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Publications: Book Reviews
Review of Child Therapy in the Great Outdoors: A Relational View

Title: Child Therapy in the Great Outdoors: A Relational View
Author: Santostefano, Sebastiano
Publisher: The Analytic Press
Reviewed By: Karen Zelan, PhD, Winter 2006. pp. 35-37

Sebastiano Santostefano�s charming book on the proper way to conduct child psychotherapy covers many pertinent issues that often arise in work with young children, and offers many rich theoretical ideas and promising therapeutic techniques. In taking issue with child psychotherapy conducted solely in the office, Santostefano recalls envisioning his �relational psychoanalytical� perspective when his supervisor advised him to analyze why he thought it therapeutic, or even wise, to accede to a child patient�s request to go outside. In contrast to �classical� psychoanalysis, relational psychotherapy champions �the ideas of interaction, participation, negotiation, mutuality, and enactment, concepts defining therapeutic technique in ways that provided me with tools to articulate my views of how child psychotherapy should be conducted and understood� (p. 4). Often citing Stern�s (l985) groundbreaking work on infant-parent attunement, the author likens the interaction between patient and therapist to the infant and his caregiver when he writes, ��principles of infant development can provide an heuristic guide for conducting child psychotherapy� (p. 3).

Santostefano delves into two clinical narratives of young children who progressed remarkably under his care. The narratives not only demonstrate the author�s inventive technique, they also testify to his gift as a psychotherapist to children, his empathic understanding of their needs, feelings, thoughts, and perspectives. He recognizes each child�s unique personality and life experience when he urges therapists to search for the child�s personal �matrix of embodied life-metaphors� (p. l8). To the usual arsenal of techniques used to communicate with children, such as speaking in language specifically geared to their developmental level (Zelan, l99l), the author adds ��nonverbal language that includes rhythms of gestures, facial expressions, tactile and kinesthetic perceptions, actions, postures, and emotional tones,� all aspects experienced by the child while interacting with the therapist (p. l7). Santostefano unearths the meanings behind these behaviors and resonates to them with his own expressed feelings and behaviors. He masterfully crafts his understanding of his young patients in language and behavior they can readily understand.

�Ernest,� a four-year-old whose behaviors suggest autistic spectrum disorder, and �Vera,� a little girl who�d spent the first three years of her life in an orphanage, engaged with Santostefano from the outset, making use not just of the playroom but also a �Therapeutic Garden,� constructed by the author to entice the children to explore and interact with the natural world, their attentive therapist ever-present at their side. The author shares with his readers not just interventions that work but those, too, that went awry, analyzing the hows and whys of these off-the-mark attempts in a way that invites us to think deeply about our own theoretical premises and favorite clinical techniques. The narratives and clinical interventions are complemented by photographs of the Therapeutic Garden, appealing line drawings of therapist and child engaged in activity together, and charts illustrating the convergence of child development theories pertinent to Santostefano�s theoretical framework.

Ernest�s story is particularly compelling. He is described as �wandering� in a detached, dreamy state, sometimes flapping his arms. He rarely gazed at people directly and spoke echolalically. His pediatrician wondered if he was developing an autistic disorder, or selective mutism, or Asperger�s syndrome. Santostefano�s therapeutic goal in working with Ernest was to free him from his autistic withdrawal.

Ernest was invited by his therapist to engage in human interaction by an intervention at once simple and exquisite. The boy hid behind a couch in the waiting room on which Santostefano sat while talking to Ernest�s mother. The prospective therapist dangled a rope over the back of the sofa, hoping Ernest would acknowledge the object, and by implication, his therapist. Eventually Ernest gave a slight tug on the rope, signifying to Santostefano that he silently understood his therapist was attempting, literally, to connect with him. When Ernest was ready to leave the waiting room, he insisted on grasping the rope, the other end held by Santostefano, as they ambled comfortably into the playroom.

Soon Ernest became interested in the Therapeutic Garden and accompanied his therapist outside to explore it, all the while hanging onto his personal rope-connection. Enticed by the garden�s layout, the young boy began to explore nature and the physical world in the manner of a child scientist (Gopnik, l999). He later spoke of his physical connection to Santostefano as �our rope� and announced to his mother, �Seb likes me� (p. 79).
Santostefano�s relational orientation and the use of a special therapeutic setting echo aspects of psychoanalytic milieu therapy as it was developed at the University of Chicago�s Orthogenic School, where I worked with autistic children. Just as Ernest and his therapist explored their garden and collaborated on nature projects, an autistic girl I treated at the Orthogenic School explored one of its yards containing a sandbox, a seesaw, and a statue of a reclining lady. While the girl often perambulated slowly around the �lady� statue, and even sat on it occasionally, her first interest was in sifting sand through her fingers to observe the effect of the tiny grains landing on and sliding down tiny sand hills. Much like Santostefano�s patient, who learned from his therapist how to fashion a bow and arrow, the autistic girl implicitly invited me to teach her about the seesaw. After climbing up almost to its center, she observed the exact point at which the other side began to tip downward. Then she slowly and thoughtfully made her way down the other end in order to examine the fulcrum positioned below. Joining autistic or autistic-like children in their investigations acts as their window to the real world, including and most importantly, the world of people (Zelan, 2003). The autistic youngster realizes that he has benefited from being in the company of a trusted adult and, not least, from his improved ability to manipulate objects and acquire knowledge.

As Ernest learned about the natural world, he learned about himself: He learned that he could protect himself by acquiring the knowledge pertinent to the world�s dangers, both imagined and real. In Santostefano�s words, �Multiple environments provide the child with more opportunities to relive and master stressful events than does the landscape of an office or a playroom� (p. 5).

The virtue of a detailed clinical account is that more than one theoretical model can be brought to explain a patient�s progress. The teaching-learning model readily applies to the understanding of Ernest�s progress. Interactions with family, friendships with peers, and learning experiences, comprise the whole of any child�s experience.

Yet, it is not so much that the therapist �teaches.� Rather, it�s that the child naturally learns, as his body grows (A. Freud, l97l, p. 2l4). Santostefano actually offers a �progressive� definition of learning, one particularly relevant to Ernest. Speaking of an important concept embedded in relational psychology, he writes, �One is the assumption of constructivism that a person continually interprets environments and acts on those environments according to those interpretations� (p. l48). In one textual stroke, the author evokes the psychological theories that helped to shape relational psychoanalysis, among which we may count Stern�s (l985) and Piaget�s (l952, l969, l973).

Ernest became comfortable with himself when he understood that he had some control over and an impact on the natural world, as he shot arrows into the air and predicted how far they would travel. The more protected he felt in the natural world, the more he developed as a person, someone who, because of his attachment to his therapist, could join the interpersonal realm with greater equanimity. Interestingly, Ernest began to spin a fantasy about a personified monster called �Monstro.� This represented a shift from his interest in nature to the personal qualities of others, wherein he recapitulated the search for what is dangerous, what is safe. Ernest and his therapist playfully foraged in the Therapeutic Garden for the dangerous persona, �Monstro,� the boy vigorously shouting Monstro�s whereabouts to Santostefano, as the two monster-hunters pretended to outsmart their adversary. Soon thereafter, Ernest kissed his therapist and said it felt �good,� and he confided that he felt �sad� about a nursemaid leaving him.
Toward the end of the book, the author describes two traditions in psychology that link the impact of the environment with an individual�s mental health: environmental psychology, which addresses the relationship between environment and behavior; and ecopsychology, which proposes that interacting with nature promotes a sense of well-being. Though acknowledging the contributions of these disciplines, Santostefano draws contrasts between them and relational psychoanalysis, showing how the latter addresses the needs of children in psychotherapy more comprehensively. This occurs because relational psychoanalysis emphasizes the therapist and child patient �growing together� (p. l63), a process which is fostered by the therapist�s consistent focus on the psychotherapeutic interactions in both interpersonal and natural environments (p. l64).

Under the aegis of the therapist�s vigilant attention to each and every new development in the child�s activity and expressive behavior, a �new self� appears to emerge, the result of new experiences in the therapeutic interaction. ��[T]he child begins to construct a new psychological landscape/self and matrix of embodied life-metaphors,� asserts Santostefano (p. l85). No longer beholden to past, traumatic life-metaphors, the child adopts a healthier perspective that, in turn, guides further growth and development.
In essence, a child�s �new self� represents a new way-of-being (Stern, l995; Zelan, 2005). Ernest�s story illustrates this well. He continued to learn prodigiously, for instance, about the life stages of butterflies, showing a �keen intelligence and sophisticated vocabulary� (p. 88). Upon conclusion of therapy, the boy continued to progress both at home and in school, where he excelled academically. Santostefano�s ingenious therapeutic methods essentially kept the young autistic boy on track developmentally. Summarizing, he writes, �Relational psychoanalysis, then, should develop techniques and concepts that address the unit formed by child plus therapist plus location in which they interact� to �integrate a child�s experiencing-developing self, behaving self, and interpersonal self� (p. 226). A worthy goal, as Santostefano�s book attests, that is at once impressive and interesting for therapist and patient alike.

Freud, A. (l97l). The writings of Anna Freud: Problems of psychoanalytic
training, and the technique of therapy.
New York: International Universities
Gopnik. A. (l999). The scientist in the crib: Minds, brains, and how children
New York: William Morrow and Company, Inc.
Piaget, J. (l952). The origins of intelligence in children. New York: Norton.
Piaget, J. (l969). The psychology of the child. New York: Basic Books.
Piaget, J. (l973). The affective unconscious and the cognitive unconscious. Journal
of the American Psychoanalytic Association, 2l,
Stern, D. (l985). The interpersonal world of the infant: A view from psychoanalysis
and developmental psychology
New York: Basic Books.
Stern D. (l995). The motherhood constellation: A unified view of parent-infant
New York: Basic Books.
Zelan, K. (l99l). The risks of knowing: Developmental impediments to school
New York: Plenum.
Zelan, K. (2003). Between their world and ours: Breakthroughs with autistic
New York: St. Martin�s Press.
Zelan, K. (2005). The importance of relatedness in the psychotherapy of
autistic youth (unpublished manuscript).

Karen Zelan has written extensively on the psychology of children�s learning. She is the author of Between Their World and Ours: Breakthroughs with Autistic Children.

© Division of Psychoanalysis, 1999-2005
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