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Ego psychological and object relational approaches—isit either/or? commentary on Neil Altman's“psychoanalysis and the urban poor”;Anni Bergman Ph.D. a b ca Professor of Clinical Psychology , City University of New York , 224 West 20th Street, NewYork, NY, 10011b Training and Supervising Analyst at the New York Freudian Society , 224 West 20th Street,New York, NY, 10011c Member of the faculty of IPTAR and of the Postdoctoral Program , New York University , 224West 20th Street, New York, NY, 10011Published online: 02 Nov 2009.

To cite this article: Anni Bergman Ph.D. (1993) Ego psychological and object relational approaches—is it either/or?commentary on Neil Altman's “psychoanalysis and the urban poor”;, Psychoanalytic Dialogues: The International Journal ofRelational Perspectives, 3:1, 51-67, DOI: 10.1080/10481889309538959

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Psychoanalytic Dialogues, 3(l):51-67, 1993

Ego Psychological and Object RelationalApproaches—Is it Either/Or?Commentary on Neil Altman's

"Psychoanalysis and the Urban Poor"

Anni Bergman, Ph.D.

IN A RECENT ISSUE OF Psychoanalytic Dialogues, Lewis Aron (1992) states,"Much of the tradition of clinical psychiatry and psychoanalysis hasbeen that the clinician sees himself or herself as healthy and mature

and looks down subtly or blatantly at the patient as sick and immature"(pp. 182-183). Later in the same paper he refers to Ferenczi, who believedthat analysts tended to blame their failures on their patients by pointingto their resistances or to their unanalyzability. Aron says:

Ferenczi was a devoted healer who placed primary emphasis onhelping patients and was less concerned with building a theoreticalsystem. . . . He believed that an analyst should try to help any patientwilling to come for analysis and that failure points not to the patient'sresistance exclusively but to our own inadequacies and personal andtheoretical limitations [p. 183].

When we treat patients from impoverished backgrounds, we must facenot only our own personal and theoretical limitations, but also thelimitations of a health system that does not give us the necessary freedomand time to work effectively. This dilemma is very well illustrated in"Psychoanalysis and the Urban Poor," where Neil Altman shows in somedetail how the health system works against the therapeutic process. Forexample, when Medicaid does not pay for missed sessions and thereby

Dr. Bergman is Professor of Clinical Psychology at The City University of New York andTraining and Supervising Analyst at The New York Freudian Society. She is also a mem-ber of the faculty of IPTAR and of the Postdoctoral Program of New York University.

51 © 1993 The Analytic Press

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puts pressure on the therapist to drop patients who miss their appoint-ments, it becomes impossible to use the analytic approach of understand-ing the reasons why appointments are missed and to use the situation asone in which the struggle about therapist as an old or a new object can beworked out. 1 fully agree with Altman that this struggle is at the veryheart of doing analytic work, especially with patients who have experi-enced a great deal of deprivation in their lives. I also hope to illustrate thispoint later by describing the psychoanalytically oriented treatment oflanguage-delayed children from inner-city backgrounds at the ChildCenter of The City University of New York.

Going back to Ferenczi's statement, I agree, especially in relation tohelping patients with severe psychopathology and patients from severelydeprived backgrounds, that therapists have to go beyond the imperativesimposed on them by their orientation and keep the wish to be of helpforemost. This is not to say that one can always succeed, only to state mybelief that if one is willing to undertake work with such difficult patients,one has to go to the limits of one's capacities and be willing to apply basicpsychoanalytic principles and beliefs with a great deal of flexibility. Atthe same time the basic psychoanalytic beliefs cannot be compromised,as they rest on the conviction and experience that in the interactionbetween analyst and patient, the possibility exists to help the patient tobecome more conscious, more aware, more reflective, both about hisown mind and that of significant others.

In his paper Altman contrasts ego psychological and object relationalapproaches to treatment of the urban poor. He believes that ego psychol-ogists tend to describe inner-city patients mostly from the point of viewof their ego strengths and weaknesses, such as frustration tolerance or theability to delay gratification. Ego psychologists assume, therefore, thatsuch patients need a great deal of ego support because they cannot toleratea more explorative approach based on interpretation of internal conflict.Altman illustrates by arguing with the ego psychological approach of FredPine. It seems to me, however, that Altman takes exception to some ofPine's formulations rather than to his way of working with patients.

Pine himself seems to be aware of the central importance of thetherapist-patient relationship and wonders why psychoanalysis has beensomewhat remiss in including these considerations in psychoanalytic the-ory. Pine (1985) says, for example, that "psychological treatment can beviewed as the relation of one person to another where part of the task isto enable the patient to take in and make his own what is 'given' by thetherapist" (p. 128).

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Altman discusses how Pine describes telling a patient who could notkeep regular appointments that he would keep her hour open whethershe was able to use it or not. To me this reflects an acceptance that thepatient could benefit by the therapeutic work but that it had to be doneon her terms. Would therapists with an object relational approach havehandled the situation differently, or would they have given differentreasons to themselves for doing it? Although it is clear that Altmandisapproves of Pine's reasoning, it is not clear to me whether he alsodisapproves of the way in which Pine handled the case. Does Altmanthink that the same action on the part of the therapist would have adifferent effect if, in the therapist's thinking, ego functioning wereparamount rather than the need of the patient for the parent-therapistunconditional availability?

Altman cites the case of Linda, who, after making good contact witha therapist in the first hour, did not return to her next appointment but,instead, came back weeks later without an appointment, hoping to get afavor from the therapist, which the therapist regarded as a way in whichLinda was denigrating herself because the favor was for money given topeople who cannot work because of physical or mental disability. Thetherapist felt caught between rejecting her or colluding with herexploitativeness and self-destructiveness. The therapist handled thesituation well by getting the patient to explore with her her decision toapply for the support and was able to convey to Linda her convictionthat she could benefit from therapy and that therapy could help her tofind new options. Linda decided to try it and made another appoint-ment. The case was definitely well handled, but one wonders if a goodtherapist with an ego psychological approach would have handled itdifferently. Clearly Linda had made good contact with the would-betherapist, but then she did not return. We might venture to speculatethat Linda had gotten too close to the therapist too quickly and had todistance herself. It seems, however, that Linda had developed a positivetransference to her therapist, which then allowed her to come back andask for help as she could understand it, not really knowing how atherapist could help her. Even middle-class patients do not know at thebeginning of therapy how therapy might help them, but the idea thathelp could come from one person to another is probably more conceiv-able to patients who have lived in more privileged circumstances. In fact,for an inner-city patient to trust a therapist before the therapist hasshown himself or herself as trustworthy would seem like poor judgment.Altman believes that Pine would have seen in Linda someone with

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impaired ego functioning. Does this mean that Altman thinks Pinewould have seen her as so impaired that he would have gone along withher request? One thing that Linda and Pine's patient seem to have incommon is the inability to accept what the therapist offers. Linda is ableto come back only when she can make a request of her own. Pine'spatient can come to therapy only when she is allowed to come or not asshe feels she needs to. This brings up what seems to me a very importanttreatment issue—the issue of control. We can well imagine that patientsfrom deprived backgrounds often have little control over how their livesproceed. Pine found a way to let his patient be in control of her therapy.When Linda came, it was without a scheduled appointment and to makea request, again an attempt to be in control. This is an important issue inthe therapeutic technique with adults whose lives are out of their controland who probably have never had the experience as children to have anycontrol or even influence on how they were treated and what they wereallowed to do or not do.

Struggles over control are not unique to inner-city patients. We know,for example, that the issue of payment for missed sessions is often abattleground. I have found that patients from middle-class families whohave been rigidly controlled in their childhood cannot accept thiscondition, which is generally expected by therapists. Missed appoint-ments certainly are not unique to inner-city patients. Among them,however, missed appointments are often the rule rather than the excep-tion; and it often seems that keeping appointments is simply not in thevocabulary of such patients who probably have not had much experiencein having their appointments kept. How about the same behavior inmiddle-class patients? Such patients often act as if they simply assumedthat the other, the therapist, will be there no matter what—but that maywell be a narcissistic defense against a deeper feeling of the other asunavailable, arising from the object relationships of the past.

I think that I agree with Altman's position that puts the primaryemphasis on the object relationship between analyst and patient becauseI believe that meaningful object relations are necessary for the develop-ment of ego functions and that ego functioning cannot be "corrected"other than through the analysis of the patient's object relationships inthe present and in the past. This analysis occurs through the therapist'soffering himself or herself as a person capable to withstand the ragecaused by the patient's failed object relationships and as a personavailable for helping the patient build healthier ones based on the

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analyst's presence as a new object who is available, nonjudgmental, andnonretaliatory and able to help the patient to gain some understandingof his or her way of being. I fully agree with Altman's statement that theanalyst has to enter the patient's world to become a meaningful object. Ialso believe that all people, no matter from which class, have to resolvecertain basic human conflicts in order to function in the world withothers. Basic among these conflicts are the ones that arise out of thenecessity to perceive others as separate enough to live in their own worldrather than act as extensions of the self and yet be close enough to feelwith or for them. Patients who have grown up in deprived circumstancesmay never have had a chance to go through a healthy process ofseparation and individuation that results in a sense of self and other asseparate and that results in the capacity for emotional object constancyand, with that, the capacity to take the perspective of the other.

In my own work with inner-city children and their families I haveobserved young children use their therapists to accomplish the task ofself-other differentiation and make enormous strides, in their egofunctioning, such as language, the capacity to tolerate frustration anddelay, and the development of empathy. This work takes place at TheCity University Child Center, a therapeutic treatment center begun in1976, which has been ongoing since with some alterations in design.The center exists as an integral part of the clinical psychology Ph.D.program at The City University of New York, primarily as a way ofteaching clinical psychology students how to work with seriouslydisturbed preschool children and their families from economicallydisadvantaged backgrounds. At this time the center serves six preschoolchildren who are usually referred for serious language delays. It consistsof a therapeutic classroom with two teachers and a number ofvolunteers. The approach in the classroom is geared toward socialinteraction and developing the ability for symbolic play. The approachis developmental as well as psychodynamic. This means that it isbased on knowledge of early development within the caretaker-childdyad as well as knowledge of the beginnings of intrapsychic conflicts.Our aim is to create a facilitating environment, in Winnicott's sense. Weattempt to create an environment that allows for the creation of a mindand the creation of meaning. In addition to the classroom, each child isseen in twice-weekly play therapy sessions by a clinical psychologystudent.

The children live in a home environment that cannot supply the

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building blocks of healthy object relationships and ego functions. Weknow that the children we see in our center have not had the opportu-nity to work on issues of attachment, separation, separateness, andautonomy in their families, where mothers are often overburdened andemotionally unavailable because of difficulties in their own lives. Weattempt to provide a therapeutic environment that offers each child theopportunity to form a close attachment with their therapist. Often theyseparate from their homes without any apparent anxiety, and only later,when they have progressed in their treatment, do they sometimes beginto miss their parents. Transitions from the classroom to therapy are oftenfilled with intense feelings, and therapists and children together find away to work on these in various play situations. Our center is, for manyof these children, the first place in which they themselves can have somecontrol over the environment in which they live. They play games withtheir therapists that are very reminiscent of the games that normalinfants and toddlers play with their mothers. For some children the focusmay be on exploration of their own bodies and the body of the therapist.For others it is controlling the distance between them and playing suchgames as following and being followed, disappearing and being found,and exploring the environment of the building in which the center islocated, for example, going into different rooms and up and downescalators and elevators.

Originally our intention was to involve the primary caretakers in thetreatment process, following a tripartite treatment design (Mahler, 1968)where the therapist sees mother and child in joint treatment sessions inthe hope of creating a corrective symbiotic relationship in which motherand child can learn to be with each other and in which the mother canlearn to read and respond to the child's cues and needs. We found thatwith very rare exceptions it was.not possible to involve the families in-tensively in the treatment of their children. At best we could enlist enoughcooperation on their part to assure somewhat regular attendance of thechildren. (Bus service is provided for them, but parents are required to getthe children on the bus in the morning and meet them from the bus at theend of the school day.) Also, at best, the therapists have been able to stayin regular contact with the mothers, more often on the telephone than inperson. Occasionally mothers have allowed us to make home visits. Be-cause the children's families are not available as a home basis, the class-room itself has taken on that role and was described by one of our students

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who worked in it as "The Classroom as Mother."1 What follows is anexample of four children described in the classroom. I then describe theprogress of individual therapy in one little girl, Tina. I hope that this willdemonstrate the approach we use, which I see as a combination of egopsychological-developmental and object relational. We have the advan-tage of being a therapeutic center rather than having to rely entirely ononce- or twice-weekly therapy sessions in a clinical setting.

The Classroom as Mother: Four Vignettes

Daniel

Daniel started school when he was three years old. He had very littleexpressive language, often seemed not to understand what others said,and had severe negative reactions to all transitions. Moving from oneroom to another provoked a tantrum. He became terrified at each moveand would open his eyes very wide and cry and scream. Over time, as hegrew to feel more confident about what the next place would bring andabout returning to the place he was leaving, he became less upset by thetransitions. Transitions continued to be difficult for him, especially themost stressful transition of all—leaving school at the end of the day.Daniel's reaction to transitions was so extreme that it suggested to us thepossibility that it was motivated by annihilation anxiety. Leaving oneroom to go to another seemed to threaten him with losing the ability to"go on being" (Winnicott, 1956). The physical space, the people, the toys,the activities, and the usual routines provided a matrix for Daniel's"going on being." Changes in these structures, people, places, andschedules continued to threaten his sense of continuity and cohesion tosome extent. This suggested one way to begin to understand the difficul-ties he had at various times in going with people from "outside" theclassroom, leaving at the end of the day, adjusting to the beginning of theday, and adjusting to new people. Until he discovered a way to connecteach person and activity to his surrogate classroom-mother, his sense of

1I would like to thank my students and their supervisors for the work they have doneand for allowing me to see the clinical accounts that they have written. In particular Ihave drawn on the work of Anne Adelman and Katherine Tobias.

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continuity would be threatened. The terror induced by separationsthrew him into a panic, and he acted out by hitting or kicking others, byacting as if he was going to vomit, or by crying and screaming andthrowing himself onto the floor.

Although Daniel's sense of continuity appeared to be bolstered by theregularity in place, schedule, and people in the classroom, finding hisown role or "place" in the classroom continued to be a struggle for him.He wanted desperately to be a part of the group. He sought repairthrough being part of his group, by belonging, and by copying the otherchildren as if by being more like them, he could be part of them.

Sammy

Sammy, another three-year-old boy, was more advanced in his capacityfor object relating than Daniel. He had fairly good language ability andthe capacity to initiate play with others. He was also able to invent gamesthat were enjoyable to himself and enticing to others. He was able tocommunicate his feelings easily and able to show concern and care forothers. In spite of these abilities, he had considerable difficulty inregulating his physiological and affective states. Thus, we might speculatethat he had experienced difficulty early on in relation to the self-regulating other. Sammy required a great deal of help with the regulationof basic physiological functions such as eating and toileting and alsorequired a great deal of soothing. For example, it was necessary for anadult to sit next to him during lunch in order for him to be able to eat.

Sammy was very sensitive to nonverbal cues from the adults aroundhim: the way in which they moved, talked to him, or touched him couldhelp him to maintain control. Whenever he sensed anxiety in anotherperson, he almost immediately became anxious as well. Sammy was alsovery sensitive to the space that surrounded him. When the boundaries ofhis play area were not clear, he seemed to lose track of where he was andwhat he was doing. The adults in the classroom found that putting anarm on his chair helped provide enough of a boundary so that he couldfocus on a task that demanded concentration. The adults in the class-room were very aware that they had to function in the role of theself-regulating other by providing soothing nonverbal communication aswell as verbal encouragement. The schedule of the classroom was helpfulto Sammy and contributed to his ability to learn to regulate himself.

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He began to say things like, "Now we have lunch; then we have story andrest." Or he would say encouraging things to himself such as, "That'sgood; try again."

Jeannie

Jeannie was referred when she was three years old with the diagnosis ofautism and almost no language. She was oblivious to her surroundings,and it seemed as if nothing existed for her outside herself unless it directlyaffected her. Any change in schedule left her feeling disoriented, andrefusal on the part of an adult to do her bidding left her feeling frustratedand angry. She used others as an extension of herself, to reach thingsthat she could not reach. When the adult refused, she screamed out inanger. As might be expected, schedule and routine were of primaryimportance. An observer said: "It is as if she has an internal clock that ispreset for the day. If there is a change, her whole world is so disturbedthat it can throw her off and change her mood for the remainder of theday." Jeannie treated the classroom as an extension of herself. She didnot appear to notice anything unless it came within her orbit. Onlyoccasionally did she make contact with another person. At such timesshe would pull an adult over to see something she was doing or wasinterested in. She looked up at the adult and then back to the toy andseemed to enjoy the moment of sharing. This seemed suggestive of theway a young child shares new discoveries and achievements with motherand in this way imbues these activities with the warmth and sustenanceof the love relationship. Perhaps Jeannie used the classroom-mother toenhance her pleasure with the world in the same way a toddler uses themother. In the classroom Jeannie was allowed to be in control of the levelof intimacy that she could bear. She then began to seek out briefmoments of closeness. The classroom-mother provided the opportunityfor Jeannie to make connections in her own time and in her own way bybeing available without being intrusive. Eventually her world and theworld of the classroom could begin to join and slowly expand Jeannie'sworld.

Suzy

Suzy was a child of extremes. She was either very subdued and barelycommunicative or very boisterous and loud. There was no middle

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ground. At times she was sad, withdrawn, and petulant and at othertimes, overly cheerful, active, and lively. She could move between theseextremes quickly and with little warning. It took a long time before theadults in the classroom could begin to see what triggered her shifts inmood. The classroom-mother served to contain all of Suzy's moods andways of being. Both the sad little girl and the cheerful little girl were fullyacknowledged and responded to, and slowly she developed the ability tobe at times just a little sad or a little happy or a little excited or a littlescared. We felt that by containing all of who and how she was in theclassroom, she could begin to see herself as more whole and less discon-nected. We thought the acceptance of her negative affects would help herbecome less dissociated when feeling bad. In this way her range ofexpression could expand and her affective experience could become morecomplex and modulated. The classroom-mother was the mother whoallowed expression of anger, sadness, grief, fear, revenge, and neediness.Suzy was also very responsive to the nonverbal communication ofothers. Her nonverbal affinity was toward softness, which was verydifferent from the brittle harshness to which she was accustomed.Eventually the classroom became a safer place for Suzy, allowing her tolet go a little. For example, at the beginning she was not able to restduring rest time. She would sit on her cot with her shoes on, back stiffand erect, head up and eyes staring straight ahead. None of the usualtechniques, such as storytelling, holding, or quiet talking, helped herrest. Finally one day on her own she took her shoes off. She continued tosit in the same way but with her shoes off. Then one day she lay down butwith her shoes on and on top of, rather than under, her blanket. Finallyone day she took her shoes off and got under the blanket and played withher resting toy but did not let herself fall asleep. Then one day she fellasleep and slept well during rest time from then on.

The Building of Self in Therapy: The Case of Tina

To illustrate how the therapeutic environment helps a child to create asense of self and other and a loving attachment, I would like to describethe development of one of the children.

Tina was referred at the age of four for severe language delays. Shecould not name common objects in either English or Spanish and used

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improper word order in making simple sentences. She had articulationproblems and was almost impossible to understand. Tina was the secondof two children. Her older brother was said to have been particularlyprecocious in language development. The siblings were reported to havea close relationship, with the older brother often functioning as inter-preter. Mother was very insistent that Tina had no emotional problemsand was not willing to come to meetings with the therapist. Thetherapist, however, discovered that when she called her on the phone atwork, Mother seemed to enjoy talking for long periods of time. Thetherapist used frequent unplanned phone contacts to build a relationshipwith the mother. Mother alternately described Tina's language difficul-ties as a nightmare from which she hoped to awaken and a minordifficulty that the speech therapist should quickly correct. She avoidedany realistic assessment or acceptance of her daughter's problems but dideventually reveal some guilty fantasies that she had inadvertently dam-aged Tina by eating something wrong during pregnancy. It was oftendifficult to get her to talk about Tina. Instead she would talk about herson and his accomplishments.

Mother had returned to work part-time before the child was a year oldand started a full-time job when Tina was 25 months old. Long hourswere normal, and she rarely arrived home before her daughter was put tobed at nine o'clock by the maternal grandmother, who spoke onlySpanish. Tina learned to press an automatic dialing function on thetelephone to call her mother at work. Mother said: 'Tina used to call meat work sometimes a dozen times a day. But the only word she could saywas 'Mommy.' So the people at work used to know it was for me whenthey picked up the phone and heard this little voice crying, 'Mommy.' "Tina was not only helpless to control her mother's comings and goingsbut also lacked the ability to articulate her distress and request thecomforting she needed. At the height of Tina's rapprochement crisis hermother not only was physically unavailable but also found it increasinglydifficult to provide adequate emotional support as Tina's language delayengendered feelings of anxiety, loss, and resentment in her. To compen-sate for the narcissistic wound of having a damaged child, the motherbecame overinvested in her son's development and also in any sign ofprecocious independence on Tina's part. Early in treatment the onlypraise she had for her daughter concerned her ability to dress herself andhelp clean the house "like a little adult." She said, "I can just tell her to goget dressed, and she'll go to her room and pick out her own clothes and

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put them on by herself—and the colors will even match." Self-sufficiencywas the characteristic most valued by her mother.

In therapy, starting in her first session, Tina was able to explore theroom, play with toys, and engage the therapist. The therapist noted thatthere was a frantic quality to Tina's games and no sign of caution orshyness about interacting with a new person in a new environment.Bravado was shown right from the start as Tina ordered the therapistabout. "Clean!" she commanded after creating a mess during the firstsession. She made the therapist "hurry, hurry hurry!" to carry out orders.She treated the therapist as a tool to be used in her play rather than as anindividual who might react in unknown ways. Slowly Tina began to beable to use the therapist in new ways, playing peek-a-boo and hiding-and-finding games. She also eventually began to be able to use thetherapy to reenact and work through traumatic events in her life. Onetraumatic event that seemed to be reenacted was the enforced separationfrom her mother when her mother returned to work full-time when Tinawas only two years old. Play of particular relevance occurred in thestairwells as she went with the therapist from the classroom to hertherapy sessions. The classroom and the therapy playroom were onadjacent floors, and there were three different stairways and threedifferent elevators that could be taken to go from one floor to another.The opening game of each session became Tina's decision about whichroute to take. She almost always chose to ascend the stairs and wouldspend up to 15 minutes playing games on the stairs before going to theplayroom. These games consisted of elaborate variations on separationfrom and returning to the therapist with Tina always in charge of theamount of distance between them. While Tina stayed at the same pointor went up the stairs, she would direct the therapist to walk down thesteps: "Go down, more, more, more, OK, stop!" Next she would rushdown a flight of stairs for a reunion. Sometimes Tina would have thetherapist follow her, regulating the distance verbally in such a way thatthe therapist stayed just out of sight. Sometimes Tina became the pursuerchasing after the therapist. And sometimes Tina would lean over therailing and wave while remaining separated by several flights. Tina nowhad some words with which to express her wishes for closeness anddistance. On the stairwell in the transitional space between the class-room and therapy room, Tina played the shadowing and darting-awaygames reminiscent of the rapprochement toddler.

There was a major difference, however, between Tina's stairwell gamesand the "chase and catch me" games of the junior toddler. Often for a

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toddler part of the excitement is the mother's active participation inrunning from, chasing after, or swooping up her child. Separations andreunions are initiated by mother as well as by child. But with Tina'sstairwell games there was no flexibility regarding when to chase, when towait, and when to catch. Tina needed to remain in complete control.

When Tina was two years old, the long separations from mother werenever within her control—mother left for what seemed much too longand returned from work at unpredictable times. Tina never knewwhether her mother or father would be home before her bedtime. Bycontrolling the separations and reunions on the stairwell with thetherapist, Tina expressed her wish for more power over when she wouldbe close or distant with adults she cared about.

The games also seemed a reenactment of the ambitendency character-istic of a child in the rappochement subphase, expressing the child'smixed feelings about the therapist and the therapy sessions. By creatinga transitional play space between classroom and therapy room in whichto play shadowing and darting-away games, Tina could act out her wishto escape the closeness with the therapist and slow her approach to thetherapy room where overwhelming and frightening feelings were some-times stirred up. Tina's behavior recalled the behavior of her mother,who tried to escape the painfulness of dealing with Tina's language delayby creating distance between them. In this connection it is important toremember that the mother chose to communicate with the therapist onlyby telephone. The telephone, while representing distance, was also alifeline between her and Tina early on when Tina was not with her butwould call on the telephone.

In the stairwell transitions, Tina showed her wish to regulate thedistance with the therapist, just as she may have wished to bring hermother home when she was two and called the office crying, "Mommy."With her orders to the therapist to go away or come closer, she seemed tobe asserting the control that she had lacked with her mother. Mother'sdirective style left the child little chance for feeling power within thefamily. It was her mother who gave the orders at home, stirring feelingsin Tina that were sometimes expressed in angry outbursts during thetherapy sessions. For example, during the 42d session, after Tina beganscreaming commands at the therapist to pick up the ball she threw, thetherapist asked whether anyone ever yelled at Tina that way:

"Mommy!" yelled Tina in reply. "Mommy yell, 'Tina, get over hereright now!' "

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"And how do you feel when Mommy yells?" asked the therapist."Me want to fight Mommy," yelled Tina, demonstrating her anger

by swinging clenched fists.

As Tina became increasingly aware of her conflicting feelings abouther mother within the therapy sessions and was able to verbalize thesefeelings, games in the stairwell became less common. As Tina's languageand other coping skills developed and as the therapeutic relationshipdeepened, Tina's need to delay her approach to the therapy roomdiminished.

Tina progressed from the reenactment of separation-individuationissues in therapy through "self-other action play" (Bergman and Lefcourt,in press), to symbolic play and role play. She showed early on that shecould express rapprochement issues through representational play. Tinashowed the therapist how she perceived her mother as alternatelyrejecting and comforting and showed her feelings about being separatedfrom mother in role play with dolls. Near the end of the session Tinapicked up a large, soft doll, sat in a chair, and ordered the therapist to sitin a chair about five feet away. "Hello, Baby," Tina said, holding the dollup to her face and smiling. Suddenly she threw the doll to the therapist,saying, "Catch." After the therapist threw the doll back, Tina cradled thedoll lovingly for a moment. Then her expression changed to a mischie-vous grin as she raised her arms to toss the doll back. She then threw thebaby doll as hard as she could toward the floor so that there was no waythat the therapist could make the catch. The therapist picked up the dolland tossed the doll back gently. Again Tina cradled the doll for a fewmoments before dashing the doll to the floor. "Go away!" she said in anangry voice as she threw the doll. The therapist asked Tina what thebaby was feeling. Tina commanded the therapist to cry, and the therapistbegan to make crying sounds for the baby doll. "Come to Mommy," saidTina and held out her arms to catch the doll.

This pattern was repeated with variations over and over. For severalminutes Tina would call for the baby doll to "come to Mommy" andwould yell, "Go away" with anger and throw the doll to the ground. Thetherapist assumed the baby doll's voice, crying when Mommy rejectedher and then talking about wanting Mommy to take care of her and howsad the baby was when Mommy made her go away. Thus, with fewwords, Tina used the role play to express her contrasting visions of hermother as rejecting and comforting. The baby doll had no choice about

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when painful separations would occur: Mommy was in charge. Tina usedthe doll-throwing game to master the conflicts over separation andcloseness.

After having established a close relationship with her therapist andfollowing a frustration in a session (the therapist did not allow her toflood the room with water), Tina began to flood the room with tearsinstead. She began to cry inconsolably, and the therapist could donothing to calm her. After this tearful session, she refused to come totherapy and when finally helped to go by her teacher, she again spent theentire session crying bitterly. The therapist became extremely upset andbegan to feel that she could not continue with the therapy as it seemed tobe upsetting Tina so profoundly. It took a great deal of support from thegroup to enable the therapist to proceed. Eventually it was possible tolink Tina's sadness to the separation from her maternal grandmother,who had left for Puerto Rico, an event that was upsetting not only toTina but to Tina's mother as well. Without doubt, however, the tearswere also meant for the separation she had experienced from her motherwhen she was two years old. Tina eventually had to defend againstsadness by the exaggerated busyness and bossiness that were describedby the therapist in the early sessions. She attempted to master thesadness by identifying with her busy and bossy mother and also bycreating a false self that was in compliance with her mother's demands,namely, that she be precociously independent. It seemed remarkable thatTina was able to experience a delayed mourning process in her therapysessions. It was made possible, in part, by the support offered Tina by theclassroom-mother, as well as by the therapist, during this difficult time.

I hope that by describing the work of the Child Center at The CityUniversity I have been able to contribute to Altman's ideas about usingan object relational approach with inner-city patients. In some waysworking with children in a day treatment center makes it easier becauseit is possible to provide more intensive treatment. On the other hand Ialso want to convey how often the work that we try to do is heartbreak-ing. It sometimes seems that all our efforts come to naught because weusually cannot really influence the families. The therapists working inour center need and receive a great deal of support from each other andfrom their supervisors, and a weekly two-hour conference is held inwhich the therapeutic work is viewed on videotapes and discussed ingreat detail. All this at times is not enough. Student therapists easily

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become discouraged and feel that their work is not sufficiently valued orthat they do not have the time or strength to put in all that is needed.Thus, they experience what I believe all therapists of such difficult caseshave to manage within themselves. They have to be helped to see theirexperience as the result of an important communication about thedifficulty and despair that are often such a big part of the lives of thosethey wish to help. For example, when children who seem to have beennumb to the pain of separation suddenly experience such pain intensely,therapists feel as if they are the ones who have caused the pain. Here theconcept of the therapist as old or new object is helpful because thetherapist as a new object can tolerate the intense affects that are inherentin meaningful object relationships and that are often very painful inpatients who have experienced traumatic childhoods.

Neil Altman has opened up important issues about the changes thatneed to occur in order to make psychoanalytic work possible with inner-city patients. Some of these changes are organizational, and unfortunatelythere is usually little that we can do to influence the organizations in whichwe work. I have described the building of a small treatment center, inwhich I had the freedom, within limits of funding, to create the kind oftreatment setting that I thought was optimal. I have tried to show howeven with such luxury and freedom the work is extraordinarily difficult.The other changes that Neil Altman speaks to are changes in our way oflooking at the problems of patients from economically deprived back-grounds. Here I think he makes an important contribution by asking usto look at such patients primarily not in terms of their ego deficits butrather in terms of what communications lie behind those deficits andconvey to us the object relational deprivation that these patients haveoften experienced. Altman feels, and I agree with him, that only by en-tering the patient's world can we hope to make a meaningful connectionthat would make it possible to do therapeutic work.

References

Aron, L. (1992), From Ferenczi to Searles and contemporary approaches: Commentaryon Mark Blechner's "Working in the Countertransference." Psychoanal. Dial.,2:181-203.

Bergman, A. & Lefcourt, I. (in press), Self-Other Action Play: A Window into theRepresentational World of the Infant. In: Modes of Meaning: Symbolic Play in Clinicaland Developmental Contexts, ed. A. Slade and D. Wolf. New York: Oxford UniversityPress.

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Mahler, M. (1968), On Human Symbiosis and the Vicissitudes of Individnation. New York:International Universities Press.

Pine, F. (1985), Developmental Theory and Clinical Process. New Haven, CT: YaleUniversity Press.

Winnicott, D. W. (1956), Primary maternal preoccupation. In: Collected Papers. London:Tavistock, 1958, pp. 300-305.

224 West 20th StreetNew York, NY 10011

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