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Argues for the necessity of confidentiality in the therapist/patient relationship.

Psychoanalytic literature has often overlooked the child's participation in organized sports, which often can facilitate or impede not only expression of aggression and narcissism, but enhance or skew the growth of the child's superego and ego ideal. Specific outcomes are largely determined by the experience and knowledge of the parents, the coaches, and sports organizations for latency-aged youth. Sports participation facilitates a major step forward in psychic development, that is, an agreed-upon adherence to a set of rules and regulations, monitored by an official embodying the final word regarding rules and their infractions. This paper is an attempt to delineate the role of sports in the life of the latency child, the parents who become involved, the coaches who teach and supervise, and the social and individual milieu within which sports take place. All these contribute to common goals: the engendering of good sportsmanship and the encouragement of psychic growth, particularly regarding how aggression and narcissism contribute to the development of superego and ego ideals. The fate of aggression and narcissism in superego and ego ideal development is influenced to a large degree by the nature, orientation, and motivations of all involved in sports for the latency-aged.

The paper begins by reviewing Freud's case history of Dora and emphasizing her involvement in and overstimulation by her parents' sexual behavior. This markedly interfered with her ability to desexualize her relationship with them. As a result she was unable to develop the illusion of parental celibacy, which I postulate is an important and necessary defensive stage in normal adolescence. This illusion facilitates the desexualization of the adolescent's relationship to the parents and so contributes to separation from them and the seeking of non-incestuous sexual outlets. The disruption of this illusion of parental celibacy by parental sex education, or by the complications of parental divorce may contribute significantly to the development of adolescent psychopathology. Clinical vignettes are presented.

Many medical procedures, while necessary and appropriate, may be experienced by a child or adolescent as a trauma, with the medical personnel considered as perpetrators in collusion with the parents. The medical procedures and the conditions requiring them are seldom the focus of routine history-taking or therapeutic process. Nevertheless, the long-range effects of these events may have serious and adverse effects on future development and psychopathology. The author presents several clinical examples.

A 17-year-old boy is brought involuntarily by his parents for admission to an adolescent unit after running away from home to join a cult. The adolescent is admitted to the hospital for a multidisciplinary assessment. Follow-up 6 months after discharge shows the family to have continued in family therapy with the patient remaining at home with no additional contact with the cult. The case raises important ethical and dynamic issues about whom the child psychiatrist serves--the parents, the adolescent, or society. Discussion by an ethicist, lawyer, and child and adolescent psychoanalyst follows the case presentation.

The role of audition as an important perceptual modality in early psychic development has been neglected. Some reasons for this neglect are suggested. In the development of psychoanalytic technique, the analyst has changed from a "tactile presence" to a "visual presence," then finally, with the analyst positioning himself behind the couch, to an "auditory presence." Several clinical examples from analytic patients as well as child development in normal and deaf children provide instances of each type of perceptual "presence." It is suggested that, in evaluating analyzability, analysis requires a specific ego ability, namely, tolerance for the analyst as an "auditory presence." It is emphasized that some patients, for reasons of development, constitution, and/or significant stress (separation), cannot work with the analyst as an "auditory presence," but regress to the analyst as a "visual" or "tactile" presence. The importance of audition in early mother/stranger differentiations, and in the peek-a-boo game, is a developmental precursor to the use of audition as a contact modality in the separation and individuation phase. Audition permits active locomotion and separation from tactile and visual contact modalities between toddler and mother, while at the same time maintaining contact via their respective "auditory presence" for each other. The utilization of the pull-toy in mastering the conflicts of the separation-individuation phase is demonstrated. The pull-toy is heir to the teddy bear and ancestor to the tricycle. Greater attentiveness to the auditory perceptual modality may help us understand developmental phenomenon, better evaluate the potential analysand, and clarify clinical problems of audition occurring in dreams and those areas of psychopathology having to do with auditory phenomena. The more refined tripartite conept of "presence" as it relates to the predominant perceptual modality--tactile, visual, auditory--is felt to be a useful conceptualization for both developmental and clinical understanding.