A Glance (Or Insight) Into The Consultation Room: A Diagnostic And Therapeutic Co-Creation

Prof. Dr. med. Dieter Bürgin

A child offers a direct access into his internal world to a psychoanalyst, who is himself a former child still carrying that status in his representational universe.


The nearly ten-year-old patient, whom I will call Kevin, is a member of an intact and mostly well-functioning family. He has a brother who is approximately two and a half years younger. The parents complain that Kevin still had the same anxieties he presented with at our first meeting a few months ago. They mainly occurred at night and led Kevin to come into his parents’ bedroom, where he slept on a mattress at first, but then, later on, he mostly slipped into his parents’ bed. As a second problem they report that Kevin produced a variety of noises, some louder than others, until the other family members, especially the parents, could not take it anymore. 

What does this boy tell us with the symptoms just described? We do not know the unconscious forces of drives and defences that likely play a part in these mentioned particularities. At a mere descriptive level Kevin’s behaviour disturbs his parents’ intimacy, and by making noises he draws attention to himself within the family. Although as analysts we will probably already have developed ideas as to which motives and conflicts Kevin might be grappling with, holding back further understanding is called for until he will allow us more insight into his inner world. 

At the very beginning of our conversation Kevin explains that often he only pretended as if nothing touched him, while internally, things were totally different. He immediately accepts my calling this fact a protective mechanism. When I suggest that he may also not have shown his feelings upon the birth of his brother (when Kevin was about two and a half years old) he hesitates slightly before agreeing with me. 

Both patient and interviewer are getting to know each other in this bipersonal situation. The boy quickly shares with his interlocutor a particularity of his inner world: he is not the same externally and internally. To the outer world he presents himself as absolutely invulnerable while knowing internally that this is not at all the case. We could call this a splitting of the ego that he ‘invented’ at some point. He shows in the following that he can take in and make use of the interviewer’s interventions, that he acknowledges the protective character of this splitting of the ego, and that he is capable of sharing this perspective with his adult interlocutor. 

Without hesitation Kevin accepts my suggestion to continue with a squiggle game (Winnicott, 1973) in order to maybe get to know and understand more of his inner world.  
Squiggle 1
(My squiggle is black, the patient draws his figural completion of my squiggle in red.)
Kevin: “A person with weirdly floppy arms. He appears to be happy. It’s not clear what is neck and what is belly.” When I ask if it could also be something like a baby-onesie, laughing out loud, Kevin seems to be thrilled at the suggestion. 

Trustfully and quickly engaging in this ‘game’, the boy does not seem very anxious when communicating with an interlocutor he does not know very well yet. Leaning on, as it were, the figure the interviewer has drawn, Kevin is creating something new. Thus, the two protagonists have created an entirely new figure; between the patient and myself a mutually shared third has emerged. Kevin shows a clear emotional reaction (laughing out loud) to the idea of his adult interlocutor. (I probably had this idea remembering that Kevin was drawing attention to himself by making noises non-verbally and because of the image he had created). My intervention was completely spontaneous. Thereby, the patient learned his interviewer’s psychoanalytic method intuitively and without further explanations. 

Squiggle 2
(We maintain the same division of color throughout the session. I complete Kevin’s drawing)
Kevin: “A landscape with a ski-lift. A slope. Somebody has skied down. No people in sight, no chairs on the ski-lift. The house seems like a face.” The patient enjoyed skiing and was better at it than his brother.The father was the best at ski-jumping.

The interviewer completed the drawing without any conscious control. (It emerged from the first idea). Neither I nor the patient knew whether the image would lead us further and if so, where it would carry us. With ‘no people in sight’, the patient introduces his brother and his father, as well as the theme of rivalry and competition. The patient is better than his brother but worse than his father.

Squiggle 3
(Kevin is completing)
Kevin: “A flower like the one here, on the table.” I ask who might take care of it. The patient suggests: “A person — you!” I remark that he was good at copying but with his symptoms, he was actually also a little inventor. Thereupon, the patient adds “air and rain” to the drawing. I say: “There has been an atmosphere.” He then adds the ground to the drawing.

The scenery shifted into the consultation room and I am attributed with caring activities.  My intervention addresses the patient’s capacity for imitation as well as his creativity. His creating a context of “air and rain” I understand as an attempt at communicating something about the atmospheric quality of a memory-image. Therefore — with the addition of the ground — the drawing gains a sort of rootedness.

Squiggle 4
(I complete the drawing. The boy has a hard time recognizing the form, until suddenly, there is a moment of revelation.) 
Kevin: “The tongue in this face is very pointy. The teeth look like an M. He is screaming!” Me: “So he also makes noises like you.” Kevin: “He is angry at someone.” His brother retreated into his room when getting angry and even moved the bed in front of the door so that nobody could come in. Kevin himself never lost it like that and acted as if he didn’t care. He did the same thing at every threat of punishment. Sometimes he flipped his finger at his brother’s head who then acted as if the patient had hit him massively. Me: “You act as if nothing could harm you while your brother makes a mountain out of every  molehill.” Patient: “My little brother often tries to kick me with a ball. He never hits though, but I do!”

In spite of my completing his squiggle rather unskillfully, it nonetheless allows the patient to let me know about an acoustic communication (screaming). My linking this to his ‘vocal expressions’ lets the boy make an affective connection (‘he is angry’). He then reports two different conscious forms of processing aggression: his brother retreated while Kevin — thus exemplifying his initial statement — acted as if nothing had happened. He also acknowledges his minor aggressive acts towards his brother (flipping his finger at his brother’s head and kicking a ball at him). I gained the impression that we were now connecting intensely within a mildly positive transference and were moving close to preconscious material. 

Squiggle 5
(The patient completes the drawing)
Kevin comments: “This figure has big round feet, very long hair and a beard. It’s a woman-man, someone who’s neither woman, nor man, nor baby but probably a clown. Oh, I forgot the hands (and he draws giant hands). One hand has thirteen and the other one only five fingers. Its hair and skirt are female, its hands and feet are male. But men don’t have such long hair. Women drive faster than men. Women have a vagina and men have a weenie.” I ask: “And here?” Kevin: “That is and will remain unclear”. Me: “Certain Indian gods or goddesses have up to ten arms!”
Many times throughout the interview the patient reaches for his penis, as if to reassure himself that it was still there.

Now, completely unexpectedly, a strangely fantastical human figure develops that cannot be categorized by gender or age. With explicating further the patient shows me that he is aware of anatomical differences between man and woman. Nonetheless, the figure brings to expression something unclear that very much surprises me on the one hand and confuses me a little on the other. Apparently, Kevin attempts to reassure himself of his being intact bodily and sexually when encountering confusing internal images. He probably also wants to keep his interlocutorin a state of a certain confusion by using a defense that has taken the form of a resistance. The omnipotent triumph possibly masks narcissistic injury and helplessness that are connected to ‘still being a kid’ while wishing to be already grown-up and adult.  


The patient explains he was going to draw a picture by himself now, but it were not complete, yet. 

Spontaneous Drawing 6.
Kevin: “This figure consists of an upper and a lower part of the body. It also has a curled and giant tail/dick” [Translator’s note: In German the word for tail, ‘Schwanz’, is also a colloquial term for penis]. I ask: “Where is the intermediate part?” As a response Kevin includes it in the drawing (with an arrow) and says: “The still missing arm will be included here. He ties up his weenie/little tail in order to be able to walk”.

By altering my initial suggestion of procedure Kevin now decides to make a drawing by himself, i.e. he is excluding me. I ask myself for a moment if this primarily served a defensive function, but then I come to the conclusion that, in this moment, he can make better use of me as an observer. At first, there are omissions (belly, arm) that will be added quickly. The penis has become overlong and nearly bothersome. In the mode of primary process, figurative elements of ‘something missing’ and of ‘too much’ indicate phantasmatic activity that the patient reveals long before any detailed understanding of these figurations becomes possible. 

He then declares he was now going to draw a “real person”. And he immediately gets to work.

Spontaneous Drawing 7
Me: “That one has an even larger tail/weenie, or maybe even two?! That should cause even more problems in walking or strolling”. Hereupon, Kevin promptly explains that one can shove in the tail/weenie at the side of the body. (He adds a sort of sack to the loins, on the side). The person would then merely appear a little bigger.

Together, we are now both operating in Kevin’s fantasy world. Whatever impresses as too much can be tucked away and still remains visible in a different form (bigger). While the penis is now not just overlong but doubled, at the same time the person as a whole is ‘right’. [Translator’s note: In German the term for a ‘real’ person, used above, is the same as ‘right’  or ‘correct’].The individual whose gender and age we could not determine has turned into a hyper-phallic figure. I am under the impression that the patient has taken me on a little journey into a preconscious and phantasmatic realm of his self, as if a part of him wanted to help me deepen my analytic understanding.

Spontaneous Drawing 8
The patient copies a small orchid that is sitting on the small table in the office. And he adds he now would like to create two more squiggles (i.e. doing something together again).
Squiggle 9
(The patient completes my squiggle)
Kevin: “That one is fat. He also has a long neck and little stick legs.” Me: “It looks like a weenie and two balls on little legs.” Kevin: “He used to be a giant. His weenie and balls fell off, and also his head. It then became a new human. Me: You describe processes of ‘falling apart’ and ‘putting back together’”.

After an excursion into his archaic and phantasmatic inner world, the patient resorts to copying a plant sitting in front of both of us. He thereby flips, as it were, out of the figurative and scenic realm of his inner world into the shared perception of the outer world. At the same time, he divides our remaining time into two units that will once more follow the procedure (of creating together). This immediately leads us back into the realm of the phantasmatic creations of primary process. In this mode fragmentation and reintegration are connected with the male genitalia in such a way that castration would only be a temporary state, and Kevin can magically make disappear and reappear this area of utmost sensitivity in an omnipotent way. 

Squiggle 10
(I complete the drawing)  
Kevin: “Oh, a face with big eyes and a squashed mouth! The nose is connected to the eyes”. I am thinking of the scheme of the human face, as described by Spitz, that allows the infant between the third and seventh month of life to recognize another person as a ‘fellow human’. I say: “Those are the main features, according to which we can recognize another human”. 

It is only retroactively that I notice I had technically started the figure with a sort of mirror image (spiral) — by analogy to the patient’s completion of the first squiggle — that was then to form the eyes of the observer. This is apparently also connected to my intervention that stands in contrast to the contents of phallic genitality and addresses much earlier states of experience.

When I ask Kevin if he wanted to show the squiggles to his mother he says no. But I could talk about them. Excitedly, he goes to fetch his mother into the consulting room and I tell her that the patient had allowed me to get to know important things about him. The boy now takes all of the squiggles in his hand and specifically shows to his mom Squiggle 5, triumphantly remarking: “No man, no woman, no baby!” He then sits down on his mom’s lap — just like a baby  — and embraces her neck from behind. Afterwards, he spreads across her legs like a toddler. I say: “Therefore none of it, and at the same time, all of it!” Kevin, highly stimulated and nearly jubilating, says: “I can be anything, a man, a woman, a baby or a nothing!” And I  reply: “It’s great to be able to be anything in fantasy, when in reality, it’s difficult to ‘just’ be a ten-year-old boy who loves his mother a lot, competes with his dad, and, on top of that, feels a little bothered by his brother”. 

It is only upon conclusion of the dyadic situation and in presence of the mother that Kevin expresses his triumph of being able to defy any danger and to manage any conflict via omnipotent fantasies — first through his behavior and then in the form of a highly condensed verbalization.    

What do we learn from analytically working with children? As participants in the analytical process we can gain immediate insight into their preconscious inner world, both regarding its development and potential disorders. We, that is us who also have been children ourselves, and, while no longer having that status, we are still carrying those old relational representations in our inner world. 

In conjunction with primary and secondary processes and the figurations of infantile sexuality (especially regarding fantasies of the primal scene), perceptions, memories, future projects, scenic, emotional and cognitive creations as well as realizations of actions — altogether — form a complex three-dimensional structure which is constantly in flux. In order for this structure to develop and grow, children need relationships with adults. If we let ourselves being made use of and at the same time remain ourselves, we partake in basic developmental processes, simultaneously learning and teaching.
Winnicott D.W. (1971): TherapeuticConsultations in Child Psychiatry. London: Hogarth Press.

Translation: Dr Katharina Rothe