A therapist about the treatment of a child
Helene Bonnaud is a child analyst and therapist who practices in Paris. The following case study is a close rendering of a case from her book ‘The Child’s Unconscious’ (L’inconscient de l’enfant.’) I am summarizing it here as it can give a sense a better sense of psychoanalytically oriented therapeutic work with children.
Sarah
Sarah just turned three. She does not move, does not speak, does not play. At the moment of the consultation she has been in treatment with an occupational therapist, and has received diagnoses of infantile psychosis and autism.
During her first encounter with Sarah, Helene Bonnaud remarks that although Sarah does not look at her (a symptom often understood as indicative of autism), she seems to ‘avoid’ her gaze (indicating she is aware of the gaze). Sarah seems also very present and attentive to what the father and the analyst are talking about. Based on this initial presentation, Helen Bonnaud thinks that the diagnosis of autism is not warranted.
Sarah is the youngest of 3. The oldest sibling, a boy, died at a very young age, which was a great loss for the parents. The second child, a girl, anxiously anticipated after the loss of their first child is doing very well. When Sarah was born, the parents were less worried. She was a quite child, posing no problems. She ate well, slept well. The only complaint the parents might have had was that she did whine and moan quite a bit. At the moment of the first meeting the father is still in shock after an incident that happened the week before: Sarah had fallen out of bed and had broken her petrous bone. This incident had reactivated the anxiety connected with the loss of the first child. She was hospitalized for 3 days and recovered well. In the hospital the nurses were impressed with the fact that Sarah had been so ‘courageous.’ Unlike a typical child her age: she did not cry, did not complain a word.
At the time the parents come to consult for Sarah they are going through a divorce. The mother is planning on moving back to her native town in the south of France where she already spends part of the week. She leaves Paris on Sunday night and returns a couple days later on Tuesday night. On Wednesday morning she accompanies Sarah to her appointment with Helene Bonnaud. ‘Going to see Ms. Bonnaud’ takes on the function of a desire for the mother, and this is crucial. At the level of needs/requests there is a certain level of reciprocity (I ask, you give). However, it is essential that beyond this level of ‘needs that want to be met’, another dimension shines through: the dimension of what the other ‘desires.’ It is because the mother has been able to formulate a demand that is not just that Sarah eats well, becomes potty trained, sleeps well, looks cute, but a demand that we call desire, that the analytic work has been able to allow for Sarah to encounter this desire of the other.
After several months Sarah is not mute anymore and starts talking to Helene Bonnaud, who is surprised that one day she calls her ‘Madame Bonnaud-lyste.’ Every week Helen Bonnaud gives Sarah an appointment card which she puts with pride in her pocket. She is very proud of this as her mother has also a card of ‘Madame Bonnaud-lyste.’
So, for Sarah the moment when her mother returns home, is in syncwith the rhythm of her weekly sessions. The appointment card, with the name of her analyst, lends itself to a little game: it becomes a train ticket for Marseille, the city of her mother. And it is very entertaining for Sarah to discover all the things one can do with it… She leaves, returns, she puts Helene Bonnaud in charge of selling the tickets, and slowly assigns her the role of the mother who buys the tickets to leave. By way of this play she starts to symbolize the absence and presence of the mother. This is an essential operation for the child, as it gives meaning to the absence and as it allows to situate this loss or separation in a back and forth movement: the object will return after she leaves.
After 10 months of therapeutic work Sarah is transformed. She speaks well and learns easily. She is lively, and determined which surprises her environment. Although at times she can still be withdrawn and a bit sad, or ill at ease.
When she moves to Marseilles, she understands that leaving is taking the train and that there is always a back and forth. She knows that her mother returns, that her father comes and goes, that traveling is like the analysis, one puts one’s name on a ticket and that means ‘see you tomorrow.’
The treatment of Sarah concerned the want for a presence and absence. The weekly sessions, combined with the coming and going of the mother allowed to symbolize something that had not been symbolized. In fact the birth of Sarah had reactualized the mother’s loss of her first baby, a boy. Unconsciously she felt guilty to not have been able to replace the lost boy. To be able to give another boy to her husband would have reduced the mourning for their first child. Sarah’s wants were left unanswered, and she became a child that did not manifest itself. This absence of a demand in the child was a response to the mother’s sadness, which took form as a failed love. It was impossible for the mother to invest the girl, as her tainted desire left her in sadness.
On top of this, because of the separation with her husband she felt abandoned as object of desire and she only saw her life as characterized by loss and abandonment. Sarah literally ‘filled’ this loss.
There are two types of want: the want for an object – a need, and the want for love, which is not a wanting of a specific object but a wanting for ‘nothing,’ a wanting for being addressed by the other. Why call this ‘nothing?’ It names what cannot be given, what cannot respond with a ‘filler-object’ to the want of the child. It is of the utmost importance for the child that there is ‘room’ for this ‘nothing’ in the way that one responds to a child’s wants. When the mother responds to each and every cry by giving to eat, or to drink, she establishes a response that excludes ‘lack’ and which can have as a consequence that the child cannot tolerate frustration.
Hélène Bonnaud: ‘L’Inconscient de l’Enfant. Du symptôme au désir de savoir.’ Navarin. Le Champ Freudien, 2013.