TREATING THE PARENTAL RELATIONSHIPAS THE lDENTIFlE0 PATIENT

IN CHIDPSYCHOTHERAPY
PasqualJ. Pantone, Ph. 0.

A BIT OF BACKGROUND
My first externship in graduate school, over 25 years ago, was at a children's
mental health center. My supervisor had two cases waiting for me on my first
day, both teenage boys. At some point during his presentation of the cases,
which had already been through an extensive intake and staffing process, he
offhandedly mentioned regarding one case in particular: "The patient really
should be the parents, not their son." In my naivete I asked him, if that were
true, then why were the parents not the patient. He told me that perhaps,
after I saw the child for a while, they might come to trust me and be open for
treatment for themselves, but they were unlikely to accept such a suggestion
so early in the treatment. He said that some parents eventually come to treat-
ment by way of their child's illness; others do not. In the meantime, he told
me, our responsibility was to treat the boy.
Intrigued by this accommodation to the parents and full of graduate school
bravado, I decided to make an attempt to see the parents more frequently
than the suggested once a month. I was identified with the child patients and
not with their parents, so I secretly wanted to right this wrong that was so
apparent to me and virtually ignored by my supervisor. I wondered what it
would take to make the parents the "real" patients. I asked my supervisor
what I could read about working with parents. He suggested a book by Dr.
Haim Ginott, called Between Parent and Teenager (1969).I bought the book
but I was alarmed at this suggestion because I had seen Haim Ginott on TV
many years earlier on the Merv Griffin Show while I was visiting my grand-
mother. "I did not go to graduate school to read books by TV personalities,"
I thought indignantly. So instead, the night before I met the parents of my
very first psychotherapy patient, I researched the topic of working with par-
enrs in the psychology library. I jotted down notes on 3x5 cards and then
memorized them. It was like cramming for a test. I felt that I had to make
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 Pasqual1. Pantone

myself an expert on a topic that I knew very little about. I had had opinions
about what constituted good parenting for years by then, but they were not
based on anything but my own biased observations.
During their first session, the parents of the first teenage boy, however,
politely but unequivocally refused to come in even once a month in spite of
all of my hastily researched reasons. They were upset to be at a clinic at all,
and certainly had no intentions of returning. I never saw the parents of this
boy again. I only saw the boy a few times before he was mandated to the
state hospital following his giving a letter to a woman on his paper route
inviting her to have sadomasochistic sex with him. I had felt completelypower-
less about helping this boy, and I questioned my resolve to work more inten-
sively with parents. In my defense, this was a formidable case with which to
begin a new project, as there was probably a history of inappropriate sexual
activity or abuse.
My other case was more amenable. These parents were cooperative in the
initial session and the mother (not the father-he was too busy) came in weekly
after that for five weeks. During the sixth parent session, the mother asked me
how old I was. I got a sinking feeling in my stomach and, not knowing how to
finesse such questions very well at the time, it eventually came out that I was in
my early twenties. She, on the other hand, was at 35 twelve years older and
the mother of two children. She said that as a young person she felt that I was
a good therapist for her son, whom I liked a great deal and who was only seven
years younger than me. She did not feel, however, that it was necessary for her
to come for any more sessions herself. I knew instantly that she was right. I did
not even confront her with my most recent "working with parents" research
from my newest set of 3x5 note cards. I truly did not know what to say to her
then or in any subsequent so-called parent sessions if we had continued. My
supervisor once again recommended that I continue with the boy individually.
The idea of intensive work with the parents was a good one but back then I
did not know how to implement it. Also, the climate of the clinic in those ego
psychology days was to do individual therapy with children, and if you chose
to see the parents you were pretty much on your own.
The literature on the subject then, as now, was scant, behavioral, and of
little assistance. Although Freud (1909)worked with the father of Little Hans
instead of with Little Hans himself, the idea of working with the parents has
had few proponents. Similarly, although Winnicott (1956,1960) placed a
great deal of emphasis in his theory on the actual mother's interactions with
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 TREATINGTHE PARENTAL RELAnONSHiP AS ME lDENTWlED PATIENT IN CHID PSYCHOTHERAPY

her child, his work did not spawn a corresponding emphasis on seeing the
parents of referred children. Furman (1957)in the classical tradition and
Fromm-Reichmann ( 1950)from the Interpersonal school had written about
working with parents, but their ideas had not caught fire within the child
literature either. Fraiberg’s landmark paper, “Ghosts in the Nursery” (1979,
which eventually did have an impact, had not been published yet.
It is not uncommon for child psychotherapists to feel that, even though
they are treating the child as the identified patient, the “true” patient is the
parents. I do not think that my trying experiences with parents as an extern
were particularly unique. I have often encountered in my supervision with
new child therapists a strong reluctance to involve themselves intensively in
therapeutic treatment with the parents of the identified child patient, while
they simultaneously ascribe blame to these same parents for not dealing better
with their own problems. New therapists are anxious about facing parents and
convincing them that work on their parenting is, in fact, both expedient and
worthwhile even though it is not what they signed up for.
On the other hand, most parents earnestly want to help their children.
Their resistance comes in when the form that helping their children takes is
for them to explore issues that they have avoided for many years. In spite of
this, many are relieved to have finally entered therapy, even if through the
proverbial back door. Some parents, of course, eventually find their place as
fully committed participants in their own individual treatment.
Over many years I have been developing a means of working with parents
intensively, but not before two changes occurred in my life. One was that I
had children myself. This is not a necessary prerequisite for everyone but for
me it was invaluable and highly meaningful. I saw first-hand how easy it would
be to drift into becoming a parent disquietingly similar to my father unless I
put more conscious thought and effort into my ideas, actions, and self-
examination as a parent. Although I had subscribed for many years to a theory
of child development that stressed the very powerful influence of parents in
the early years, it really came home to me when I was actively doing parenting
myself. I remember with horror, during the time when my daughters were
first learning to talk, how they would routinely repeat and incorporate into
their verbal repertoires throw-away phrases from my everyday speech, such
as “Oh, my God.” I thought to myself, “Oh, my God, this is just the tip of
the iceberg.” What else of a less mundane nature were they picking up in
unquestioning packages from my psyche and my behavior? Good or even
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 Pasqual J. Pantone

adequate parenting does not arrive automatically. It is the product of hard

work, enormous control, patience, and support. I realized in the most per-
sonal of ways that all parents need help with parenting, not only because they
may be having problems but more importantly because it is an all-consuming
and constantly changing relationship where mistakes are ever-present and not
easily forgotten. Not everyone needs to consult a therapist about their
children, but all parents need to talk to someone about their experiences with
their children at one point or another. When my children’s pediatrician began
to refer parents with parenting issues to my practice I realized that my ideas
were now more solidly formulated than previously and I welcomed the
opportunity to work intensively with patients identified as parents. Also I
believe I found myself able to identify with the parents of my child patients
more than I had before when my identification was primarily with the plight
of the child.
The other change that eventually propelled me to develop my thoughts
about working intensively with parents was that at some point in the last ten
years I became weary of seeing a particular type of child patient, specifically,
hyperactive 8 year-old boys on Ritalin who were behavior problems at school-
not to mention in my office-and whose parents avoided or patently refused
to have parent sessions or individual psychotherapy for their own problems
and contributions to their son’s pathology. Sometimes, when I would talk to
the teachers or remedial tutors of these boys, we would lament the futility of
working with such boys because their parents were the “real” problems.
I vowed not to do that anymore. After years of joining with some fami-
lies to maintain the fiction that individual child treatment was the best option,
I began to tell selected parents in initial evaluations that I believed it would
be beneficial to their current situation if the couple were seen for treatment
around couple and parenting issues before the child was brought to the office
and identified as the patient. I was focusing the treatment on the parental
relationship as the identified patient, not the child, for the initial phase of psycho-
therapy. In many cases, this so-called initial phase of treatment was the only
stage and lasted for years. I never did meet the child in many of these cases.

APPROACHING THE PARENTS

This emphasis on the parental relationship has roughly divided the parents
who came for consultations into four groups. The first group were those cases
where it was appropriate from the start for the child to be seen individually
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 THE PARENTAL
TREATING PATIENTIN CHIDPSYCHOTHERAPY
RELATIONSHIPAS THE IDENTIFIED

and the parents to be seen as often as possible in collateral sessions: self-de-

structive children, children with severe pathology, most teenagers.
The second group were those parents who chose not to work as a couple
in the first session or even during the initial telephone contact, based upon the
parenting emphasis. I always offered to refer them to a therapist who would
work individually with their child. These rejections represent a free choice on
the parents’ part to adhere to their original and justifiable plan to have their
child seen in individual treatment. Just as we as therapists have the freedom to
choose our preferred modality in which to treat children, so too the parents
have the right to make their choice. The premise of this paper is not against
individual psychotherapy for children but in favor of working with parents when
there is some concurrence, or even just a glimmer of willingness, in the family
that such an approach is both viable and potentially productive.
The third group of families were willing but initially doubtful parents who
complied with the couple sessions but questioned the validity of the approach.
These couples typically limited the focus to parenting issues at first. Eventu-
ally many of these couples became more curious and comfortable with a fo-
cus on their relationship and the connection of their issues as a couple with
their child’s symptoms.
The fourth group immediately saw the utility of couple’s sessions and im-
mersed themselves in their issues as a couple, as parents, and with the rela-
tionship these issues have to the difficulties of their child. These parents did
impressive work on a range of issues not limited to their functioning as a
couple or as parents, for example, career, their own parents and siblings, or
socialization. Particularly important, I felt, was that this approach engaged
several ambivalent fathers who would otherwise have joined the ranks of the
many men who are notoriously absent from their children’s treatment. Some
of these fathers openly stated that they would never have voluntarily entered
individual psychotherapy but they became fairly comfortable facing personal
issues in this format with their wives present to support and encourage them
as well as to confront them appropriately, especially with their denial of their
important role in the family.

THE TREATMENT
CONCEPTUALIZING
The technique of working with child psychopathology advocated in this
paper-specifically treating the parental relationship as the identified patient-
is drawn from both the Relational position within psychoanalysis (Altman
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 Pasqual J. Pantone

1992, Aron 1996, Ghent 1992, Mitchell 1988, Warshaw 1992) and the field
of infancy research (Beebeand Lachmann 1988, Stem 1985).The focus in these
parent sessions is predominantly on the unique qualities of dyadic relational
patterns typically formed during one’s development and how these patterns
are manifested in one’s present-day life, as well as inside the therapy office.
Specificallyin working with the parental relationship as the identified patient
in child psychotherapy, one draws upon relational theories and infancy re-
search that support the concept that children in their early years internalize,
in interaction with their parents, relational patterns that eventually become
the bedrock of their interpersonal relatedness and character structure for many
years, and that children are enacting these patterns with their parents and
others on a daily basis. Thus interventions directed toward helping the parents
to change their participation in dysfunctional or psychopathogenic patterns
with each other and with their children will lead to the child having to find
different ways of handling previously problematic situations with their par-
ents and others.
Parents, also, were once children with parents of their own, and the recent
research that focuses on how parents continue to act out with their children
their unfinished business with their own parents is impressive and powerful
(Fonagy et al. 1995, Main 1995). Thus, one could say that there is a lot of
material to be worked through in any child psychotherapy even before the
child ever enters the consulting room. This approach suggests that intensive
intervention at the parental level is a necessary condition for a successful out-
come in child psychotherapy, and in some cases it is a sufficient treatment
alternative. In these cases the child may not need to be seen individually at
all following a course of treatment with the parental couple.
In addition to the focus on the relational patterns within the parent-parent
and the parent-child dyads, attention to the relationships that develop within
the treatment itself are involved. Thus the interactions explored in sessions
with parents who are experiencing trouble with one of their children are many
between each parent and the child-that’s two; between the parents them-
selves-that’s three; between each parent and the therapist-that’s five; and
finally between each participant and the therapy itself-that means that there
are at least eight levels of various kinds of interactions that we are monitor-
ing in such a session, whether we recognize it or not. (While these eight may
constitute a sort of core of the interactive work, I can think of many other
interactions, such as the relationship each parent has to the differing roles
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 TREATINGTHE PARENTAL RELATIONSHIPAS THE lDENTlFlED PATIENT IN CHILD PSYCHOTHERAPY

that she and her spouse play in daily life: parent, spouse, career, etc.) In the
adult literature, Ogden (1994) has called the unique pairing in the room of
the analyst and patient as the analytic third. If we keep Ogden’s term then
there are many analytic thirds in the room as each interactive pair is consid-
ered to contain its own hybrid psychodynamics that deserve open consider-
ation from each participant.
For an example of how complicated these relationships can become as
they are explored, please consider the following. Recently one husband said
in a parent session, “I like coming here [the therapy sessions] a whole lot
more than I thought I would, but I hate this whole process of examining
my life so minutely. I wish there were some way to just help Johnny with-
out all of this digging up the past, so I wouldn’t have to think about all of
this old stuff all the time.” This man’s avoidance of his impact on his son
was painful for him to face, but he continued in treatment, partly due to
some complex transference to the therapist and the treatment, and partly
due to his love for his son. The interactive matrix that he created for him-
self to sustain his participation focused on the camaraderie he obtained in
the sessions while he attempted to underplay the energy he was willing to
apply to rectifying his son’s presenting symptoms. If his wife and the thera-
pist came at him directly with his denial of his importance in the family, he
shied away. If, however, he were approached with an emphasis on how he
enjoyed his relationships with his family and the therapist, he was a full
participant. Eventually he put some concerted effort into his relationship
with his son, which both he and his son enjoyed. While the therapist and
the wife attribute this to the results of the therapy, the husband preferred
to think of it as the natural evolution of their father-son relationship as the
son got older. His son made progress in his daily life. It started with the
husband’s beginning to recognize that he, as father, had some unconscious
agendas in his parenting of his son that were determined in our sessions to
be associated with his son’s symptoms. Until his son had trouble and the
husband came to examine his role in the situation in treatment, he had
claimed to be aware of everything in his life and in no need of a therapist.
He had no interest in psychology or his own unconscious. As Silverman and
Lieberman (1999)put it, “The meanings that the child holds for the mother
and the interactions between them offer a window onto the mother’s inter-
nal world-a window that could remain inaccessible in individual treatment”
(p. 164).
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 Pasqual J. Pantone

THE SUPPORTINGCONTEMPORARY PSYCHOANALYTICLITERATURE

The psychoanalytic concepts that have been the most helpful in conceptual-
izing this parent work draw from four areas (at least) of the psychoanalytic
literature that are highlighted briefly here. These research and clinical tradi-
tions provide support for the notion of a child psychotherapy that departs
from the concept of an identified child patient and instead explores treating
the parents’ relationship either exclusively or primarily.

PARENTAL PROJECTIVE IDENTIFICATION

While projective identification as a concept is usually presented as a process

that moves from the child to the parent, as a clinical phenomenon it is usually
presented as a process that moves from one adult to another. The parent-
infant literature has made a profound contribution in our work with children
and parents by emphasizing the nature of the projective identifications that
move in a third direction-from the parent to the infant (Alvarez 1999,
Lombardi and Lapidus 1990, Seligman 1999, Silverman and Lieberman
1999). Seligman (1999),using the language of abuse and trauma, describes
it as follows:
Parents who have been thus traumatized will themselves often force their
own children to experience internal images of self and others of which
they are not aware, through coercive patterns of highly asymmetrical
influence in actual interactions, such that the infants cannot think. In
addition, especially in older children, any demonstrations to the abusers
that things could be thought otherwise may be brushed aside or even
suppressed, on pain of loss of whatever relational comfort is available,
and sometimes in response to threats of violence or other more explicit
forms of coercion. [p. 150, italics added]
This concept might be considered the familial extension of the Kleinian
concept of projective identification (Klein 1946). In working with children
and their parents I have become keenly interested in how parental projec-
tions, usually of split-off negative feelings about oneself and/or one’s spouse,
become powerfully influential in regulating and reinforcing children’s behav-
ior and eventual personality trait acquisition after many years of projecting
these feelings onto their child. The tendency as parents, and even as adults
who work with children, to project split-off material onto children as if these
perceptions were actually representing a stable personality trait of the child
is rampant. It seems that we often behave as if children are a completed prod-
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 TREATINGTHE PARENTAL
RELATIONSHIPAS THE IDENTIFIED
PATIENTIN CHILD
PSYCHOTHERAPY

uct capable of withstanding such character assaults, instead of the formative

beings they are.

What the young child lacks is the affective and cognitive capacity to psy-
chically step back from the situation and assess the exaggerated charac-
ter of the parent’s projection and become aware of the existence of other
possible realities. Thus the parent’s projection comes to feel to the child
and to the later adult like an uncanny truth about the self, which could
not be hidden from the parent. [Demos 1999, p. 2231

Altman (1992)makes a similar point with regard to therapist’s role as “new

object” in the therapy. The therapist must be able to comprehend the projec-
tions that he himself is receiving from the parents without actually enacting
the roles himself. An enactment on the part of the therapist with the parents
would constitute his taking on the role that the parents’ projections assign
him instead of helping them to analyze it.
Lieberman makes a distinction between parental projective identification
and negative parental attributions. She states that when these parental
expressions “ are the primarily conscious manifestations of projective identi-
fication and involve cognitive structuring that functions to provide one with
comprehensible experience” (Silverman and Lieberman 1999, p. 182), they
are more appropriately referred to as negative parental attributions. She is
referring to the parent’s conscious and manifest ideas about their child, which
are often used by parents to explain their projective perceptions of the child.
Lieberman reserves parental projective identification for the unconscious
process behind the conscious awareness. In other words, negative parental
attributions are the tip of the projective identification iceberg.
For example, a mother in parent psychotherapy around issues with her
child said, “I’m really worried because Jim shows all the signs of having the
same problems with expressing anger that I have. He lets it build up until he
explodes just like I do.” Now on the face of it, this statement does not neces-
sarily reflect the projection from the parent to the child of unaware split-off
parts of self. In many of the cases that reach our offices, however, these nega-
tive parental attributions often seem to be an admission or a clue to the pro-
cess of parental projection that confines the child to a particular negative role
that is related directly or indirectly, partially or massively, to the parents’ diffi-
culties. In this example, as it turned out, the mother felt hopeless after many
years of her own therapy that she had not changed her typical method of
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 Pasqual J. Pantone

handling her own anger sufficiently. She realized in parent sessions that she
was working overtime to prevent her son from getting stuck in the same
pattern. Since she could not cure herself, she had dedicated herself with a ven-
geance to “curing” her son. Her intense focus, however, took on a punitive
and explosively angry style of which the mother had been unaware until
facing it in the relatively safe confines of a parent session with her husband
while the purported focus was on the welfare of her child. Thus she was
able to see that she was unconsciously enacting the behavior that she was
intent on extinguishing.
Parental projective identification relates to a lack of awareness on the
parents’ parts of how their tendency to avoid or deny certain crucial prob-
lematic dynamics of their own may be visited upon their children, unless they
attempt to be alert to relational patterns within the family.

ATTACHMENT THEORY
The original emphasis in the attachment literature on the child’s attachment
style has been joined in recent years by an interest in the parent’s parenting
style, particularly as to how it is influenced by their own internal working
model of their experiences with their own parents. Specifically, the research
of Mary Main, Peter Fonagy, and their colleagues (Fonagy et al. 1995, Main
1995)on the internal representations of parent-child interactions that parents
hold in their minds from their own childhoods as they parent their own
children have been very powerful. Main and her colleagues have found that
new parents who were able to relate a cohesive narrative of their childhood
experience of their own parenting on a standardized instrument (Adult
Attachment Interview) were found to be more likely to have securely attached
children than those whose interviews lacked cohesion, sufficient detail, or
ample demonstration of some introspection on the topic of one’s own par-
ents. This finding was true even in some cases when the parenting reported
by the adults contained evidence of disturbed parent-child relating from their
pasts. Thus, in some cases the actual pathogenic parental behavior was less
important than the new parent’s ability to find an honest and focused ap-
proach to the material.
While unfinished business with one’s parents is a potentially pathogenic
factor, with or without children of one’s own, it takes on added significance
when one is operating from these deficits of awareness while raising a child.
Thus an intergenerational transmission effect is operating, since conflicts and
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 TREATING THE PARENTAL RELATIONSHIPAS THE loENTIFlED PATIENT IN CHILD PSYCHOTHERAPY

outstanding issues one has with one’s parents have the potential to become a
part of the package of one’s own parenting of one’s child. Parental sessions
can help parents become more aware of these universal tendencies to recre-
ate one’s own childhood with one’s child in spite of a very clear resolve not
to do so. If a new parent is less aware of the circumstances of his own child-
hood experiences with his own parents, it seems probable that in raising
children that such unfinished issues may find an unwelcome outlet in child-
rearing, which even in the best of circumstances is an emotionally intense
experience fraught with probable difficulties.

AFFECT REGULATION THEORIES

Also considered pivotal in working with parents to alleviate the psychological
problems that their children are experiencing is the examination of affect
regulation as it occurs in the family (Beebe and Lachmann 1988, Emde 1981,
Schore 1994, Weston 1994). Often affects between parents and between
parent and child in referred families are overly intense and displaced from
other relationships inside and outside of the family. Misattunement and lack
of individual and mutual regulation (Aron 1996, Beebe and Lachmann 1988,
Stern 1985) are an everyday feature of interactions in some families. This keeps
the pathology reinforced daily and deters attempts to establish more under-
standing and caring ties among family members.
Many changes occur to one’s personal dynamics and relationships to
others when one becomes a parent. The manifestations of these family
dynamics are not wholly predictable from one’s pre-parent life. All of us know
people who are, to the naked eye, unimpressive in some aspects of their
psychological repertoire, yet they rise valiantly and lovingly to the task of
being a parent. Conversely some truly remarkable, high-functioning people
struggle helplessly and ineffectively as parents for reasons that are not easily
apparent. One takes on the role of the parent, when it happens, with all that
that great leap entails. There are the practical changes such as loss of sleep, a
fixation on the welfare of the child, the responsibility of providing for another
human, the impact on the marital relationship as it goes from a dyad to a
triangle, less time available for friends and personal interests, the sacrifices,
the rewards, and so on. In addition, and ultimately more important, are the
directly psychological and affective changes. Issues, particularly those involv-
ing mutual affect regulation around the trying situations with one’s child that
resonate with out of awareness issues from one’s own life, tend to be acted
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 Pasqual J. Pantone

out in some families without sufficient regard for the impact on the child.
Feelings about one’s own infancy and childhood are similarly carried into
the mix of taking on the role of parent and performing those functions. It is
not uncommon to hear parents say that they do not want their child to have
to experience what they went through as a child. How the parent enacts this
wish is where the opportunities for the successes and the difficulties lie.
Let us use what has become a common example in child practices. Often
parents, with the very good aim of not having their child experience the
oppressively strict regime of their own childhoods, may handle their dis-
pleasure with their own childhood anger with confining rules by having
virtually no rules at all. On the one hand, this is a way of ignoring the reser-
voir of anger generated in one’s childhood due to overly strict parents. On
the other hand, however, and usually out of conscious awareness, it gives
the child free rein to be as aggressive and angry as the parent was never able
to be when he was a child, and this unchecked behavior becomes a family
issue. In some cases the parents hold back their anger with the chaos that a
demanding child creates for a long time, until it erupts in an affective explo-
sion where more heat is generated than light. Thus they recreate a situation
similar to the one they faced in childhood: an unregulated angry child with
an unregulated angry parent who has difficulty handling the authority as par-
ent judiciously. These parents may explore with the help of a therapist their
avoidance of taking an active stance with their issues and thereby to evolve a
more measured and introspective approach to the complexities of regulating
anger, authority, rule-making, and enforcement in their new family, which
would also incorporate their fears of “being just like” their own parents.

PARENT-INFANT PSYCHOTHERAPY
The fourth area of the psychoanalytic literature that supports a focus on the
parental relationship is the proliferating field of parent-infant psychotherapy.
This relatively new area of treatment is described in clear and exciting detail
in Daniel Stern’s book The Motherhood Constellation (1995)and in the work
of Alicia Lieberman (1992) and other followers of the pioneering work of
Selma Fraiberg. Their success in helping very young children by focusing on
parenting lends a great deal of support to the idea of working with parents
of school-age children. Stern (199s)views working with parents as one “port
of entry into a single dynamically interdependent system” (p. 16).He suggests
that changes in one part of the system reverberate throughout and foster change
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 TREATING THE PARENTAL RELATIONSHIPAS THE lDEMlFlED PATIENT IN CHILD PSYCHOTHERAPY

so that, in a way, “it matters little how or why or where the initial change was
brought about” (p. 16). Lieberman (1992, Silverman and Lieberman 1999),
following in the footsteps of Selma Fraiberg, sees mothers and young children
together in psychotherapy sessions. In this model the psychotherapist skill-
fully moves back and forth between working with the child’s play and inter-
acting in dialogue with the mother.
The approach described in this paper includes the father with the mother,
unlike most of the mother-infant programs (Stern 1995), because the father
is a valuable and often ignored link to alleviating many family problems. Of
course, the child can be brought into sessions occasionally or weekly in order
to discuss certain issues with the parents. A focus on the parents often proves
to be a very effective means of working on issues in the family of school-age
children as either an initial phase or as the sole treatment modality.

CASEEXAMPLE
The referral came from a pediatrician. He was suggesting individual child
treatment for Jennifer, a girl of 5 who was having trouble in kindergarten.
Jennifer’s teachers felt that she had an “emotionally based” attention prob-
lem because Jennifer had great difficulty being one of a group of children
rather than someone singularly special to the teachers-read narcissism. The
teachers had been very patient with her but they now thought that Jennifer’s
need for constant individual attention was showing no signs of diminishing.
The teachers wanted her to be in individual therapy where such needs could
be met and rechanneled into ways that could eventually be gratified in a group
setting such as school. The parents, who trusted their pediatrician, consulted
with him first as to whether he agreed with the teachers’ recommendation,
which he did.
When I received the phone call, I asked the parents to come to the first
session without Jennifer. The parents were well educated, successful profes-
sionally, and rather overwhelmed. The father had been considered by his
mother, when he was a child and even now as an adult, to be a genius who
thrived on the deferential treatment he had received from her. He was
extremely successful in his field of law and also as a writer. The wife, who
was the daughter of another highly successful and iconoclastic father, also
considered her husband to be a genius and she was very supportive of his
many needs so that he could work and/or write for nearly sixteen hours a
day, sometimes seven days a week. When their first daughter, Jennifer, was
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 Pasquol 1. Pantone

born, it became clear after a short time, probably because of a combination

of temperament and parental projective identification, that she was very much
like her father. The wife eventually quit her job and became a full-time
caregiver to these two members of her family who had voracious appetites
for her care. When the second child was born three years later the wife became
overwhelmed by her fear that she would now be catering to three "geniuses."
The wife never let herself experience this as a worthy thought but instead con-
sidered herself to be selfish and uncaring for disparaging her own family. This
was how she had felt in the presence of her father when she was a child too:
her function was to support others at the expense of her own needs. The wife
had never allowed herself to question her role with her father and now she
was unwittingly and resentfully acting it out again with her husband and
daughters.
During the initial session I told the parents what I now tell most parents
in the first session: that I have become conservative about seeing children and
locating the problem solely in them by prescribing individual psychotherapy
for the child. Instead and simultaneously I have become liberal about asking
parents to commit to a period of coupledparents treatment before I ever see
the child in order to work on the problem from their perspective. Jennifer's
parents were skeptical, since they had received a mandate from their daughter's
teachers to get individual treatment for their daughter, which had been
supported by their pediatrician. A few things occurred, however, during the
first session to convince them that it was worth a try. First, it was striking,
several times in the first session, that the two parents could not agree on several
important details of their reports of the child's problem. This is not an unusual
situation in the first session. Parents see their children differently, but these
discrepancies often provide the opening for the therapist to test the role that
parental projections place on the child.
For instance, while the wife said that Jennifer had no real friends, the
husband felt that her friendships were fine. When I asked about their own
patterns with friends they were surprised at the shift in focus but they answered
it. The husband said that the wife had a lot of very close friends and that he
had only a few. The wife timidly disagreed and said that while it was true
that she had many friends she felt that her husband had none and she had
always worried about that. "Something l i e your feeling about your daughter's
current situation with socialization," I said. This provided a forum for the
wife to talk about her fears, projected or real, that Jennifer was on a colli-
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 TREATING THE PARENTAL RELATIONSHIP AS M E ~DEMlFlEDPANEM IN CHILD PSYCHOMERAW

sion course to replicate her father’s narcissistic and schizoid tendencies. The
husband, on the other hand, described his irritation with his wife’s tendency
to believe that time spent with others was always more valuable than time
spent alone. This dialogue helped to deconstruct the presenting problem from
a focus on Jennifer’s socialization difficulties to one exploring the family
tension created by parents with vastly different styles of interpersonal related-
ness, which affected their relationships with each other and their daughters.
The husband unsurprisingly spent relatively little time with his daughters,
while the wife guiltily tried to overcompensate by spending “every waking
hour” with them. The emphasis for the therapist is not to place the onus on
one parent or another, but to have them discuss their differences and the
impact that these discrepancies have on the family.
The other event that was momentous in tilting the treatment toward a
parentdcouple mode in the first session was when the wife discussed her feeling
that Jennifer insisted on having all the attention and that this was keeping
her from their other daughter. She worried that Jennifer was doing this pur-
posefully. I asked, “I wonder how Jennifer’s trying to get all of her mother’s
attention compares to the way attention gets distributed between the two of
you?” The wife said quickly, “He gets it all.” The husband said, “I’m afraid
that is close to the truth.” I formulated that some of the wife’s unfinished
business with her husband and her father was getting visited on their daughter
and it would be worthwhile to explore those areas before involving their
daughter as the one with the problem. During the first session it became gradu-
ally clear that the wife was the manager of a team that she disliked and she
did not feel good about herself or her teammates. Each time they talked about
their daughter’s behavior, I would ask broader systemic questions, such as:
“Doesthis remind either one of you of your own childhood?” or “There seems
to be a cross-generationalprocess going on here; have you noticed that before?”
Eventually the wife started crying and vaguely expressed her fear that their
daughter was turning out to be just like her husband. Her husband replied,
“What’s wrong with that?” She said, “Nothing, 1guess.” I added, “ Maybe
it’s scary to say what you’re thinking.” I said to the husband, “Your wife
may be scared to tell you something that she fears about the similarities
between you and your daughter.” The husband was startled by this turn of
events but, to his credit and partly due to the largest quantity of self-confidence
that I may have ever seen in one human, he told her that she should feel free
to say whatever she felt. He then added, somewhat as an afterthought, that
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 Pasqual J. Pantone

he valued her opinions on “people matters” since this was not an area of
strength for him. At this she cried until the end of the session. The husband
hugged his wife but said that he did not understand why she was crying. The
wife could not speak. I asked if I might venture a reason why she was crying
because I too had a strong emotional reaction to the sudden demonstration
of tenderness from this “bull in a china shop” type of man. When she nodded
agreement, I said that I wondered if it was because her husband said he
“valued” her. Again she did not speak but she cried even harder, sobbing.
This was how the session ended. In the next several sessions the wife would
typically open with her doubt of the process of parental sessions without my
seeing her daughter in individual child psychotherapy. Eventually she told
me that she had tried therapy herself several times before but had always quit
within the first few sessions. I said that apparently she could only come to
treatment around her concerns for her daughters and that was OK. Her
daughter eventually started showing changes at home and teacher reports also
became more positive. The treatment consisted of approximately one year of
parent sessions.

Although one can never be sure what constitutes an effective treatment,

in this case I would speculate that the parents’ examination of their own
relational dynamics, particularly their antecedents in their own past child-
hoods, brought the functioning of their family relational patterns into clearer
perspective. By the end of a parent psychotherapy treatment one can hope to
make progress in several areas:

1. No one member of the family should be considered any longer to be

the one with the problem, and no one member should be blamed as
the fault for the problem either. This is a goal of such parents’ treat-
ment, as the locus of the problem in the minds of each parent needs to
shift from a blame of self or other to one of comprehension that the
constant interactive effect within the family sometimes perpetuates
problem situations.
2. For the treatment to be considered successful, there needs to be some
signs of greater awareness in each of the parents’ minds of the inter-
play of each member with the others and how each member’s role in-
volves helping to regulate the needs of one’s self and any other mem-
ber particularly in affectively intense interactions.
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 TREATING THE PARENTAL RELATIONSHIP AS THE IDENTIFIED PATIENT IN CHILD PSYCHOTHERAPY

3. It adds to the possibility of a good prognosis if the family realizes that

anyone in the family can be the one who effectively intervenes in prob-
lematic situations as they arise. That is, any member can interrupt a
pathogenic relational pattern as he or she becomes aware of his or her
part in enacting and perpetuating the problem.

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