BOOK REVIEWS
to address the child saying how her mother_s illness was hard mentalizing. It is not surprising that group therapy turns into
for everyoneVBmummy, daddy and baby[ (p. 75). Not only
did the therapist link the feelings of the family triad, she
engaged the baby_s sound as meaningful to the moment and
in doing so made the depressed mother aware that her child
had meaningful intentions to contribute in the same way that
she shared her story and feelings.
Out of the mentalizing stance flow many of the concepts
and techniques that compose the parent Yinfant psycho-
therapy outlined by the authors, members of the Anna Freud
Centre group. These techniques include scaffolding, repre-
senting the infant_s mental states, mirroring affective states,
and modeling. In the above example, the therapist served to
scaffold the baby_s communication when she engaged the
baby directly; she recognized, labeled, and structured her tiny
sound ahead of her capacity to do so. The therapist repre-
sented it as a meaningful communication to her parents using
emotional language. Obviously, the words the therapist said
would be meaningless to the infant, but by expressing interest
and mirroring the baby_s affective state, the therapist
validated her contribution as a separate person in the family
triad. Finally, the therapist modeled a mentalizing interaction
to the parents by treating the child as having something
meaningful to say.
As the case progressed, the therapist_s psychodynamic
formulation that the mother_s depressed withdrawal was
related to unresolved conflicts with her own mother came to
fruition in later sessions. This resolution points to an
important aim of parent Yinfant psychotherapy: the therapist
becomes a Bghostbuster[ by attempting to interrupt the
negative intergenerational patterns that hinder a positive
attachment between mother and child. Most efficacious in
banishing the ghosts in the nursery is linking a parent_s
maladaptive relationship in the past with how she repeats the
pattern in the here and now of the therapeutic session. If a
mother understands that she is treating her infant in the same
way she experienced being poorly treated by her own mother,
then that knowledge may engender change.
The termination phase of parentY infant psychotherapy
begins when the therapist believes the parent_s developing
mentalizing capacity can beneficially influence the develop-
ment of the infant into secure attachment and individua-
tion. Although this therapy works primarily with mothers
and infants, an important task is to keep the Bpresent
absence[ of the father in mind. The therapist must address
the mother_s thoughts about her partner as well as the
developing infant_s representations and fantasies about who
Bfather[ is.
The authors also introduce analytic group therapy among
mothers and infants, providing a Bhall of mirrors[ in which
the emotional state of the infant can be reflected, not only by
the therapist but also by other mothers in different stages of
J. AM. ACAD. CH ILD ADOLESC. PSYCH IATRY, 45:7, JULY 2006
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
a drama approximating that of a family. However, the real
surprise is that this much theory and techniques on
parentY infant psychotherapy can be introduced elegantly
in one slim volume. The authors are skilled in their ability to
make complicated theory accessible, lively, and down to
earthVespecially considering the Breal-world[ settings in
which they engage mothers and infants. Whether or not child
therapists work with patients in this kind of therapeutic
setting, this volume provides an invaluable guide to
observing, understanding, and intervening in the emerging
relationship between parent and infantVand for considering
how the ghosts of past parenting re-emerge when parents
bring their baby home.
Prakash K. Thomas, M.D.
Linda Mayes, M.D.
Yale Child Study Center
New Haven, CT
DOI: 10.1097/01.chi.0000219825.85731.ec
Disclosure: The authors have no financial relationships to disclose.
Fraiberg S, Adelson E, Shapiro V (1975), Ghosts in the nursery: a
psychoanalytic approach to the problem of impaired infant-mother
relationships. J Am Acad Child Psychiatry 14:387 Y 422
Face to Face With Children: The Life and Work of Clare
Winnicott. Edited by Joel Kanter. London: Karnac Press,
2004, 294 pp., $35.00 (softcover).
Looking back, my earliest interest in child psychiatry
started with my fascination in the richness and depth of
childhood experiences. I still have deep impressions of the
earnestness and contentment of the jump rope group on the
second grade playground. Since I completed my training,
child psychiatry has changed a great deal and we have learned
much about the relationships between the architecture and
functioning of the central nervous system and adaptive
behavior and emotional regulation. Still, it seems important
that we maintain the connection to the world of children as
we integrate newer information into the biological Bhows[
and Bwhys[ that may well govern them.
Face to Face With Children, the Life and Work of Clare
Winnicott can help us to that end. Edited by Joel Kanter, this
book contains a memoir of this fascinating woman as well as
885
BOOK REVIEWS
a collection of her works. Clare Winnicott was a wife,
colleague, collaborator, and playmate to Donald Winnicott,
the famous pediatrician turned child analyst. Many people
will be drawn to this book by their interest in Donald (as I
was), only to find their encounter with Clare rewarding and
thought provoking in its own right. The memoir provides a
fascinating look at the story of these two perceptive and
talented individuals, with the good fortune to find each
other, set against the uncertainty of Britain before and during
World War II. These golden years also saw the intense
development of child analytic theory in London, through the
works of Anna Freud, Melanie Klein, and Donald Winnicott.
After graduation from the London School of Economics_
course in psychiatric social work, Clare sought work in the
Bhurly burly of what_s going on in the world[ (p. 15). She
became involved in the evacuation of children from London
during the Blitz, work that changed her life as well as Donald_s:
Clare_s work with evacuated children in Oxfordshire was the defining
experience of her life: not only did she meet Donald Winnicott, her
future husband there, but her talents as social worker emerged at a time
when Britain was undergoing a change in its child welfare policies and
programmes. The work of Clare and others during the war established
precedents that altered the course of children_s services for the half
century (p. 14).
However, over the years, Clare_s contributions in the fields
of social work and psychoanalysis have been largely subsumed
into her identity as Donald_s wife and editor. Kanter believes
that at least part of this is because of the straightforward
quality of Clare_s writings and lectures. Clare expressed
complex analytic ideas in the context of her experiences with
children and in plainspoken English, a Bclarity that can,
unfortunately, be dismissed as common sense[ (p. 62).
Personally, I found this refreshing and in keeping with the
idea of relating to children simply and directly, without
sentimentality or the burdens of professional jargon.
Two thirds of the book contains Clare_s collected writings,
starting with the problem of homeless children and her
experiences in Oxfordshire. Much of the content is relevant
today in terms of how to help large numbers of suffering
children, often displaced, and with scarce resources. Clare
and Donald evolve a system of working together that is
reminiscent of today_s treatment team concept. The social
environment was conceived of as a potential therapeutic
space, a Bholding environment[ of direct caregivers (foster
parents or hostel workers) acting as the Btherapists[ and
treatment team members. Clare put much thought into the
fit of the relationship between a child and the primary
caregiver working with that child, recognizing that not all
caregivers work equally well with all children. She put much
importance on the ability of the caregiver to be authentic and
886
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
mature enough to listen and hear the real communications of
the children, going beyond the obvious content. In her way
of thinking, when caring for a child, educational background
was not as important as the ability to let the child be himself
or herself, with all that this implies. This requires a caregiver
who can be himself or herself as well. These thoughts are just
as relevant today as we grapple with state departments of
children and families trying to ensure that children receive
the services they need and that the staff receive enough work
satisfaction to continue on with their hard work.
Clare Winnicott directs a significant amount of her
writing to the qualities and professionalism that allow people
to work in these areas successfully. One problem she
identifies is the problem of suffering in children and our
response to that suffering. In her 1963 essay BFace to Face
With Children[ (p. 166), she directly addresses our roles and
responsibilities to the children we serve. She states that the
expression Bface to face with children[ gives us
no possible loophole for escape from facing the nature of our
responsibilities for the children who are our clients. And if I am not
mistaken, brings us face to face with our own uncertainties, not only
about our techniques but about our role in relation to children (p. 167).
She suggests that one of the most important things we can
do is enter their inner worlds, accept their suffering, and
respond in a way that Bconveys our willingness to under-
stand[ (p. 172):
It seems to me that in work with children we are really trying to reach
the suffering in them arising out of their deprivations and handicaps.
Obviously we cannot force children to suffer, and some will not be able
to reach this point; all we can do is give them an opportunity to reach it
by being able to stand it ourselves and by believing in it. If we do not do
this nobody else will and the child will either be left with the burden of
it or will develop defences against all real feelings (p. 173).
With all of our current-day pressures of managed care,
brief therapies, and briefer residential and acute treatments, it
is easy to lose track of the inner child, solely focusing instead
on behavioral problems and outward family conflict. These
essays serve as reminders that suffering is real, at times
unavoidable, and that human relationships are complex and
messy and do not readily fit into neat categories.
Other essays in the book include reflections on Donald
Winnicott, his childhood, his life, and his work, as well as
the relationship between Clare and Donald. Clare describes
Donald as a man of playfulness and vitality. Despite the
war and their commitment to their work, their joyfulness
and celebration of life is apparent. Her love and respect for
him shine through in all of her writings about Donald
and his family. Donald grew up in a large active family.
His home was safe and secure with much space for play
and exploration. The family was financially prosperous.
J. AM . AC AD. C HILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006

Again, understanding Donald Winnicott_s own relational
history deepens our ability to understand his theories and
their evolution. In short, the Winnicotts sound like
fascinating people one would like to know and have over
for dinner.
There are essays on more psychoanalytic topics and spe-
cific case material. Examples of these include a description of
the treatment of a musician illustrating Winnicott_s theory of
the fear of breakdown; a child reunified with a large, possibly
overwhelmed family after a prolonged hospitalization for the
treatment of polio; a 17-year-old girl in foster care disturbing
hostel staff by taking a baby bottle filled with milk to bed
with her. Finally, there are essays on understanding the
possible motivations for taking on this type of work with
children and the professionals_ need for increasing self-
awareness to be truly present for the child. This book should
be interesting to child and adolescent psychiatrists, develop-
mental psychologists, psychoanalysts, and social workers, as
well as readers interested in the response to the problem of
displaced children in Europe following World War II. It is
well written and organized. The memoir is helpful in truly
understanding the context of the original writings. Reading
this book inspired me to order several volumes of Donald
Winnicott_s writings as well. I truly enjoyed reading it and
strongly recommend it.
Lynn Taylor, M.D.
Department of Psychiatry
Division of Child and Adolescent Psychiatry
University of Arkansas College of Medicine
Little Rock
DOI: 10.1097/01.chi.0000219825.85731.ec
Disclosure: The author has no financial relationships to disclose.
Raising an Emotionally Healthy Child When a Parent Is
Sick. By Paula K. Rauch and Anna C. Muriel. New York:
McGraw-Hill, 2006, 224 pp., $14.95, (softcover).
Chronic, life-limiting illness is a fact of personal, family,
social, and medical life in the 21st century, more so than at
any time. As the authors of this important, thoughtful,
straight-talking, and moving book tell us, 1.3 million adults
are diagnosed with cancer annually in the United States. Of
these, one in four is a parent of one or more children younger
than 18 years of age. At least 1 million more adults with
epilepsy, cardiovascular disease, and diabetes, and many
thousands with other chronic illnesses further contribute to
J. AM. ACAD. CH ILD ADOLESC. PSYCH IATRY, 45:7, JULY 2006
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
BOOK REVIEWS
the estimated millions of American children affected by
parental life-limiting disease.
Child and adolescent psychiatrists Paula K. Rauch and
Anna C. Muriel founded the Parenting at a Challenging
Time (PACT) Program at the Massachusetts General
Hospital in 1997, Brecognizing the concerns that parents
with cancer had about how to help their children cope during
the parent_s treatment with recognition that some parents
would not survive to see their children become adults.[
This is a book written for parents, either ill themselves or
living with an ill coparent, and is drawn from the authors_
years of direct clinical experience in this program.
As acute and often fatal infectious diseases such as
meningitis and pneumonia were conquered in the 1950s
and 1960s with vaccines and antibiotics, cancer, metabolic,
renal, and other noninfectious diseases took their place on the
wards of children_s hospitals. With the advent of life-limiting
pediatric chronic illness came a rich descriptive and emerging
empirical research literature on such topics as cognitive and
psychological development of concepts of death and dying,
psychotherapeutic and pharmacological interventions for ill
children and their families, pediatric pain management, and
the like. Rauch and Muriel break new and fertile ground by
turning what has become the standard psychosocial approach
to the medically ill child on its head, addressing instead the
psychological needs of children whose parents are seriously or
terminally ill. As such, they fill a crucial and heretofore
unfilled niche in the larger fabric of psychological under-
standing and approaches to intervention for this important,
previously underserved, and growing population of children.
Raising an Emotionally Healthy Child When a Parent Is
Sick exemplifies a bold approach to a unique and growing
population of children using what I would term Bapplied
child development.[ The first fourth of the book is devoted
to child development in the broadest sense, from infancy to
young adulthood. Using prose at once lucid, parent centered,
jargon free, and theory driven, each developmental period is
summarized not only from the point of view of the special
needs of children of ill parents at each stage, but in the context
of normal development. Indeed, principles of guidance to ill
parents and their partners as their children develop are drawn as
logical extensions of the fundamentals of normal development,
an impressive accomplishment in a relatively short chapter.
After laying a foundation in normal development,
subsequent chapters address in specific, informed detail
every conceivable issue, practical, behavioral, and psycho-
logical, apt to be encountered by an ill parent and/or his or
her partner. Earlier chapters are more global, such as BNew
Diagnosis: Organizing Your Support System[ and
BCommunicating With Your Child About the Illness,[
and later chapters more specific and brimming with
developmentally informed, practical wisdom. Has a chapter
887