Child psychoanalysis

1. Introduction

Version followed: two named versions side by side. [AF] Anna Freud / Hampstead (The Psycho-Analytical Treatment of Children, lectures 1927, English ed. 1946; Normality and Pathology in Childhood 1965; the Hampstead Clinic, now Anna Freud). [K] Melanie Klein's play technique (The Psycho-Analysis of Children 1932; "The psycho-analytic play technique: its history and significance" 1955; Narrative of a Child Analysis 1961). [C] Contemporary UK child and adolescent psychoanalytic psychotherapy (Tavistock / Association of Child Psychotherapists (ACP) training), used for current setting, parent work and safeguarding. Each item below is tagged [AF], [K] or [C].

Child psychoanalysis applies psychoanalytic treatment to children, using play, drawing and talk where adults use free association. It is a clinical tradition with founding texts, not a manualised therapy. There is no session-by-session protocol, and the "phases" below come from the founders' descriptions and current training practice. [source: A. Freud 1926/1946 lecture 1; UEL/Tavistock programme specification]

Core idea of change:

• [AF] The child's ego is strengthened. Defences and anxieties are made conscious, from the surface down. Development, which has been blocked by internal conflict, is set moving again. The child's "insight into the malady, voluntary decision, and the will towards cure" (A. Freud 1926, p. 5) cannot be assumed and has to be built first. [source: A. Freud 1926/1946; Normality and Pathology 1965 via Developmental lines summary]
• [K] Play is treated as equivalent to free association. The analyst interprets the child's most pressing unconscious anxieties and phantasies as they appear in play and in the transference, both negative and positive, from the first session. This relieves anxiety, frees play and symbolisation, and moves the child from persecutory toward more integrated (depressive) functioning. [source: Klein 1927 Symposium and 1961 Narrative, quoted via Montaut (IAHIP); Renn (TherapyRoute) summary of Klein's "anxiety–interpretation–response" sequence. Klein 1932/1955, described from the published texts as recalled [uncertain]]
• [C] Current practice rests on a consistent setting, close observation, use of transference and countertransference, and interpretation pitched at the child's developmental level, with parents and the professional network held in parallel. [source: UEL/Tavistock programme spec; Edwards, Five Books (Tavistock repository)]

2. Framework

No founder sets fixed session counts. The figures below are typical ranges from the texts and current practice, and are marked where uncertain.

Format

• [AF] Classical child analysis ran 4–5 sessions a week of about 50 minutes, often for years. At Hampstead, intensive analysis was the norm and was discussed in weekly case conferences. Parents were seen regularly. [source: freud.org.uk Hampstead page (weekly case conferences); frequency from Sandler, Kennedy & Tyson 1980 [uncertain]]
• [K] Daily sessions (5 a week) of 50 minutes in a dedicated playroom with an individual toy drawer. Richard (Narrative 1961) was a time-limited wartime analysis of about 4 months (93 sessions). [source: Klein 1955, 1961, from recall [uncertain]]
• [C] Most NHS CAMHS work is once a week for 50 minutes, often for a year or more. "Intensive" means 3–5 sessions a week. Parent work runs in parallel, usually with a separate clinician. Brief and consultation models also exist. [source: UEL/Tavistock spec ("intensive and non-intensive, long-term"); frequencies from training norms [uncertain]]

Phases

3. Guiding principles

Shared

• Play and drawing are a language. Treat what the child does with the materials as communication and record it in sequence. [source: Klein 1955; A. Freud 1926 lecture 2; inflibnet chapter]
• The setting is part of the treatment. Keep the same room, time, materials and length, and prepare the child for breaks. [source: Klein 1955 [uncertain]; [C] practice]
• The child does not come by choice. Expect reluctance, and build or interpret motivation instead of assuming it. [source: A. Freud 1926, p. 5]
• Parents are part of the treatment field. The child depends on them for attendance, history and daily life, so work with them in a planned way. [source: A. Freud 1926 pp. 7–8, 13; [C] UEL spec "Work with parents" seminar]

[AF] Anna Freud

• The ego is the field of observation. Start with what the child can see in themselves (defences, behaviour) and go from surface to depth. [source: A. Freud, quoted in Edwards, Five Books]
• Use development as the yardstick. Judge symptoms against the developmental lines, and treat a temporary regression differently from a fixed disturbance. [source: Developmental lines (Wikipedia summary of A. Freud 1965)]
• Work with a positive attachment. "The really fruitful work always takes place with a positive attachment" (A. Freud, quoted in Montaut). Deal with hostility quickly rather than letting it build.
• The child's real parents are still present, so a full transference neurosis is limited. Separate transference from current reality. [source: A. Freud 1927 lecture 3, via Montaut; recall [uncertain]]
• Analysis and education were combined (1927). She wrote that the analyst must combine analysing and educating (1926 preface, p. xii). Today, keep any guidance explicit, minimal and in the parent work rather than in the child's sessions [synthesis].
• Clarify the contract with the parents. She records one analysis failing because her position between the child and the paying parents was never clarified. [source: A. Freud 1926, p. 8]

[K] Melanie Klein

• Play equals free association. Interpret the child's play, talk and behaviour together, as you would an adult's associations. [source: inflibnet chapter citing Klein; Klein 1955 [uncertain]]
• Transference is present from the start, including the negative transference. Analyse "consistently the negative as well as the positive transference" (Klein 1961, via Montaut).
• Interpret at the point of greatest anxiety. Address the most pressing anxiety directly and in the child's words. A change in the play and relief of anxiety are the test. [source: Renn summary; "point of urgency" is Klein's 1932 term, not verified online [uncertain]]
• Deep interpretation is safe and relieving. It is "perfectly possible and also salutary to probe the Oedipus complex to its depths" (Klein 1927, via Montaut). In practice, follow the material and do not impose theory [synthesis].
• The analyst does not educate. Avoid reassurance, gifts, moral guidance and taking sides. These blur the transference. [source: Klein 1927 via Montaut; Klein 1955 [uncertain]]
• Privacy of the child's material. Each child has their own toys, and their productions are kept, not shared. [source: Klein 1955 [uncertain]]

[C] Contemporary

• Observe before interpreting. Detailed process notes are written after each session and taken to supervision. [source: UEL spec; Bick infant-observation tradition]
• Countertransference is data. Your own feelings are information about the child's states, to be thought about and not acted on. [source: Edwards (Winnicott, "Hate in the counter-transference"); Heimann 1950 [uncertain]]
• Match the interpretation to the child's level. Deprived, traumatised or autistic children may need descriptive or vitalising comments before explanatory ones. [source: Alvarez 2012 [uncertain]]
• Safeguarding overrides confidentiality. Tell the child and parents the limits of confidentiality at the start, and follow local child-protection procedures. [synthesis based on UK statutory guidance, Working Together to Safeguard Children 2023 [uncertain]]
• Work within the network. Liaise with school, social care and CAMHS colleagues, in a way that protects the privacy of the session. [source: UEL spec, "communicate effectively with CAMHS colleagues"]

4. Intervention inventory

This section is grouped by version. All example language is the guide's own illustrative wording unless it is in quotation marks with a citation.

[AF] A1. Parent intake and developmental history

• Purpose / when: Before seeing the child. This gathers history, current functioning and the parents' motives, and clarifies the arrangement with them. Anna Freud records a failed case in which her position between the child and the paying parents was never clarified (1926, p. 8). [source: A. Freud 1926 pp. 7–8, 13]
• Steps:
  1. Meet the parents (both, where possible) without the child.
  2. Take a history of pregnancy, birth, feeding, toileting, separations, illnesses, losses, school and peers.
  3. Ask when and how the symptom began, and what the parents have tried.
  4. Ask who wants treatment and why. Explore ambivalence; she describes parents hesitating after trial weeks (p. 7).
  5. Agree on frequency, fees, how sessions will be reported, what parents will and will not hear, and how they will support attendance.
  6. Explain that the child may get worse before getting better and may complain about sessions [synthesis].
• Example language (illustrative): "I won't pass on what your child says or plays, but I will meet you regularly to talk about how things are going at home and how I understand them."
• Watch for: A parent who wants the analyst to discipline the child or report on the child's secrets. A parent who seems likely to sabotage the treatment (A. Freud: a parent who opposes it makes the situation impossible, p. 13). A real conflict of interest between the child and the parents.

[AF] A2. Developmental assessment: developmental lines and Diagnostic (Developmental) Profile

• Purpose / when: At assessment and at reviews. Use it to place symptoms in their developmental context, to decide whether analysis or another help is indicated, and later as an ending criterion. [source: A. Freud 1965, summarised in Developmental lines article; freud.org.uk Hampstead page]
• Steps:
  1. Rate the child on each line, for example: dependency to emotional self-reliance; suckling to rational eating; wetting and soiling to bladder and bowel control; irresponsibility to responsibility in body management; body play to toys to play to work.
  2. Note disharmony between lines, such as a child who is advanced intellectually but clings like a toddler. Note lags behind age norms.
  3. Distinguish a temporary regression under stress from a fixed arrest or a neurotic conflict.
  4. Complete the Profile headings: reason for referral; description of the child; family background and history; environmental circumstances; assessment of development (drives, ego, superego); fixation points and regressions; assessment of conflicts (external, internalised, internal); general characteristics; diagnosis.
  5. Choose the treatment: analysis for internal conflict; guidance or environmental change for external conflict; developmental help for deficit (see A10).
• Example language (to parents, illustrative): "His clinging is more like a much younger child's, while in other areas he's ahead. That unevenness is what we want to understand."
• Watch for: Over-reading a normal, phase-specific behaviour as a symptom. The Profile is a thinking tool, not a scored scale. Do not reproduce it as a form for the family.

[AF] A3. Winning the child's confidence (introductory phase, 1927 version)

• Purpose / when: In the opening weeks, with a child who is mistrustful, unmotivated, or sees no problem. It creates the attachment that makes analytic work possible. She called this a "dressage" for analysis, not analysis itself (1926, p. 6). [source: A. Freud 1926, pp. 5–13]
• Steps (choose to fit the child):
  1. Be interesting. Follow the child's moods and interests (she joined a boy's tricks and knot-tying and talked about pirates and stamp collections), with no visible educational aim (pp. 9–10).
  2. Be useful. She typed a boy's letters, wrote down his daydreams and stories, and knitted clothes for a girl's dolls (p. 10).
  3. Be a protector (historical; see current limits below). She showed a boy that confiding in her brought better results than punishment, and in one case acted for him with his parents. Only once he depended on her did she ask him to give up his secrets (pp. 10–11).
  4. Side with the child against the environment. She did this with an 11-year-old girl, and the analysis failed because her relationship with the parents was unclear (p. 8).
• Current ethical limits [synthesis]: Do not give money, make restitution for the child, make confessions on the child's behalf, or form alliances against the parents or carers. Any action outside the session goes through agreed parent or network work, with the child's knowledge. Present-day use is to show real interest, be reliable, and follow the child's lead in play.
• Example language (illustrative): "You didn't choose to come here. Maybe we can find out together whether there's anything here worth having."
• Watch for: A seductive or over-gratifying relationship that later blocks negative feelings. Loyalty conflicts with the parents. Signs it is working: the child arrives willingly, brings stories, dreams or daydreams spontaneously, and starts to ask for help.

[AF] A4. Creating insight into the illness (symptom as a "foreign body")

• Purpose / when: With a child who denies the problem, is proud of the symptom, or enjoys the distress it causes. It turns the symptom into something the child wants help with. [source: A. Freud 1926, pp. 6–14]
• Steps:
  1. Notice how the child relates to the symptom (proud, indifferent, ashamed).
  2. Help the child set the symptom apart from the self. She framed one 6-year-old's obsessions as a "devil" the child asked to have removed (p. 7). She gave a 7-year-old's naughtiness a name and confronted her with it (p. 12).
  3. Where the child is proud of a symptom, she showed concern and invited the child to try to control it. A boy failed to stop his rages, and they became for him "a disturbing foreign body" he wanted help with (pp. 11–12).
  4. Agree that the child will tell everything, and that the work will take time. One child counted sessions on the carpet medallions (pp. 6–7).
• Current ethical limits [synthesis]: Do not frighten or shame the child. Her comparison of a boy to a madman beyond help would now be avoided. Use playful naming, as in externalising, and leave out threat.
• Example language (illustrative): "It sounds like the worrying thoughts boss you around. Shall we find out more about them together?"
• Watch for: Shame or a sense of being labelled. It is working when the child refers to the symptom as something to deal with and brings examples spontaneously.

[AF] A5. Means of analysis: dreams, daydreams, drawings, conversation and play

• Purpose / when: Throughout. Anna Freud thought young children's free association was limited and relied on several sources. [source: A. Freud 1926/1946 lecture 2 (contents per edition; lecture not drawn on in full) [uncertain]; her doubts about symbolic readings of play from Montaut]
• Steps:
  1. Invite dreams and daydreams. Write them down if the child wants (she transcribed daydreams, p. 10).
  2. Ask the child to say what comes to mind about parts of a dream. Children often accept dream interpretation readily [uncertain].
  3. Use drawings as associations: ask about them, and note the sequence.
  4. Treat play as observational material. Do not read every act as symbolic of drives. She objected to interpreting a child knocking over a toy figure as aggression against the father (via Montaut). Look for repeated themes that link to known history and current events first.
• Example language (illustrative): "In your daydream the hero always rescues everyone and nobody rescues him. I wonder what that's like."
• Watch for: Interpretations that are not anchored in the child's history or repeated material.

[AF] A6. Defence analysis, from surface to depth

• Purpose / when: The core interpretive work, once the child is engaged. It makes the child aware of how they protect themselves before addressing what they are protecting against. [source: A. Freud, The Ego and the Mechanisms of Defence 1936; Edwards (ego as "the proper field of observations"); 1946 preface [uncertain]]
• Steps:
  1. Notice a defence in action in the session: denial in fantasy, turning passive into active, identification with the aggressor, reaction formation, avoidance, clowning.
  2. Name the behaviour first.
  3. Name its function: the feeling it keeps away.
  4. Only later, link it to the underlying wish or anxiety, and to the past or the transference.
  5. Repeat across sessions. This is working through.
• Example language (illustrative): (1) "Each time we get near talking about school, the game gets very loud." (2) "Maybe loud is better than feeling small." (3) Later: "Being the big shouting teacher here might be a way to not feel like the little one who gets told off."
• Watch for: Interpreting content before the defence, which tends to raise resistance. It is working when the child notices the defence themselves ("I'm doing the loud thing"), with less need for it and more access to feeling.

[AF] A7. Verbalisation and interpretation in the displacement

• Purpose / when: For younger children or when direct reference is too threatening. Put feelings into words, first through the characters of play or story, then about the self. [source: Hampstead technique as set out in Sandler, Kennedy & Tyson 1980 [uncertain]]
• Steps:
  1. Name the feeling a figure in the play seems to have.
  2. Stay in the displacement until the child can tolerate it.
  3. Then bridge to the child ("sometimes children feel..."), then to "you".
• Example language (illustrative): "That baby elephant got left behind and he's furious." Later: "Sometimes children get furious when they feel left behind too."
• Watch for: The play stopping when the bridge comes too early, which means going back into the displacement.

[AF] A8. Handling transference (Anna Freud's version)

• Purpose / when: Throughout. Her 1927 view was that the child does not form a full transference neurosis because the real parents are still present. Later she distinguished transferred habitual relationships, transferred current feelings, and transference proper [uncertain: from recall of 1965 and Sandler et al 1980].
• Steps:
  1. Prefer to keep a positive tie. Take up hostility early ("dealt with as soon as possible", A. Freud via Montaut).
  2. Ask whether a reaction is new transference, a carry-over of how the child treats all adults, or a reaction to current home events. Address it at the level it belongs to.
  3. Watch for externalisation: the child puts a part of the self (such as the critical conscience) into the analyst. Name it gently [uncertain: Hampstead concept].
• Example language (illustrative): "You've decided I'm going to be cross about the mess before I've said anything. I wonder who usually gets cross about mess."
• Watch for: Mistaking a real current event (for example a parent's illness) for transference.

[AF] A9. Work with parents (guidance, information, and treatment via the parent)

• Purpose / when: At regular intervals throughout. Its aims are to keep the treatment going, to understand the child's daily life, to reduce environmental pressure, and, for very young children, to work through the parent. [source: A. Freud 1926 pp. 7–8, 13; Hampstead "treatment via the mother" (Burlingham et al. 1955) [uncertain]]
• Steps:
  1. Hold regular parent meetings, for example monthly in intensive cases [uncertain].
  2. Collect current events: illness, moves, school, sibling births.
  3. Share your understanding of the child in general developmental terms without disclosing session content.
  4. Give guidance where an environmental problem maintains the symptom.
  5. With under-fives, consider treating mainly through the parent, who brings observations; the analyst interprets with and through the parent.
• Example language (illustrative): "When she refuses to go to bed, it may be less defiance and more fear of the separation. What happens if you sit with her a little longer?"
• Watch for: Parents feeling blamed. Parents competing with the analyst. The child fearing that the analyst reports to the parents.

[AF] A10. Developmental help (later Hampstead / Anna Freud Centre)

• Purpose / when: For children whose difficulties come from developmental deficit (impaired ego functions, poor regulation, deprivation) rather than neurotic conflict. Interpreting conflict alone is not enough for these children. [source: Edgcumbe 2000, Anna Freud: A View of Development, Disturbance and Therapeutic Techniques; Hurry (ed.) 1998, Psychoanalysis and Developmental Therapy [uncertain]]
• Steps:
  1. Identify the missing capacity, such as naming feelings, tolerating frustration, or telling fantasy from reality.
  2. Act as a developmental object. Model and label mental states, help regulation, and support play that is just beyond the child's level.
  3. Use interpretation sparingly, and only when the capacity to use it is present.
• Example language (illustrative): "Your body's going fast. Let's see if we can slow it down together, then we can think about what made it speed up."
• Watch for: Drifting into teaching or coaching without understanding the child. It is working when the child shows the capacity independently, in sessions and in reports from home and school.

[K] K1. The playroom setting

• Purpose / when: Set up before treatment begins. It gives a stable, simple, robust space where the child can express aggression and mess without damage that matters. [source: Klein 1955, content from recall [uncertain]; inflibnet chapter (simple room, sink with taps, non-illustrative materials)]
• Steps:
  1. Use the same room every time, sparsely furnished: a washable floor, running water or a basin, a simple table and chairs, a small couch or cushions. Klein moved from the child's home to her own room for this reason.
  2. Remove anything breakable or personal.
  3. Keep sessions at the same time and length, and start and end on time.
• Example language (illustrative): "This is our room. We'll meet here at this time on these days."
• Watch for: Changes to the room or interruptions. Expect these to appear in the material (see K6).

[K] K2. The individual toy drawer (or box)

• Purpose / when: From the first session. It gives each child private, simple materials that can stand for many people and situations. The drawer itself becomes part of the transference: it is looked after or attacked, and it is a container. [source: Klein 1955 [uncertain]; Edwards, Five Books (Klein's toy box); Renn summary (small toys, male and female figures)]
• Steps:
  1. Provide small, non-mechanical toys: small human figures of different sizes (adults and children) that are not tied to particular occupations, animals, cars, trains, fences, bricks, cups. Add paper, pencils and crayons, scissors, string, a ball, plasticine and glue.
  2. Keep each child's toys in their own drawer or box, used only by that child and the analyst.
  3. Keep the child's drawings and productions in the drawer between sessions.
  4. Do not replace broken toys automatically. The damage and the child's response to it (guilt, wish to repair) are material to work with [uncertain: Klein 1955 discusses broken toys and reparation; recall].
• Example language (illustrative): "These are your things for our time together. Nobody else uses them. They'll be here waiting for you."
• Watch for: How the child treats the box: checking it, hoarding, emptying, contaminating, or worrying that other children have touched it. Each is transference material.

[K] K3. Opening without a preparatory phase: interpreting from the first session

• Purpose / when: In the first sessions. Klein argued, against Anna Freud's introductory phase, that early interpretation of anxiety, including negative transference, establishes the analytic situation more securely than winning the child over. [source: Klein 1927 Symposium, via Montaut; Cottone 2014 abstract (controversy over introductory phase, transference, parents)]
• Steps:
  1. Show the child the room and the drawer. Say briefly why they are there, in terms the parents have agreed, and that the child may play and say anything.
  2. Observe the first play sequence and any inhibition, shyness or anxious behaviour.
  3. When anxiety is evident, make a short interpretation linking the play or behaviour to a feeling about you or about being here.
  4. Watch the response. Klein's test is reduced anxiety and resumed or deepened play.
• Example language (illustrative): Child stands frozen by the door: "Perhaps you're frightened of what I might do to you in here, like the lady at the doctor's."
• Watch for: Over-long or theory-laden interpretations. It is working when the child moves into the room, plays, or adds to the theme.

[K] K4. Play as free association: observing sequence, repetition and interruption

• Purpose / when: Continuously. Treat everything the child does (play, drawing, talk, movement, use of the room, toilet trips, attacks on objects) as associations whose sequence carries meaning. [source: inflibnet chapter citing Klein (play as "substitute for the free association"); Klein 1955 [uncertain]]
• Steps:
  1. Watch which figure does what to which, what follows what, what is repeated, and where the play stops.
  2. Treat a sudden stop, a change of activity or a request for the toilet as a sign of anxiety at that moment.
  3. Link the current sequence to earlier sessions and to what you know of the child's life.
  4. Write detailed notes after the session, in sequence (see C4).
• Example language (illustrative): "The little car keeps getting pushed off the road just as it reaches the house."
• Watch for: Play inhibition (the child cannot play) is itself the first thing to understand and address (see K8).

[K] K5. Interpreting anxiety at the point of urgency (depth and timing)

• Purpose / when: At the moment the most pressing anxiety shows. The interpretation names the unconscious phantasy and anxiety directly, in the child's own vocabulary, including aggressive and Oedipal content. [source: Renn (Klein spoke directly; "anxiety–interpretation–response"); Klein 1927 "probe the Oedipus complex to its depths" via Montaut; "point of urgency" Klein 1932 [uncertain]]
• Steps:
  1. Find the play element that carries the most feeling at that moment.
  2. Say what the figures seem to be doing and feeling.
  3. Name the phantasy: who is attacking or damaging whom, and what the child fears in return (retaliation, loss, guilt).
  4. Link it to the people it stands for (parents, siblings, the baby inside mother) and, where the material supports it, to you.
  5. Use the child's own words for body parts and actions.
  6. Check the effect: relief, new material, or a change in the play confirms it. Increased anxiety or a stop means re-thinking.
• Example language (illustrative): "The daddy and mummy dolls are in bed together and the little one has smashed the bed. Perhaps you feel very angry that they are together and you're left out, and then you're frightened they'll be angry back."
• Watch for: Interpreting from theory rather than from material. Klein's criterion is the child's response, not your conviction. [synthesis: in contemporary use, calibrate depth to the child's ego strength; see C6]

[K] K6. Interpreting the transference, negative as well as positive

• Purpose / when: From the start and throughout, particularly around beginnings and ends of sessions, weekends, breaks, lateness and other children. Klein aimed at "analysing consistently the negative as well as the positive transference" (Klein 1961, via Montaut).
• Steps:
  1. Notice how the child treats you and the setting: suspicion, seduction, contempt, attempts to control, attacks on the box.
  2. Link play figures to you when the material points that way, for example a mean teacher figure appearing after a break.
  3. Name hostility and fear of retaliation directly, without retaliating or reassuring.
  4. Prepare for weekends and breaks, and expect, then interpret, reactions to them.
• Example language (illustrative): "You've made me the policeman who locks the boy up. I think you feel I locked you out all weekend."
• Watch for: Collusion with idealisation (only positive transference interpreted). Lasting negative transference that never gets interpreted, which undermines attendance.

[K] K7. Taking the roles the child assigns

• Purpose / when: When the child casts you in their play. It lets the child externalise internal figures and relationships, which can then be understood. [source: Edwards, Five Books (Klein accepted roles such as "naughty dog or monster mummy"); inflibnet chapter (therapist as naughty child to child's strict teacher)]
• Steps:
  1. Accept the role within limits of safety and decency. Play it simply, without adding your own drama.
  2. Notice what it feels like: humiliated, frightened, bossed about.
  3. Interpret from inside or after the role what the child may be showing about how they are treated, or how they treat themselves.
• Example language (illustrative): (as the naughty child) "I'm in trouble again and I don't even know what I did." Then: "Maybe that's how it feels for you at school."
• Watch for: Roles that require physical intimacy, real hurt or humiliation beyond pretend. Step out of the role, set a limit, and interpret (see K9).

[K] K8. Working with play inhibition and the older child (latency and puberty)

• Purpose / when: Latency children are often inhibited, controlled and repetitive in play. Adolescents are more verbal. Klein described adjusting the medium while keeping the same interpretive aims. [source: Klein 1932, Psycho-Analysis of Children, chapters on technique in latency and puberty [uncertain]]
• Steps:
  1. Treat inhibition as defence against anxiety, and interpret the anxiety behind the reluctance to play.
  2. Offer drawing, cutting out, writing, board games or conversation as the medium. Treat these too as associations.
  3. With adolescents, use talk more as with adults, and keep play material available.
• Example language (illustrative): "You want to keep everything tidy and in order in here. Maybe you worry about what might come out if you let things get messy."
• Watch for: Repetitive, joyless games that function as a wall. Interpret their function rather than just playing along indefinitely.

[K] K9. Limits on aggression

• Purpose / when: When the child attacks the analyst, the room or themselves. Klein allowed aggression to be expressed in play and against toys, but not physical attacks on the analyst [uncertain: Klein 1955, recall]. Limits protect the setting and the child from guilt and fear of retaliation.
• Steps:
  1. Stop physical attacks on you or dangerous behaviour, briefly and calmly.
  2. Interpret the anxiety or phantasy behind the attack.
  3. Offer a symbolic outlet: hitting a cushion, making a drawing, or a game with figures.
  4. If it continues, end that activity or, rarely, the session, and say it will continue next time [synthesis].
• Example language (illustrative): "I won't let you hurt me. I think you're scared that if you get very angry with me, something terrible will happen to both of us."
• Watch for: Escalation when limits feel like retaliation. Reaching for reassurance or punishment instead of understanding.

[K] K10. Contact with parents (Kleinian stance)

• Purpose / when: At intake and as needed. Klein gathered history from the mother before starting with Richard (via Montaut), but kept the analyst out of an educating or advising role. She sought parental support for regular attendance. [source: Montaut; Klein 1927 Symposium (against combining analysis and education); Klein 1932/1955 [uncertain]]
• Steps:
  1. Take a history from the parents at the outset.
  2. Agree on attendance and how to manage practical communication.
  3. Avoid educational advice from the child's own analyst. Where guidance is needed, today this goes to a separate parent worker (see C2) [synthesis].
• Example language (illustrative): "It'll help most if you bring him regularly, even when he doesn't want to come. That reluctance is part of what we work on."
• Watch for: Parents feeling shut out, which is a common reason for premature ending.

[K] K11. Using drawings and continuous series (Richard model)

• Purpose / when: With children who draw readily. A series of drawings over many sessions (Richard's maps and drawings of ships and empires) carries an evolving phantasy that can be followed. [source: Narrative of a Child Analysis 1961, via Edwards ("Empire of Mum") and Renn (ships representing parents)]
• Steps:
  1. Keep all the child's drawings in the drawer, in order.
  2. Note recurring elements and how they change.
  3. Interpret the drawing as you would play, linked to the transference and the week's events.
  4. Refer back to earlier drawings when themes return.
• Example language (illustrative): "The red country keeps getting bigger and swallowing the small ones. Last week it was the blue country doing that."
• Watch for: Over-interpreting colours or shapes in isolation. Follow the sequence.

[C] C1. Psychoanalytic assessment of the child

• Purpose / when: After referral, before committing to treatment. It tests whether the child can use a psychoanalytic relationship, gives a first formulation, and decides frequency, setting and parent work. [source: Rustin & Quagliata (eds) 2000, Assessment in Child Psychotherapy [uncertain]; UEL/Tavistock spec (CAMHS setting, multidisciplinary teams)]
• Steps:
  1. Meet the parents first (and the network if social care is involved). Clarify the referral question and consent.
  2. Offer about 3–4 sessions with the child in the same room, at the same time, with a simple box of toys (C3) [uncertain re number].
  3. Observe how the child separates from the parent, uses the materials, relates to you, and responds to trial interpretations.
  4. Note your countertransference (C5).
  5. Feed back to the parents, and to the referrer with consent, as an understanding plus a recommendation: individual therapy (once-weekly or intensive), parent work, family work, or another service.
• Example language (to child, illustrative): "We'll meet a few times so we can both get a feel for whether talking and playing here could help with the worries."
• Watch for: Responsiveness to interpretation, which favours treatment. Severe environmental instability (placement about to change) may mean the network needs to settle first.

[C] C2. Parent work by a separate clinician

• Purpose / when: In parallel with most child treatments. It supports attendance and the parents' own understanding of the child, and works on how the parents' history and current difficulties shape the parenting. It protects the privacy of the child's sessions. [source: UEL spec ("Work with parents" seminar; family interventions); ACP book listing on work with parents and families; Rustin 1998/2000 and Tsiantis et al. 2000, Work with Parents [uncertain]]
• Steps:
  1. A colleague (a child psychotherapist or other CAMHS clinician) meets the parents, often fortnightly to monthly [uncertain].
  2. The aims vary: support for the child's treatment; consultation about specific behaviour; or exploratory work on the parents' own experience of being parented.
  3. The child's therapist and the parent worker meet regularly. They share understanding, not session detail.
  4. Hold periodic reviews with the parents and both clinicians.
• Example language (parent worker, illustrative): "You've said the bedtime battles leave you feeling like your own mother. Could that be making it harder to stay calm with him?"
• Watch for: Splitting between the two clinicians (one idealised, one blamed). Parents using the parent sessions to get information about the child's sessions.

[C] C3. Setting and the toy box (current practice)

• Purpose / when: Before treatment begins and throughout. It is the modern form of Klein's drawer (K1–K2). [source: Edwards, Five Books; Klein 1955 [uncertain]; Lanyado & Horne (eds) 2009, The Handbook of Child and Adolescent Psychotherapy [uncertain]]
• Steps:
  1. Give each child a lockable box, with their name on it if they wish. Contents: a small family of figures (adults and children), wild and domestic animals, fences, vehicles, bricks, plasticine, paper, crayons, pencils, scissors, glue, sticky tape, string, a ball.
  2. Use the same room, time and length. Begin and end on time.
  3. Use a calendar to mark breaks.
  4. Explain confidentiality and its limits to the child at the start (see C8).
  5. Keep the room free of other children's materials.
• Example language (illustrative): "This box is just for you and the things you make here. I'll keep it safe till next time."
• Watch for: Ruptures in the setting (a room change, lateness), which are often worth taking up as transference material.

[C] C4. Observation and process recording

• Purpose / when: After every session. It preserves the sequence of play and interaction for reflection and supervision. It comes from the Tavistock infant-observation method. [source: UEL spec (pre-clinical observational course; "observing, recording and presenting clinical material"); Rustin & Emanuel (Tavistock repository); Bick 1964 [uncertain]]
• Steps:
  1. Do not take notes in the session.
  2. Soon afterwards, write the session in sequence: arrival, what the child did and said, what you said, and the child's response. Then note your own feelings.
  3. Bring the notes to supervision. Look for patterns across sessions.
• Example language: none. This is a clinician task.
• Watch for: Notes that summarise rather than record sequence. The meaning is usually in the order of events.

[C] C5. Using the countertransference

• Purpose / when: Throughout. It treats the therapist's feelings (boredom, despair, rage, protective urges, sleepiness) as possible communications of the child's unprocessed states. [source: Edwards, Five Books (Winnicott, "Hate in the Counter-Transference"); Heimann 1950 [uncertain]]
• Steps:
  1. Notice the feeling.
  2. Ask whether it is yours (personal analysis and supervision help with this) or induced by the child.
  3. Use it to shape your understanding, and occasionally name it in terms of the child's experience. Do not disclose it as your own.
• Example language (illustrative): (feeling useless) "Maybe in here you want me to know what it's like to feel nothing you do is good enough."
• Watch for: Acting on the countertransference: rescuing, punishing, extending sessions, giving gifts.

[C] C6. Levels of interpretation for different children

• Purpose / when: With deprived, traumatised, autistic or very disorganised children who cannot use explanatory ("because") interpretations yet. [source: Alvarez 1992, Live Company; Alvarez 2012, The Thinking Heart [uncertain]; Edwards (Alvarez reconsidering play and idealisation)]
• Steps:
  1. Explanatory level: links the play to the reasons behind it (classical K5 and A6). Use when the child can hold two ideas.
  2. Descriptive level: names the experience or state without explaining its cause. Use when the child is just beginning to symbolise.
  3. Intensified, vitalising level: draws attention to and amplifies any spark of interest or contact. Use with withdrawn or very flat children.
  4. Move up a level as capacities grow.
• Example language (illustrative): Descriptive: "You really want that tower to stand up." Vitalising: "Oh, you looked at me then!"
• Watch for: Interpreting defences that are actually developmental achievements (Alvarez's point on idealisation) [uncertain].

[C] C7. Breaks and endings

• Purpose / when: Before every holiday break and at termination. It lets the child work through separation, anger and loss in the transference rather than act them out. [source: Klein 1961 (Richard's analysis ending, via Montaut and Renn) [uncertain]; current practice [synthesis]]
• Steps:
  1. Announce breaks several weeks ahead and mark them on a calendar.
  2. Interpret reactions as they come: lateness, attacks on the box, sudden "I don't need this".
  3. For termination, agree the ending date with the parents and the network well in advance (months for long treatments) [synthesis].
  4. Review the work with the child, with drawings and toys.
  5. Agree what happens to the box. Some services let the child take a few things; others keep everything [uncertain: practice varies].
• Example language (illustrative): "There are three more times before the holiday. I think you might be wondering if I'll still remember you."
• Watch for: Symptom recurrence before the end. This is usually a separation reaction, not failure.

[C] C8. Safeguarding and confidentiality

• Purpose / when: At assessment and whenever risk arises. It protects the child, and keeps therapy within the law and professional codes. [source: UEL spec ("legal framework affecting children and young people"); ACP Code of Ethics and UK statutory guidance (Working Together to Safeguard Children 2023) [uncertain]; steps are [synthesis]]
• Steps:
  1. At the start, explain confidentiality and its limits to the child and the parents in simple words.
  2. If a child discloses abuse, or the play strongly suggests current harm, listen and do not interrogate or lead. Record the child's own words and actions verbatim, with date and time.
  3. Tell the child what you will do next.
  4. Consult your designated safeguarding lead the same day. Follow local procedures, including referral to children's social care or the police where indicated.
  5. Do not investigate yourself. Distinguish phantasy content (sexual or violent play is common and not evidence on its own) from indicators of current harm: specific details, sexualised behaviour toward you, injuries, fear of going home.
  6. Self-harm or suicidal ideation: carry out a structured risk assessment according to your service's protocol and NICE guidance, and involve the parents and the CAMHS team.
• Example language (illustrative): "What you say here stays between us, unless I'm worried you or someone else isn't safe. Then I'd need to tell people who can help, and I'd tell you first."
• Watch for: The analyst's wish to protect the therapy over the child. Collusion with secrecy. Over-reading symbolic play as disclosure.

[C] C9. Network liaison

• Purpose / when: For looked-after children, children with school or social-care involvement, and multi-agency cases. It helps the network understand the child and protects the conditions for treatment: stable placement, transport, attendance. [source: UEL spec (multidisciplinary teams; communication with allied professionals); Edwards (Lanyado & Horne on looked-after children); Boston & Szur 1983, Psychotherapy with Severely Deprived Children [uncertain]]
• Steps:
  1. Agree with the parents and carers (and the child, at an appropriate level) what will be shared.
  2. Attend or write to network meetings with formulations and recommendations rather than session content.
  3. Advocate for stability of placement and attendance.
• Example language (to network, illustrative): "He tends to test new adults by being rejecting. That's a sign of how much he expects to be dropped, not that the placement isn't working."
• Watch for: Over-disclosure. Being drawn into the network's splits.

Historical note: dual relationships (no steps; describe only)

Both founders practised in ways now regarded as boundary violations. Klein's early analytic work included analysing her own children; this is documented in Grosskurth 1986, Melanie Klein: Her World and Her Work [uncertain]. Anna Freud was analysed by her own father, and she treated children of a family she lived and worked with [uncertain: secondary biographies]. The stated rationale at the time was that analysis was new and child analysis was being discovered. The documented harm is contested in biography rather than established. Current limit: never treat your own children, relatives, or children in families you have personal, financial or social ties with. Follow the ACP and BPC codes of ethics.

5. Handling problems

Guidance below is tagged by source. Much of it is the guide's own [synthesis] from the founders' principles, because the primary texts deal with technique more than troubleshooting.

The child refuses to come in or to separate from the parent

• [AF] Treat it as a lack of motivation and build trust: follow the child's interest, and be useful and interesting (A3). [source: A. Freud 1926]
• [K] Interpret the fear of the analyst and of separation right away, at the door if needed (K3). [source: Klein 1927 via Montaut]
• [C/synthesis] Let the parent come into the room for the first sessions, and talk about the gradual separation. Interpret the anxiety in the transference, and agree a step-by-step plan with the parent.

The child won't play, is silent or repetitive

• [K] Interpret the inhibition itself as anxiety (K8). [source: Klein 1932 [uncertain]]
• [C] Use a descriptive level (C6). Comment on what the child does with their body and eyes. Tolerate the silence and track your countertransference (C5). [source: Alvarez [uncertain]]
• [synthesis] For repetitive games, take up the function of the repetition ("keeping things the same so nothing surprising can happen").

Resistance and negative transference (hostility, contempt, "this is stupid")

• [K] Interpret it early and consistently as fear or anger directed at the analyst (K6). [source: Klein via Montaut]
• [AF] Deal with it promptly to restore a positive tie, and analyse it as a defence (A6, A8). [source: A. Freud via Montaut]
• [synthesis] Do not punish or appease the child. Check for real-life triggers (a break, a new sibling, a placement change).

Overwhelm: escalating aggression, mess, panic, dysregulation

• [K] Set a limit on physical attacks and interpret the anxiety behind them (K9). [uncertain]
• [AF/C] Move to developmental help: regulate first, interpret later (A10, C6). [source: Edgcumbe; Alvarez [uncertain]]
• [synthesis] Remove dangerous materials. Shorten, or end, a session only as a last resort, and say when you will see the child next. Review with the parents whether frequency should rise (often more containing) or fall.

Non-attendance, lateness, early ending by parents

• [AF] Clarify the contract with the parents at the outset (A1). Unclear parental agreements can wreck a treatment. [source: A. Freud 1926 p. 8]
• [C] Strengthen parent work (C2). Explore the parents' ambivalence, rivalry with the therapist, and practical obstacles. [synthesis]
• [synthesis] Interpret missed sessions with the child as material, but don't blame the child for adult decisions. If an ending is imposed, ask for a few planned ending sessions rather than an abrupt stop.

Rupture in the relationship (a perceived betrayal, a holiday, or a safeguarding referral the child resents)

• [K/C] Interpret the feeling of being abandoned or betrayed in the transference (K6, C7).
• [synthesis] After a safeguarding action, explain plainly what you did and why, acknowledge the child's anger, and keep the setting going as normal. Treat the reliability of the next session as part of repair.

Parents ask what the child said, or want the therapist to discipline the child

• [AF/K/C] Restate the agreement. Offer understanding in general terms through the parent worker (A9, C2, K10). [synthesis]

Sexualised play or behaviour toward the therapist

• [K] Oedipal and sexual phantasies are part of normal analytic material and can be interpreted in words. [source: Klein 1927 via Montaut]
• [synthesis] Stop any physical sexual contact at once, and interpret the anxiety in words. Assess whether this is phantasy or a sign of abuse (C8), and consult the safeguarding lead. Write it up carefully and take it to supervision.

Gifts, food, wanting to take toys home, wanting to extend sessions

• [K] The non-educative, non-gratifying stance holds: understand the wish rather than gratifying it (K2). [uncertain]
• [synthesis] Small gifts at endings or festivals can be accepted and thought about. Keep the box in the room.

Divided theory: which version to use

• [synthesis] Most UK training now combines the two. Kleinian attention to transference and phantasy is used alongside Anna Freudian attention to development, defence and parents. Use Anna Freudian developmental help (A10) and descriptive interpretation (C6) for children with deficits. Use deeper Kleinian interpretation for children who are anxious but symbolising well. Tell your supervisor which version you are following for each case.

Self-harm or suicidal ideation (older children, adolescents)

• [synthesis] Follow your service's risk protocol and standard structured risk assessment (C8). Work with the parents and the CAMHS team. Continue analytic work around the risk rather than in place of risk management.

Sources

Pages actually opened

• A. Freud, The Psycho-Analytical Treatment of Children, first lecture and preface (PDF, SPSI)
• Montaut, Anna and Melanie and Richard and Hans (IAHIP)
• Renn, Klein Case Study (TherapyRoute)
• Edwards, Five Books (Tavistock and Portman repository)
• Priya, Play therapy: Melanie Klein's approach (INFLIBNET)
• Developmental lines (Wikipedia)
• Hampstead Child Therapy Courses (Freud Museum London)
• Programme specification: Psychoanalytic psychotherapy with children, parents and young people (UEL/Tavistock)
• Cottone, Controversies on the beginnings of child psychoanalysis (abstract)
• ACP: Work with parents and families (book listing) [listing only]

Further reading (cited from the published works)

• Freud, A. (1927/1946). The Psycho-Analytical Treatment of Children. London: Imago.
• Freud, A. (1936). The Ego and the Mechanisms of Defence. London: Hogarth.
• Freud, A. (1965). Normality and Pathology in Childhood: Assessments of Development. New York: International Universities Press.
• Klein, M. (1927). Symposium on child-analysis. International Journal of Psycho-Analysis, 8.
• Klein, M. (1932). The Psycho-Analysis of Children. London: Hogarth.
• Klein, M. (1950). On the criteria for the termination of a psycho-analysis.
• Klein, M. (1955). The psycho-analytic play technique: its history and significance. In New Directions in Psycho-Analysis. London: Tavistock.
• Klein, M. (1961). Narrative of a Child Analysis. London: Hogarth.
• Sandler, J., Kennedy, H. & Tyson, R. L. (1980). The Technique of Child Psychoanalysis: Discussions with Anna Freud. London: Hogarth.
• Burlingham, D. et al. (1955). Simultaneous analysis of mother and child. Psychoanalytic Study of the Child, 10.
• Edgcumbe, R. (2000). Anna Freud: A View of Development, Disturbance and Therapeutic Techniques. London: Routledge.
• Hurry, A. (ed.) (1998). Psychoanalysis and Developmental Therapy. London: Karnac.
• Rustin, M. & Quagliata, E. (eds) (2000). Assessment in Child Psychotherapy. London: Duckworth.
• Tsiantis, J. et al. (eds) (2000). Work with Parents: Psychoanalytic Psychotherapy with Children and Adolescents. London: Karnac.
• Boston, M. & Szur, R. (eds) (1983). Psychotherapy with Severely Deprived Children. London: Routledge.
• Alvarez, A. (1992). Live Company. London: Routledge. Alvarez, A. (2012). The Thinking Heart. London: Routledge.
• Lanyado, M. & Horne, A. (eds) (2009). The Handbook of Child and Adolescent Psychotherapy (2nd ed.). London: Routledge.
• Bick, E. (1964). Notes on infant observation in psycho-analytic training. IJP, 45.
• Heimann, P. (1950). On counter-transference. IJP, 31.
• Grosskurth, P. (1986). Melanie Klein: Her World and Her Work. New York: Knopf.
• HM Government (2023). Working Together to Safeguard Children.