the children's room. Josie began crying when she saw her stepfather's blood stained shirt. She later learned the traumatic details of her mother's death.

Josie was taken into the custody of her natural father, who was living in a drug rehabilitation program. He had remained drug free for 18 months. In spite of his history of drug abuse and incarceration, he took some interest in the well-being of his daughter. He made arrangements for Josie to be cared for by a woman friend and visited her on a regular basis. Josie's half- sister was placed in foster care.

Several weeks after the murder, Josie manifested the following symptoms: frequent nightmares, lack of appetite, expression of responsibility for her mother's death, and social withdrawal. In addition the school psychologist

This paper was the winner of the Raymond J. Greenwald Foundation Award for 1986.

Meryl Brown, C.S.W., is a social worker in private practice and a candidate at the American InstRute for Psychoanalysis.

The American Journal of Psychoanalysis Vol. 47, No. ~, 1987 © 1987 Association for the Advancement of Psychoanalysis

4 BROWN

had diagnosed a reading disability and recommended that Josie be placed in a special educational program. Therapy was recommended by her natu~ ral father's probation officer, and Josie began treatment on a biweekly basis at the Karen Homey Child and Adolescent Program.

Early aims of treatment focused on developing a consistent, safe, supportive, and friendly therapeutic environment for a child who had been severely traumatized. Josie chose to play simple board games, which were developmentally below her age level. The games were generally predict~ able and structured. Josie rarely spoke and avoided fantasy play. After two months of Tic-Tac-Toe and Candyland, I questioned the benefit of playing these repetitive activities. One day, engrossed in Candyland, an insight occurred to me. No one had ever engaged in a consistent activity with this child. There was an unspoken rhythm developing between us, a rhythmic exchange which would begin to challenge this child's chaotic perception of the world, a world developed out of an early environment of abuse, violence, unpredictability, and terror.

Josie was the product of an unplanned pregnancy and was born to a 17-year-old mother who reportedly received no prenatal care. In spite of ad- verse beginnings, the delivery was normal and Josie was born a healthy baby with no major difficulties. As an infant Josie was described as "active, a picky eater, and restless sleeper." Her father claimed that she never sat still. He stated "she was always wiggling, we put her in bed with us and she would kick us in the face, but she smiled a lot and always wanted affection." In the first two years of life Jose was already exposed to a great deal of tension, turmoil, and stress. When she was 14 months old her mother overdosed on pills and was hospitalized for two weeks. Her father reported that Josie was physically abused by her mother. He would intervene during these violent episodes between mother and daughter and was seen by Josie as a protector.

It was no surprise that Josie became distraught at age four when her father was arrested for drug possession and sent to jail for 18 months. When she visited him in prison she reportedly became so "hysterical" tha~ her father requested that her mother not bring her back for future visits. Josie's father was parolJed one year later, and by that time her mother had begun living with Josie's stepfather. Her natural father maintained contact with Josie by visiting her on a regular basis.

One year later he violated parole and was sent back to prison for three years. Consequently, few details are known about Josie's life between the ages of 6 and 8. There was some indication that Josie was expected to fulfill many adult responsibilities including homework, laundry, ironing, and full time care of her younger stepsister. Her stepfather physically abused her mother and threatened to "kill the child~en" cn two occasions. He reportedly "hid his machine guns" under Josie's bed.

TREATMENT OF A TRAUMATIZED CHILD 5

When ]osie turned 9, her father completed his sentence and was released from prison. Josie spent the summer with him while her mother served a brief jail sentence for "threatening Josie's stepfather with a gun." Returning to her mother's new apartment, Josie was instructed not to tell anyone where she was living. One day while playing outside with her friends, she was approached by her stepfather who asked her where her mother was staying. Josie, out of fear, told him and then ran home to tell her mother what she had done. Her mother then beat her with a plastic bat and frantically began packing. The stepfather came to the apartment and the couple began fighting. Josie and her half-sister were sent to their room. josie then recalls hearing a "click." After shooting Josie's mother, the stepfather apparently took her mother to the emergency room at a local hos-- pital. He then returned to the apartment. After seeing his blood soaked shirt, Josie became distraught and demanded to know where her mother was. The stepfather told her he had hit her mother in the mouth and that was the reason for the blood. He then took the children to his brother's apartment. Josie was located 24 hours later by police and told of her mother's death.

It is difficult to imagine how Josie survived under such overwhelmingly severe conditions. Before I formulate the impact of these early experiences on her character development, I will review Karen Horney's developmental theory of neurotic and constructive growth.

According to Horney's Neurosis and Human Growth (1950), a child spontaneously relates to others in three ways. He moves toward others in friend- [iness and trust, against others in self defense, self assertion, and constructive mastery, and away from others to foster feelings of independence, reflec- tion, and constructive solitude. These three harmonious expressions are holistically integrated and constitute the foundation of healthy development. [n her paper on "Basic Anxiety," Ivimey (1946) contends that these expres~ sions are as vital to the child as the physical need to take in food and to evacuate waste matter. This implies that the capacity to express oneself in these three ways provides a social nourishment essentiai to the meaningful development of one's real self and one's constructive relations with others.

In a chaotic environment marked by what Ivimey calls "unwholesome relations with others," the child loses his sense of belonging and develops profound feelings of apprehensiveness and insecurity. This leads to feelings of anxiety interwoven with hostility. The child, fearing possible abandon- ment, retaliation, or loss of love, adapts himself to the situation by repress-- ing his hostility. In its unconscious state of repression, the hostility becomes magnified, unbearably, forcing the child to project the feelings to the outside world. This projected hostility leads to the child's perception of the world as a hostile, unsafe place (Homey, 1937).

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Basic anxiety has taken hold. The child feels "isolated and helpless in a world conceived as potentially hostile" (Horney, 1950, p. 18). A search for safety begins. The three previously mentioned moves lose their flexible synthesis and become strategic, compulsive ways of achieving safety with others who are seen as hostile. Ways of relating become indiscriminant and compulsive. Moving towards activity is now expressed in rigid behavior such as clinging, whining, overly submissive behavior, overly compliant behavior, or compulsive helpfulness. Moving against behavior now becomes destructiveness, fighting, cruelty, and other forms of inappropriate aggressive behavior. Moving away now becomes shyness, social withdrawal, or overinvolvement in solitary activities (Paul, 1984).

These moves are what Horney (1945) calls neurotic trends. Because they occur simultaneously they are mutually incompatible and hence constitute the beginnings of a basic conflict with others. One cannot desperately cling to others and fight them at the same time. A child who compulsively withdraws from emotional contact must battle with his excessive need for affection. Horney states that these conflicting attitudes toward others gradually pervade the child's entire personality. This leads to intrapsychic conflict which constitutes the core from which neurotic development ema- nates. New solutions are needed to handle the child's inner feeling of being split and torn apart. Horney writes:

The longing for unity within ourselves is no mystical desire but is prompted by the practical necessity of having to function in life, an impossibility when one is con- tinually driven in opposite directions-and by what in consequence amounts to a supreme terror of being split apart. Giving predominance to one trend by sub- merging all discrepant elements is an unconscious attempt to organize the personality. It constitutes one of the major attempts to solve neurotic conflicts.

Homey speculates that the child tries to solve his inner dilemma by elevat- ing one neurotic trend to predominance. This protective device provides a temporary respite from the child's inner battle among contradictory trends but inevitably leads to more anxiety and hostility and more drastic attempts at solution.

With these theoretical constructs in mind, let's explore what factors led to Josie's early experience of basic anxiety, basic conflict, and attempts at solution. Given the severe environmental conditions in which Josie was raised we can speculate that her experience of basic anxiety developed early, rapidly, and as Ivimey states, "with catastrophically crushing effects" (op. cit., p. 10). Her stepfather was an unpredictable, sociopathic, possibly psychotic individual who brought a great deal of violence and fear into the home. Her mother seemed to be a morbidly dependent, possibly borderline


woman who externalized her self-contempt to Josie resulting in the physical abuse of her daughter. Based on reports from the natural father, Josie's mother impressed me as an erratic individual who vacillated between extreme dependency and volatile, unwarranted rage. Highly entangled in her own egocentric needs, she developed little capacity for understanding the basic emotional needs of her child. Josie's natural father, the only parent able to express affection, spent half of his own life narcotized and half of his daughter's life in prison.

We can surmise that the combination of inconsistency, violence, unpredictability, and terror led Josie to experience profound feelings of isolation, helplessness, and hostility. It is difficult to assess accurately what impact these severe conditions had on Josie's character development due to large gaps in our knowledge of her early life. Based on her father's report we know she was an active, friendly baby. With all the violence expressed in the home, Josie probably repressed rageful feelings, fearing retaliation from those whom she depended upon for survival.

Josie was described by her father as a "cooperative child who did what she was told." Josie's cooperative attitude impressed me as compliant behavior used strategically to avoid the dangers of her environment rather than compulsive pleasing behavior used to ensure affection. Overt helplessness and clinging behavior was probably not tolerated given the severe hopelessness and despair operating in egocentric parents who had little capacity for understanding the needs of a child (Symonds, 1968). Unable to move against and fight, and unable to move toward to ensure affection through love, Josie gave up her hope for human contact. She withdrew from others and found temporary asylum from inner turmoil. Based on the predominant symptom Josie presented during the intake evaluation (social withdrawal), we can surmise that the combination of feeling responsible for her mother's murder, the murder itself, and separation from her half- sister exacerbated basic anxiety and led to the continued development of her moving-away behavior.

Although Josie's presenting trend was that of withdrawal from others, in the third month of treatment she unveiled new aspects of her inner world. Josie allowed me a glimpse into this world by producing her first two drawings. The first drawing (Figure 1) enables us to speculate that Josie relates to others in two main ways. She moves toward others in her efforts to bring fruit to her family and she moves away from others by hiding herself under the water. Her move toward others is apparent but not yet developed as a compulsive strategy, at least in this drawing. She makes it clear that her move away from others is predominant (you can only see the front of him; the rest is underwater). The compulsivity of her moving away trend is sub- stantiated by one of her presenting symptoms, social withdrawal. The fruit

8 BROWN

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FIG. 1. "A fish carrying a package on his back. Fruit-He is taking it home to his family. You can't see all of him cause he's underwater. You can only see the front of him."

may be a constructive symbol of her deep desire to feed on and to taste the fruits of her undeveloped self.

Josie's basic conflict is further exposed in the next illustration (Figure 2). This drawing manifests basic anxiety. Josie projects her hostility in the form of a vulture. The world becomes a frightening, unsafe place. Josie copes with her anxiety by "huddling together" with the other birds (moving towards), and flying south (moving away). Here we see the beginnings of basic conflict between three incompatible trends, hostility (the vulture), helplessness (clinging birds), and isolation (flight).

FIG. 2.

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During the fourth month of treatment, Josie's natural father became reinvolved with drugs. He became quite ill and returned to a drug program. Josie consequently moved to her maternal grandmother's home, which was located near the scene of her mother's murder. With the help of her father's probation officer, Josie was fortunately able to continue treatment.

The trauma of her father's reinvolvement with drugs and the move to an apartment near the scene of the murder generated a great deal of anxiety in Josie. This anxiety was expressed in treatment over the next two months.


It began when Josie spontaneously created a story. The main character in the story was "Cathy," a girl who grew up to be a nurse. Cathy's task was to take care of her family. The first two patients were her mother and father. (See Figures 3 and 4.) From an interpersonal perspective these pictures represent Josie's desperate attempt to save her parents. Through the use of imagination she elevates herself as a magical healer to soothe her unbear- able reality and deny the traumatic impact of her mother's violent murder and her father's physical deterioration.

FIG. g. "Cathy is listening to daddy's heart. Daddy's got a fever and his heart hurts. Cathy felt sad cause something happened to her father. He got sick for no reason. She fixed him like a pin. Daddy was very sick. He didn't go on a diet, that's why his heart hurted."

FIG. 4. "Father was out of the hospital and mom had a surprise party for her (Cathy) because she made everyone feel better. Then the mother got sick. She had to rush mother to the hospital. She had to get operated. She had a heart attack. They opened her, a lot of blood coming out of her heart. Cathy went to the hospital and made her mother feel well and morn came out. They had another party for Cathy for making everyone feel well."

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In his 1952 paper, "The Dynamics of Insight," Martin states: "I t is not painful memories, experiences, or ideas that are repressed by the patient, rather the memory of painful and serious inner conflicts, of contradictory inner attitudes aroused by a situation" (p. 28). This idea shifts the focus to the intrapsychic realm and challenges us to look at what contradictory attitudes are aroused by her father's illness and her mother's death and how she is trying to resolve this inner conflict. Based on Horney's concept of basic anxiety we can speculate that Josie is torn between her helplessness and her hostility. She copes with this by moving towards others through compulsive helpfulness and against others by externalizing her hostility as illness within her patients. Despite inner conflict and despair Josie is making a constructive attempt to work through her loss and repair her inner world. Her real self is operating, shown by the healing forces at work in her unconscious mind as expressed in the story.

Her intrapsychic struggle becomes more apparent as she faces her next patient, a lady (see Figure 5). Josie moves closer to her struggle by objec- tifying the patient as "a lady." This objectification allows for a deeper expression of her despair over the trauma of her mother's death as well as of her terror of being split apart by conflict. "The blood is all over and the lady is

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FIG. 5. "Cathy saw this lady in the hospital that had open heart surgery like her morn. The lady is in pain and Cathy is upset. Blood is all over. Cathy said she would do something about it so she bandaged up the lady."

TREATMENT OF A TRAUMATIZED CH[i.D 11

in pain," she despairs. Josie is in pain at the prospect of losing her real self (Homey, 1950). She is overwhelmed in the conflict between her helplessness and her hostility. She desperately tries to heal this inner split by ban- daging herself. This leads to the development of two new characters in the story~ the snake and Dr. Smith (see Figure 6)~

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FIG. 6. "Cathy saw a snake crawling up her leg and in her hair. He cut all her hair off, took her shoes. He was mean. All her hair sticks up. Somebody saw the snake and saw Cathy yelling. They called Dr. Smith. He said maybe it came from outside, gut how did it get in here. Maybe someone played a trick on Cathy. It was one of the patients, the lady with all the blood. 5he didn't like Cathy so much. She didn't want to go home, she wanted to stay in the hospi~ tat. She didn't want to go home to her 12 children. Dr. Smith was her husband and nobody knew it." (Josie proceeds to pretend she was the snake, took my shoes off, and hid them downstairs.)

Josie's hostility (moving against) crawls up her leg in the symbol of a snake. This snake is "mean" and "cuts all her hair off." Josie then becomes the snake and hides my shoes. I believe that Josie is angry about leaving the safe, supportive environment of the playroom (the hospital), and returning to the chaotic environment of her grandmother's home (a two- room apartment occupied by three adults and four children). Josie secretly wishes to marry this therapist ("Dr. Smith was her husband and nobody knew it") by remaining in the hospital as a suffering bleeding patient. Hence we see Josie's investment in staying ill and the development of a neurotic trend (a suffering bleeding lady) used strategically as a means toward achieving safety (remaining in the playroom married to this therapist). When this neurotic trend is challenged (leaving the hospital/playroom after being bandaged), Josie becomes angry, turns into a snake, takes my shoes, and cuts off Cathy's hair. Josie is both the snake and the bleeding

12 BROWN

lady. By experiencing both sides of her conflict (hostility and helplessness), a new development occurs as depicted in Figure 7.

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FIG. 7. "Or. Smith I deserve to be a doctor and graduate. A doctor can be a boss, he does operations, he can go anywhere he wants to."

Is Josie's becoming a doctor a further integration of a neurotic trend or a healthy mastery over inner conflict? My impression is that "Dr. Cathy" is an evolutio~ of constructive mastery. What evidence do we have that growth has occurred? Looking over the Cathy figures as the story unfolds, we see three physical changes: (1) Cathy's hair grows, (2) Cathy dons earrings, and (Ji Cathy becomes a doctor. Before discussing the significance of these changeg, I wilt clarify the concepts of constructive and pathological identification from a Horneyan perspective.

In their paper on "Unresolved Grief," Zisook and DeVaul (1985) emphasize identification as a normal part of the grieving process. When the identifi- Cation process is unresolved, the bereaved may develop signs and symptoms suffered by the deceased before their death. How does the concept of pathological versus normal identifica~ici~ fi{ into a Horneyan model? In her writings on early childhood Homey discusses the importance of pro- viding an atmosphere where a child can develop his given potentialities and root himself on the road toward self-realization and growth. The atmosphere described includes characteristics such as warmth, the good will of others, guidance, encouragement, and healthy friction (Homey, 1950).

Though she does not deal specifically with issues of identity, Homey implies that the developing self is strongly influenced by the child's identification with both constructive forces and pathological solutions operating


consciously and unconsciously within the character structure of parental figures. I think it is important to emphasize the factors that lead to constructive and pathological identification with parental figures. If a child watches his parent joyfully bake bread and then expresses his wish to do the same, he is constructively identifying with his parent's activity. This type of identification will resonate with the child's developing self and provide further incentive for learning and growth. When a child in basic conflict witnesses the parent react with prideful hostility if the bread burns he will, over time, either identify with the parent's major solution (expansive- ness) or find an alternative neurotic solution to solve his inner conflict. This type of identification does not resonate with the child's developing self and serves as the early beginnings of neurotic character development.

Websters Third International Dictionary' (1964) defines identification as: "An orientation of self in regard to something with a resulting feeling of close emotional association." It is derived from the Latin root idem mean- ing "same." Here we see the child's intrinsic need to associate with someone in the process of building his inner structure. Constructive identification adds to the building process, while pathological identification does not and eventually leads to the formation of an idealized self (Horney, 1950) which becomes static and no longer open to integration and inner growth. Perhaps this is why Homey refers to self-idealization (a defensive operation occurring in a later stage of neurotic development), as having "revolution- ary effects" on the individual's future chances for inner growth (ibid., p. 24). Fortunately for children, the drastic move toward self-idealization has not yet gained a firm hold.

The concept of pathological versus constructive identification can be applied to the bereaved child. A constructive identification with the deceased serves as a vital building block to the inner potentialities of the child. This helps to strengthen the child's capacity to master conflict and cope with the loss, a reinforcement of the real self. Pathological identification is a neurotic solution to inner conflict and a strategic means toward achieving safety. It undermines the child's real potentialities and decreases the child's capacity to integrate and resolve inner conflict aroused by the loss. With this in mind, let's return to the discussion on how pathological and constructive identifications are manifested in the evolution of Josie's story.

Iosie has pathologically identified with her mother's bleeding body. She has neurotically elevated helplessness and suffering trends as a means toward unifying conflict and achieving safety. As the story unfolds and her experience of inner conflict expands, three constructive identifications evolve. First, Cathy's hair grows. This impresses me as a sign of regenera- tion and growth. Second, she dons earrings. I believe this is a constructive identification with her deceased mother, who was known to wear beautiful

14

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earrings. Third, she becomes a doctor, a constructive identification with the therapist. Josie experiences the doctor as someone who has more power, "he can do operations and be a boss," she states. This is a healthy amalgam of mastery and helping: The constructive identification with the therapist indicates that the therapeutic relationship has now become a vital force in fostering the developing of Josie's constructive forces. This serves to combat a neurotic trend (helplessness and suffering) formed out of a pathological identification with her deceased mother. The importance of the analytic relationship is further developed in the next series of drawings.

Six drawings, shown in Figure 8, were done consecutively during one session shortly after Josie completed the "Cathy" series. In the first drawing, Josie associates me with a lady who has the body of a heart. This is fol- lowed by a cold winter wind leading to a rainstorm at her grandmother's home. Then two rainbows appear, one partially formed and supported by a steadier rainbow with a stronger foundation. This leads to another expression of affection toward the therapist. Then Dr. Cathy appears with the bleeding lady and tearfully acknowledges that Dr. Smith is married. (It is important to note that earlier in the day Josie coincidenta[ly saw me walking on the street with my husband.) These pictures indicate that a major neurotic trend and the emergence of constructive forces are expressed within the context of the therapeutic relationship, Neurotic trends are manifested by the elevation of helplessness and suffering (the bleeding lady), and idealized love (I love Mrs. Brown, the lady with the body of a heart). This is done as a means toward unifying conflict and achieving safety from the outer storm of her grandmother's home and the inner storm of basic conflict.

Constructive forces are also apparent. They include her attempt to integrate a self based on a healthy identification with the therapist. This identification is most clearly depicted in the rainbow picture. The image of the two rainbows brings to mind a newborn foal trying to stand on its legs for the first time as his mother protectively watches and silently guides his efforts. Further development of constructive forces can be seen in compar- ing "Nurse Cathy" to "Dr. Cathy's" relationship with the bleeding lady. In Fig. 5, Nurse Cathy appears fearful, overwhelmed, sad, and helpless as the bleeding woman suffers. [n this picture Josie is dominated by conflict. In picture no. 6 of Figure 8, Dr. Cathy is disappointed but not crushed when discovering that her claim to be taken care of because of her suffering has not been fulfilled. She is frustrated because the therapist is married and cannot be merged with. Despite this she appears to have developed expansive coping activity shown by her physical dominance over the bleeding lady; who is now smaller. The constructive identification with the therapist (Dr. Cathy) is now a vital force in combating neurotic trends formed out of a pathological identification with her mother (the helpless bleeding lady).

T R E A T M E N T O F A T R A U M A T i Z e D C H I L D ~ 7

Over the next tinree months of treatment several important incidents occurred. One afternoon while ]osie was playing outside with her friends, two men drove up in a car and brutally gunned down a woman walking on the street. Josie related the details of the shooting during our next session. She seemed particularly preoccupied with the part of the sidewalk stained by the blood from the woman's body. She had the following dream the night of the murder. "The lady was following me. I tried to tell my family, but they all thought I was seeing a ghost. I was sure it was real."

The next session Josie insisted I wait outside while she drew a "special picture" for me. Upon my return she insisted that I try to find the picture, which she had hidden. After she gave me several hints, I discovered the whereabouts of the painting, opened it up and read the fol lowing message: "Happy Mother's Day." We spent the remainder of the session discussing her feelings about the upcoming Mother's Day weekend and the difficulties she anticipated. Josie had in fact visited her mother's grave on Mother's Day and reportedly cried while her father read a prayer.

Toward the end of our next session Josie developed a bloody nose. I sug- gested that she lie on the couch in my office to stop the bleeding. During this time I called her father, who was in the waiting room, and consulted with him in a room next to my office. As we were talking losie slipped a note under the door (see Figure 9). Josie had become frightened. The combination of the recent murder in her neighborhood, Mother's Day, and her

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18 BROWN

own bloody nose evoked the memory of her mother's murder. The last time she was closed out of a room occupied by a man and woman, her mother was murdered. Elevation of suffering trends (her own blood) were again used to gain reassurance and safety.

Shortly before summer vacation, Josie asked me to lie down on the floor with her and pretend we were in coffins. She then requested that I take the wooden blocks and build a bigger grave for her mother because the one she was in was too small.

Josie has been working through two parallel developments. First are her feelings of terror and bereavement associated with the trauma of her mother's murder. She began therapy as a nonverbal child whose relating capacity expanded in treatment through structured games, pictures, stories, direct conversation regarding her feelings, and the eventual descent with me into coffins. We can speculate that her wish to enlarge the space in her mother's coffin is a step toward working through the profound grief aroused by the trauma of her mother's murder. The second development involves intrapsychic conflict aroused by the trauma of her mother's murder. Josie's basic conflict is between her hostility toward her caretakers and her dependence on their care. As the treatment progressed, her experience of basic anxiety and basic conflict was expressed through pictures and stories. This led to a major intrapsychic battle between the snake (hostility), the bleeding lady (helplessness), and Dr. Cathy (an attempt at healthy mastery). Through the strength of the therapeutic relationship Dr. Cathy grew into a vital constructive force ready to contend with the bleeding lady. We can speculate that her wish to enlarge her mother's coffin indicates her desire to outgrow inner conflict, and through the support of our relationship, develop her true potentialities and inner constructive forces.

After summer vacation Josie's father, who had remained drug free for 6 months, began a full time job. This made it difficult for him to transport Josie to the clinic. In addition, he had become involved with a woman who took a "motherly" interest in Josie. Josie had grown fond of this woman and referred to her as her "stepmother." Shortly after these eventst Josie requested termination of her treatment, stating that she could now deal with her own problems. I was surprised at the abrupt change, but realized that Josie had been feeling conflicting loyalties toward her father's girlfriend and her therapist.

Despite her conflicts there seemed to be a constructive intention in her wish to terminate. Josie was now sleeping through the night without nightmares, eating heartily, and interacting appropriately with peers and adults. She had moved to the home of her paternal grandmother, a supportive woman who provided Josie with her own bed, good food, and a warm safe environment. In general Iosie seemed happier and better able to cope with

TREATMENT OF A TRAUMATIZED CHgLD 19

her feelings. After several discussions with Josie, her father, and his girlfriend, we mutually agreed the time was right to terminate.

During the termination period Josie missed more than half of her ses- sions. Her father, who was now working in his new job, left the responsibility of transporting Josie to the clinic to his girlfriend. The girlfriend would frequently call several hours before the session stating various reasons why she could not make the appointment. I became aware of the girlfriend's resistance to treatment and thought it might be beneficial to meet with her alone to discuss her concerns. During our meeting she revealed to me her insecurities about my relationship with Josie and felt that her mothering role was being challenged. We were fortunately able to discuss her fears and work through this conflict. After several meetings she revealed to me her deeper concern regarding her relationship with Josie's father. I consequently recommended that the couple enter therapy together to work on what seemed to be some rather serious problems.

This woman's reaction to my relationship with Josie stimulated me to reflect on my own countertransferential feelings. Throughout the year and more poignantly during termination, I was aware of the deep feeling of affection I had developed for this child. Josie had evoked in me a strong desire to nurture and protect her. I recognized the possibility that my feelings of affection might have neurotically gratified this child's strategic need to gain safety through compulsive pleasing and neurotic suffering. I'm more inclined to believe that my desire to nurture Josie had a constructive influence on her development given an increase in her capacity to master inner conflict and a decrease of neurotic symptomatology.

In reference to his work with psychotics, Winnicott (1949) states that the analyst must provide certain "environmental essentials" to those patients whose early experiences have been severely deprived and deficient. I believe this idea also applies to deprived children. When there is no consistent nurturing parent, the therapist must be deeply responsive and provide the child with the opportunity to express all of his inner feelings. The therapeutic relationship becomes the vehicle through which the child risks entering his total experience.

Many psychoanalytic thinkers have made reference to the deep mutuality developed in the therapeutic relationship used to broaden experience and reduce neurotic conflict (for example, Kelman, 1949; Martin, 1956; Wassell, 1957). Martin (1952) describes it as "living with and in the all." He writes that "the therapist endeavors to give the patient a feeling of extensity, of strength, of roots, of inner constructive forces so that he gradually becomes aware of his total involvement in conflict" (p, 174). He adds that mutuality in the analytic relationship and total participation in conflict lead the patient toward abreaction and insight, which are integrative experiences. For the

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child, I believe that insight is emotionally based and occurs in the integrating effect of abreaction within a constructive therapeutic alliance. This latter conclusion regarding children and insight is drawn from two assumptions. First, insight in children evolves out of a full experience and expression of inner conflict and emotion. Second, abreaction of emotion and conflict has an integrating effect when supported by constructive forces developed in the child through a therapeutic, nurturing relationship.

Children remain closer to all of their feelings, constructive and neurotic. Homey (1950) makes reference to this when she writes that the child's first attempt at solving neurotic conflict is less integrated than solutions developed later on. She implies that unlike the adult neurotic, the child has not yet developed a rigid defensive structure which would alienate him from his adaptable nature. Kelman (1949) points this out when he states that children have more access to their real selves. Paul (1984) writes that the child's flex- ibility gives him more access to his own feelings and a greater openness to constructive environmental influences. I believe that with severely deprived children, we as therapists become essential environmental influences. We cannot be the child's parent, and we must remain vigilantly aware of our neurotic need to rescue the abused child. We can, however, convey to the child our openness to real emotional contact, a deep responsiveness, a genuine concern, and a passionate interest in his or her growth.

Through the trust, safety, and good will developed in my relationship with Josie, through the days of Candyland, Tic-Tac-Toe, the fish, the birds, the vulture, Cathy, the bleeding lady, the snake, and Cathy's graduation, Josie extended her capacity to experience all aspects of her inner world. This led to a mobilization of constructive forces, a decrease in anxiety, and a renewed willingness to make contact with those around her.

REFERENCES

Horney. K. (1950). Neurosis and Human Growth. New York: Norton. Homey, K. (1937). The Neurotic Personality of Our Time. New York: Norton. Homey, K. (1945). Our Inner Conflicts. New York: Norton. Ivimey, M. (1946). Basic anxiety. Am. J. Psychoanal., 6:3-11. Kelman, N. (1949). Child analysis and Homey theory. Am. J. Psychoanal., 9: 38-47. Martin, A. R. (1956). The whole patient in therapy. Progress in Psychotherapy, 1:

170-179. (Reprinted in Am. J. Psychoanal., 46: 108-117, 1986.) Martin, A. R. (1952). The dynamics of insight. Am. J. Psychoanal., 12: 24-38. Paul, H. (1984). Homey developmental psychoanalytic theory and its application to

the treatment of the young. Am. J. Psychoanal., 44: 59-70. Symonds, M. (1968). Disadvantaged children growing in a climate of hopelessness

and despair. Am. J. Psychoanal., 28: 15-24. Wassell, B.W. (1957). The analytic relationship, unresolved transference. Am. J.

PsychoanaL, 17: 173-181. Winnicott, D.W. (1949). Hate in the countertransference. Int. J. Psychoanal., 30:

69-74. Zisook, S., and DeVaul, R.A. (1985). Unresolved grief. Am. J. PsychoanaL, 45:

370-377.

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Application of Horney theory in the treatment of a traumatized child