There are many occasions in clinical practice when the problem of what to do (within which I am including verbal 'doing'), as opposed to understanding the question of 'why', raises great uncertainty in the therapist. I suspect that work with children and adolescents is particularly difficult in this respect as often a great deal of the therapeutic process is embodied in the manner in which the basic boundaries of the therapy are established and maintained by the therapist, and then challenged by the patients. Particularly with very young patients, acting out adolescents and very deprived and fearful patients, the therapist's actions and body language are more likely to be listened to than their actual words. It can be argued that the therapeutic environment in which the therapy sessions themselves take place is as important in facilitating change as the other tools in the psychotherapist's clinical bag. This is the third strand in the total therapeutic relationship referred to in Chapter 1. These activities of the therapist in the real external world need to receive similar thought and scrutiny to the total transference relationship and the contents and quality of the psychotherapist's reverie.
The significance of the therapeutic environment in which therapy takes place is particularly evident when children and young people who need more help than they can get while living at home become members of residential therapeutic units and communities. Such units and communities vary a great deal in the philosophy and manner in which they work. A good number of them are based on psychodynamic principles. Some have child and adolescent psychotherapists on the staff and some of these therapists work directly with the children, while others work only with the staff dynamics (Ward et al. 2003).
1 Much of this chapter was originally published in 1991 as 'Putting theory into practice: working with perversion and chaos in the analytic process', Journal of Child Psychotherapy, 17(1):25-40. The ideas in the original article have been expanded somewhat in the context of this book.