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younger brother most, but there is some confusion about which of her siblings she likesbest. She would like to be out on roller blades like the older ones but she is not allowed toyet. She also desperately wants a dog and does not want to have to share it with the otherchildren.

I mention the session last week and her telling me that she hated going to the languagelessons. She grows serious and says she doesn't think she is any good at it. I say thatperhaps she feels embarrassed. Her mother is a teacher there, so I say that that must bedifficult for her. I wonder if she's good at school, and she says she thinks so. She is gettinganxious; she puts away the pens that she has used to draw, and begins to fidget with herfingers. I wonder how she's felt coming back to see me today, and she remembers that shewas crying last time. I say that today she is showing me something else about herself:telling me about her monkeys and the way she is with her sisters and brothers. Maybe sheis worried about me remembering that she has cried so much; and that I will think of her asa girl who only cries. She nods. I comment on her looking at me as if to check whether Iam still the same person and she nods with a little smile. I wonder whether she has anymore ideas about why mummy and daddy want her to come. She says, `I start arguments,they say I cry for more attention, but it's not true.' This was the end of the session.

Third Session: One Week Later

Natalie comes in smiling, and begins the session with enthusiasm. She opens up the packetof plasticine and begins to make a ball with layers of colour. She makes a caterpillar withmixed colours. She then makes a flower and a tree. We talk about herself feeling big orsmall; how she seems to be between the older and the younger children. She describes thedifferent figures. The tree is father; mother is the caterpillar; she is the flower, her sister isan ant. She shares a room with her sister, they seem to get on very well. She does havemore arguments with a brother, they argue and cannot share toys. Natalie is obviouslyfeeling very jealous of her younger brother who is very close to mother. When I spoke toher about how she might have felt pushed out as the baby of the family when the youngerbrother was born, she listened attentively. At the end I said that I would speak to herparents about whether she should continue to come. She said in a quiet voice that shewanted to.

End of session.

CLINICAL COMMENTARY BY A CONTEMPORARY FREUDIAN CHILDPSYCHOTHERAPIST AND A CONTEMPORARY FREUDIAN ANALYST

General Issues

We are presented with an account of Natalie's first meetings with the clinician. There is noapparent distinction between an assessment process and the beginnings of a therapeuticcontract, and we do not know why there are three sessions. This has implications fortechnique, e.g. the level of exploration and interpretation, the pacing of interventions, thetacit assumption of continuity of the process by the same clinician.

The account does not tell us many significant details such as family composition, agesof siblings, reasons for referral, duration of Natalie's problems. This way there is muchfreedom with which the clinician can observe the way the patient presents,

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without being blinkered by too much information. However, there are advantages inhaving prior knowledge and many therapists would draw on the history in making sense ofthe contact with the child, especially with children who might be resistant. The history isalso important in reaching an understanding of the child's psychopathology in adevelopmental context. What is so interesting about Natalie's sessions is how she bringsher problems. Indeed she talks about them and she shows them.

We are not told if Natalie has been prepared for these meetings, and it seems from theaccount that the clinician does not address whether Natalie quite knows when or howoften she will be seen and for what purpose.

Also omitted throughout the description of the sessions is an ongoing account of thetherapist's countertransference responses to Natalie's communications. What is she feeling,or thinking? What moves her to make the interventions described? This information wouldflesh out our sense of the interaction between the couple and give a richer picture ofNatalie's internal representations.

Comment on the Content of the Sessions

Because of the way the sessions were recorded, it was frequently difficult to follow thesequence of the material. We were often left unsure as to the rationale behind the timing ofthe therapist's interventions.

At the opening of the first session more detail would have been helpful, for instance,how Natalie and her mum separate, the observable state of mind of the mother, and theemotional atmosphere between them. It seems that a crucial aspect of the presentingproblem is the interaction between mother and daughter and it surfaces throughout theconsultations. It is interesting how the therapist allows Natalie to present herself in herown way before she addresses the reason for them meeting together. Natalie draws apicture which is both composed and stylized, but alerts us to her needy self-representationas a little, isolated girl who wants to be big but who conveys hunger. Following thetherapist's comment linking the picture directly with Natalie, which we might havehesitated to make so soon, she then addresses the reasons for their meeting. Natalie isimpressively forthright and forthcoming, and the problems come tumbling out. They areabout her distress at her parents' inability to 'handle' her and the battles in which theyengage. The therapist takes up her angry, unhappy feelings. It would have been interestingto see how the session might have unfolded if she had located these feelings in the contextof Natalie's relationship with her parents. As it is, the therapist seems to turn away fromthis communication, back to the picture and there is a sense of disruption between them.Natalie is very still, she says she doesn't want to look in the box, and after a brief glance inthe dolls-house she begins to cry and sobs for 20 minutes. She is now in an exposed state,unable to defend against her distress, and refuses the clinician's attempts to reach out toher until near the end. Is this an enactment of the scenario Natalie has just described,prompted by the therapist's not sustaining emotional contact made after heracknowledgement of Natalie's unhappiness? In Natalie's mind has the therapist becomelike her mummy and daddy who cannot 'handle her when she is crying'? It would havebeen illuminating to have a description of the therapist's countertransference responseduring this long 20 minutes of uninterrupted sobbing. This is a very difficult ending forboth parties, with Natalie seeming to feel very exposed, and one wonders whether theclinician had concerns about her return. We are not told if they talk about another meeting.However she does return and is still crying.

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Natalie's problems are right there to be observed between mother and child, and theyounger brother as well. In the second session the therapist does not make use of theopening interaction between Natalie and her mother to explore the feelings of anger,jealousy, deprivation and the object's unavailability. It seems to us that, as a consequenceof this, Natalie angrily retreats into the spurious safety of drawing, and she lifts herselfrather too quickly into an apparently bright state of mind. The therapist brings her back toher unwanted, previously unacknowledged feelings of sadness and loneliness, but thenseems not to sustain it. We do not know why the clinician suggests Natalie looks in herbox, and there is a risk Natalie will once again retreat. The therapist manages to preventthat with a timely interpretation about Natalie's conflicts about her regressive wishes andinterests. Indeed in the subsequent play one gets a sense of the central anxieties of this littlegirl: the sense of loss of a loved object, the desperate need for rapid replacement, lack ofpining and mourning for the lost object, holding onto the object out of fear that she herselfwill lose the treasured object, sibling rivalry and deep ambivalence in relation to herselfand her objects. Poignantly she tells the clinician that she "does not take Biggo out becauseshe does not want to lose him". The therapist is sensitively in touch with her patient at thispoint and there is a deepening of rapport between them.

Following the above material, the therapist attempts to explore another area of Natalie'sdifficulties, and this seems to raise her anxieties. The therapist starts to work on making adifferent ending with her compared to the last session and tries to voice and gather togetherthe worries Natalie has displayed and told her about. We were not sure why she understoodNatalie's looking her as conveying anxieties about object constancy; it did not seem to be inthe material presented. The session ends rather abruptly, without enough time to addressNatalie's owning some responsibility for the conflict with her parents and her overt denialof her need for attention. It is interesting that she conveys her need for attention just as thesession ends. The familiar scenario described earlier by Natalie is re-enacted.

The summary of the third session presumes a therapeutic contract and alliance. Thetherapist has gone straight from the assessment process to the therapy. There is nodiagnostic formulation; we have no idea what the therapist's assessment is of the degree ofpsychopathology in the child, and why individual therapy is the treatment of choice at thispoint.

From the material provided we would hazard the following formulation. Natalie is ayoung 7-year-old girl having difficulties in making real strides into latency. She is caughtup in earlier issues, particularly entanglement with her mother and battles with her parents.Her regressive wishes and her problems with her aggression are clear. However it isdifficult to establish how much her sense of deprivation arises out of a loss offundamentally good experiences, or whether it encapsulates persisting early needs whichwere largely unmet.

From the material it is unclear how far she has approached the oedipal situation: herpreoccupations seem to be around re-establishing an affirming dyadic relationship; theconflicts with her parents do not seem to have a full oedipal flavour. This however might behidden at the assessment phase. A fuller knowledge of the presenting problems and Natalie's developmental history might have been helpful here.

As regards her ego functioning, in the sessions Natalie uses drawing both defensivelyand expressively, but her defences are primitive and not very effective. She resorts tolengthy sobbing, perhaps in identification with her younger brother,

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whose arrival seems to have had great significance in her life. Her learning is threatened,we do not know about the quality of her peer relationships.

In her internal world, we have the impression of an angry impoverishment, withdisappointment and dissatisfaction with objects who are only precariously present. Hergood experiences are not easy to recapture; valued others are in danger of being lost. Thereis strikingly little phantasy material, perhaps reflecting her inhibition. However, Natalieexperiences a substantial range of affects, sadness, anger, animation, loneliness, jealousy.There is a sense of continuity from one session to the next, with the therapist beingremembered if not with much pleasure but perhaps hope.

The assessment has blurred into the treatment. The clinician seems to feel that theimportant issues will continue to be communicated in the ongoing work. As therapists wewould feel we were going into the work with much uncertainty about her psychopathology.We know very little of the detail of the clinician's counter-response. Perhaps Natalieevoked a need for an urgent response to her distress which propelled the rapid move intoregular treatment.

Jenny DavidsSenior Child PsychotherapistAngela Joyce Psychoanalyst

The Anna Freud Centre, 21 Maresfield Gardens, London NW3 5SD

CLINICAL COMMENTARY BY A KLEINIAN CHILD, ADOLESCENTAND ADULT PSYCHOTHERAPIST

This clinical material belongs to the initial stages of the psychotherapy treatment of a 7-year-old girl. All we know about her is her age, the fact that she is the third of fourchildren, and a reference made by herself about inconsolable crying, abdominal pains andthe refusal to attend some classes.

Natalie seemed to come into the consulting room easily. She is described as a slightchild', which probably refers to her build, but maybe also about a way to enter situationstrying not to take too much space. Hesitant when she comes in, she appears to thepsychotherapist to be relieved when she is invited to sit down on a child's chair. It brings tomind that, for Natalie, there is a relief in being allowed to be a child; not to have to takecare of anybody or make decisions herself. In her drawing the frame seems to be important.I thought that the picture expressed her need to have a context within which she could be achild that could nourish and grow into a chair that is too big at the moment. It may be areference to something in herself that requires to be fed so that she can learn. Something inpain, unattended, that contributes to a level of anorexia. She is a hungry girl in a tracksuit,which hints at a certain sexual ambiguity, perhaps a desire to be a boy.

Natalie seems surprised, `uncertain', when she hears the interpretation. I think that inthese first moments of the session she has projected what she hopes this new relationshipcould provide for her - to satisfy her need of nourishment. The psychotherapist does notpause over this as long as I would have done and chooses to refer to the reason for beingthere, and the possible likely meaning of the abdominal pains.

For myself, the presence of the big chair led to the thought that Natalie may feel thatshe has been given a role that she is too small to fulfil; involving taking care of herself