The Problems of Training: A View form the west

Lydia Tischler

1. Introduction

This is a personal account of my experiences of working with colleagues in the Child and Adolescent Section of the Czech SPP as a visiting teacher coming from the west. Although I have confined myself to the situation as it obtained when regular visits began, there are aspects, which apply equally to other countries both east and west when new trainings were or are being set up. This week-end we are looking specifically at the nature of the interface of importing or re-importing psychoanalytic thinking from the west, when teachers from the west with its very different social, political and economic conditions and cultural traditions come to offer their expertise to their colleagues in central and eastern Europe with its diverse systems and traditions. The title of this session is Problems of Training. Hopefully understanding the problems will help us to find solutions, or at least make a beginning.

Teaching psychoanalysis creates a particular complex organisational dynamic between the trainers and those being trained and has been well documented in the literature. It is a paradox that the aim of psychoanalysis is to free the individual from unresolved unconscious and infantile conflicts and thus allow for greater inner freedom, while the very process tends to infantilise its candidates and creates a culture of dependency. However, literature on the organisational dynamic of psychoanalytic institutes has received less attention. In a recent EFPP monograph on Psychoanalytic Psychotherapy in Institutional Settings, (1998) Frisch has taken a much needed look at this subject in his chapter «The legacy of power play in societies for psychoanalytic psychotherapy.» Among others he quotes Anzieu “psychoanalytic training seems to degrade into an apprenticeship as it is institutionalised”, creating in Kernberg’s words, “an atmosphere of indoctrination rather then free scientific development”. He also deals with the tensions between psychoanalysis and psychoanalytic psychotherapy and in her introductory comments to his chapter Pestalozzi poses the question, which is pertinent to our conference this weekend. “How should a new framework be constructed, a new biface envelope that will be firm and supportive but not strangling, devouring and inimical to fresh thought?” How indeed!

The Czechs can boast to have Freud’s birthplace within their borders. (Refer to video) Přibor, in Moravia or Freiberg as it was known then was Freud’s birthplace and home until the age of 3 and it “left an indelible impression” of which he speaks in a letter to the Mayor of Příbor after his visit there in 1931…. “Deep in me overlaid, there still lives on the happy Freiberg child… who received his first inextinguishable impressions from this air and from this soil” In this soil Psychoanalysis had to lie dormant during the Nazi occupation. After the war it faced a further setback, when during the darkest days of total Communism it was again a subject “non grata” Nevertheless even then it managed to continue a clandestine existence training therapists and seeing adult patient. However nothing similar was possible in the field of working with children. Training in psychoanalytic psychotherapy with children and adolescents could only come into being after the Velvet Revolution and it came about through series of happy coincidences. It began with a chance meeting in London with Michael Sebek. Perhaps it wasn’t altogether chance that I went to hear Michael give a talk on “psychoanalysis underground”, in London in 1994. Michael was there at the invitation of an enterprising Hungarian psychoanalyst Judith Sekacz who had set up an organisation Imago East-west to bring together speakers form behind the Iron curtain and those practicing in the west.

Although I have lived in England all my adult life and received my training there my roots are in central Europe more precisely in the Czech Republic I never completely lost contact with colleagues and friends there.
As result of my meeting with Michael Šebek in London, where we discussed the possibility of setting up a training I subsequently met with a group of child psychiatrists and child psychologists who were interested in developing training in psychoanalytic psychotherapy with children and adolescents.
I still recall my first encounter when met to consider the feasibility of setting up a training Programme. I don’t know with what preconceived ideas and expectations they came to this meeting, perhaps if they remember they can tell us. I know that in my enthusiasm and somewhat omnipotently I had in my mind the setting up of a training that would be based on the Association of Child Psychotherapists Outline for Trainings. This document sets out the requirements, which established training schools are expected to follow and new trainings have to put in place. These include a minimum of 3x weekly personal therapy for the duration of the training, weekly observation of an infant for two years, three intensive training cases, an under 5 a latency child and adolescent seen 3x weekly one for two years and two for one year, supervised weekly by different supervisors. We stumbled across a problem. I was told very politely but in no uncertain terms that there was no way these requirements could be met, infant observation was out of the question, for a number of reasons (I will come back to this later), most cases were seen once a week, at most 2x weekly and only rarely seen for two years. I had to do some quick thinking, do I insist that it is the whole package or nothing or do I compromise and work with what is possible?
In my training as a therapist I learnt to work with whatever material was presented. I believe it is a useful axiom, and that it applies equally to social situations when to ignore local conditions and customs will at best it stifle any progress and at worst will be an imposition of ones own preconceived ideas, a form of mental colonisation This axiom is a good antidote to curbing one’s omnipotence and missionary zeal. I am glad to report that reality prevailed and a dialogue began, which after much work on both sides turned wishful thinking into a practical reality.

Three years earlier in 1991 the EFPP was founded. You will hear about its development from Serge Frisch. By another happy co-incidence Miranda Feuchtwang the then Chair of the ACP and myself as the Chair of Association’s Training Council became part of the Steering group which brought the EFPP into being The good relationship which existed between us made Miranda the obvious choice to invite her to join me in this exciting new enterprise. Perhaps it is not too fanciful to describe us as the midwives who assisted in the birth of a Czech child and adolescent Training.

2. The Training

The training was inaugurated in February 1996 by Michael Šebek, who was then president of the CSPP, and who ” welcomed the participants on this historic occasion… to establish the Training of the Child and Adolescent Section of the CSPP (Česká Společnost pro Psychoanalytickou Psychotherapii)”.
Potential course member were psychoanalysts or candidates of the psychoanalytic Institute of the Czech Study group of the IPA, or psychotherapists with the great advantage that they all were in personal psychotherapy and already had grounding in psychoanalytic theory and concepts.
In this respect the Czech Child training began with important advantages over other trainings that have not yet been able to provide their own training therapists for their candidates. As we have heard creative solutions are being found and heroic efforts and sacrifices are being made by individuals in other countries to avail themselves of personal psychotherapy, the corner stone of any training.

The Czech training therefore had a head start, it also had the advantage that one of its trainers spoke Czech and that made it possible for members of the group whose English was not fluent enough to have supervision of their cases in their native language. However this also created its own problems and tensions in the group between those who had a good command of English and understandably felt resentful that they were being slowed down by the necessity to translate the lectures, which were all delivered in English for those who could not follow the English. In the second phase of the training when it took on a different format this problem was resolved, when theoretical expositions were opened to a wider professional public and lectures were translated beforehand and participants were able to follow speakers in translation.

To come back to the beginning: the aim of this first training course was to supplement the existing resources and expertise in psychoanalytic psychotherapy, in order that a nucleus of qualified trainers could be created. In response to their letter of October 22nd 1995 from Michael Sebek and Ivana Ruzickova “requesting assistance to set up training in psychoanalytic psychotherapy with children”, we suggested a programme, we considered feasible within the constraints of their current situation. The programme was to cover some of the components of the minimum training standards lay down by the EFPP. This we hoped would provide a basis for the further development of child psychotherapy in the CR. In addition as course co-ordinators and supervisors we planned to call on specialist tutors as guest speakers from the Anna Freud Centre, the British Association of Psychotherapists and from the Tavistock Clinic. The course was to run over six weekends a year, from Friday evening, all day Saturday and Sunday morning consisting of clinical and theoretical seminars illustrated with videos and individual supervisions.
The theoretical seminars were to cover the following topics:

Childhood development and its disturbance

1.Early infant development; mother child interactions and interventions
2.Assessment based on Anna Freud’s Profiles, including defence mechanism
3.Latency;
4.Learning difficulties and behaviour problems
5.Adolescence and disturbances of Adolescence (anorexia nervosa, sexual deviations, delinquency)
6.Psychosomatic disorders
7.Borderline Atypical Autistic and Psychotic children
The work of Melanie Klein, Anna Freud and Winnicott

Aspects of practice and technique

a. Play and symbolic communication
b. Transference – countertransfernce
c. Work with parents.
To bring this plan to fruition needed financial resources and given the prevailing economic situation it was not going to be an easy task. It says much for the determination of the Czech organisers that they managed to get support form the British Council who covered our expenses for the first two visits.

In the event we managed four visits in the first year and one per term in subsequent years. This was in part due to financial constraints and in part my protracted illness. The visits were supplemented by monthly reading seminars and peer group supervision. The main source of reading material was the Journal of Child psychotherapy. We managed to find some spare copies to add to their library and when Ivana was invited to become a member of the advisory board she automatically received a copy of the Journal. Finding suitable reading martial in Czech has not been easy and few book had been translated, however I am pleased to say that the Handbook of Child and Adolescent Psychotherapy in now in process of being translated into Czech. One of the editors Ann Horne has been active in the training programme.

3. Problems

a) Absence of Sponsors

Although we had the blessing of our professional organisation the ACP, it was not in a position to offer any more tangible support. The fact that that we were not linked to and did not represent any of the training schools had both advantages and disadvantages. The disadvantage was not being able to call on the organisation’s resources and support for us as trainers and no organisation could to take this fledging training under its wing, nor importantly, provide it with the status of being linked to an established training Since 1997 it has come under the umbrella of the EFPP as part of the CSPP and the conference this week end will I hope help to strengthen the links On the other hand not being linked to a training school gave us the freedom to invite guest speaker from a wider spectrum and theoretical orientations. Over the years guest speakers came from the Anna Freud Centre the Tavistock Clinic and the British Association of Psychotherapists.

b) Working Conditions
External factors

While the newly founded child training had a place within the CSPP structure it lacked a an infrastructure and a physical base, such as a clinic or clinical service with its own referral network which could provide suitable training cases for its candidates, it lacked a multidisciplinary team, which would offer assessment and provide work with parents and suitably equipped therapy rooms for children.

The group consisted of more or less experienced independent practitioners with variable skills in their core profession, working in diverse mental health settings, often in unfavourable external conditions within a medical hierarchy and in a treatment culture which if not inimical often did not place any value on a psychoanalytic perspective. Similar situations can obtain though fortunately less frequently for our trainees in the UK However, not only can the training schools can offer more support and protection to the trainees in their clinical placements, people are working completely different health care systems. In the UK most trainee and qualified child psychotherapists work in the National Health Service and are salaried employees with their own career and salary structure. In this respect the system, which obtains in the Č.R. is like the rest of continental Europe based on Insurance schemes, who are increasingly curtailing funding for psychotherapy. The insurance companies therefore often determine the length and intensity of treatment and not the needs of the patients In the change over to a free market economy I believe a similar system was introduced in the in the Č.R.
The work setting itself often did not provide a suitable room to establish a therapeutic space with appropriate boundaries and suitable play material.
So much for the external conditions.

Psychological Factors

Learning involves integration of new knowledge: learning about psychoanalysis not as an academic subject, but as a personal experience involves giving up defences, confronting ghosts from the past, letting go of outdated ideals and idealised objects, facing loss, feeling vulnerable and for professionals there is the additional narcissistic injury of feeling temporarily deskilled. It involves giving up certainty, however restricting and stifling and tolerating not knowing. In short it is a process involving psychic pain. It is a difficult process at the best of times but I suspect it is much harder when simultaneously familiar external structures are being dismantled. I am of course referring to the political changes, – which began with perestroika in Russia and culminated in the Velvet Revolution in the Czech republic- and the effect these had the on identity in its many layers and facets both on the individual and on society. The problems of identity have been of especial interest to psychoanalysts who had personal experience of growing up in a totalitarian regime even while they were resisting its influence. They have written extensively , covering such aspects as the ramifications on family life, intergenerational conflicts and the upbringing of children. It is a fascinating and complex issue and was subject of a conference held in Prague 1998 entitled «Identity in post totalitarian reality».

4. Establishing a Terapeutic Relationship

The role of Supervision

Supervision is the most important learning experience wherever psychoanalysis or psychoanalytic psychotherapy is taught I believe it was the pivotal contribution we made to the training The participants themselves valued them most highly.
The supervisions were not formal training supervisions, where cases are selected and approved as suitable by the training supervisor. They were of part of the individual members caseload and varied in severity of pathology.

We take it for granted that children have their own inner world which we as therapists respect and that their experiences of external reality are coloured to a lesser or greater degree by their inner drives and psychic reality, including internalised relationships to their objects Not only that they have their own internal world but also that they are entitled to it and in therapy we engage with it.
Of course children are not free agents and they come into therapy because someone in their external their environment usually their parents or their teachers are concerned form them. Parents bring them with more or less ambivalence, whether conscious or insomnious or both. Usually out of a sense of guilt that they are responsible for whatever is wrong with their child. This is not unique to parents in the Č.R.
When we began meeting with individual participants for supervision we had the impression that the therapists saw themselves agents of the parents whose task it was to take the parents agenda to “make the problem go away” and that influence their approach to the child. The idea that the therapist could be a transference object for the child was at first a foreign concept, and difficult to accept as was the idea that the child had his own perception of the world which needed to be understood; that the therapist has to deal with the parent the child has internalised.
This was not to deny that the parents have a right to information about the progress of their child’s treatment, indeed unless they have support for themselves they can easily undermine the therapy.

SUMMARY

I have touched on the some of the efforts involved in any new venture, and obstacles which had to be overcome, some more general some specific to the local circumstances.
I have tired to convey something of the flavour of the experience of being part of this venture Despite the limited input we were nevertheless able to impart a psychoanalytic attitude and to bring a therapeutic perspective on work with children. The credit for this success belongs as much to the group who stayed the course who were receptive and eager participants. They now face the task of passing their knowledge to the next generation. I would like to leave the last word to Ivana Ruzickova one of the two Czech course co-ordinators. Writing in the January 1988 EFPP newsletter she has this to say, “gradually we are finding a new approach to theoretical thinking and a psychodynamic way of working is developing. A substantial shift is occurring as we learn to really see the child as or client and the centre of our attention.”
The changes that have taken place are very noticeable.