Child and Adolescent Psychoanalysis as Contemporary Psychotherapy: Insights From a Semistructured Interview of Practitioners

Child and adolescent psychoanalysis is a very small and isolated field of contemporary psychotherapy. Little systematic research is performed in this area. Without research to advance the field and to create healthy scientific communication with the other fields of psychotherapy, child and adolescent psychoanalysis remains disadvantaged.

There is increasing interest among child and adolescent psychoanalysts in bringing systematic research to the field. This spirit reflects an observation that child and adolescent psychoanalysts may be more progressive and similar to providers in other fields of psychotherapy than may traditionally be thought. To clarify the mindset of the contemporary child and adolescent psychoanalyst, we undertook a systematic evaluation of the characteristics of child and adolescent psychoanalysts and their motivations for choosing and actively practicing in the field. The objective was to clarify key factors concerning the field in relation to other contemporary psychotherapies with the goal of helping to create a bridge between child and adolescent psychoanalysts and providers in other fields of psychotherapy.

Background

Since its conceptualization, child and adolescent psychoanalysis has always been seen as somehow isolated and different. Little Hans (1) was more of an opportunity to explore the etiology of adult psychopathology than to explore direct work with children, and in the first published direct account of work with a child, Ferenczi (2) assessed child psychoanalysis as “impossible.” In her introduction to the technique of child psychoanalysis, Anna Freud (3) wrote, “I am prepared for the practicing analysts among you to say . . . that my methods with children are so different that they cannot be called real analysis at all, but a form of ‘wild’ analysis” (p. 69). From the start, there was a sense that child and adolescent psychoanalysis was outside the arena of “real” psychotherapy, which in those decades was nearly entirely psychoanalytic. Schmidt (4) reviewed this trend in psychoanalytic circles through to contemporary times.

Already isolated from adult psychoanalysis, child and adolescent psychoanalysis became further isolated when adult psychoanalysis increasingly distanced itself from flexible integration with other fields of psychotherapy. This occurred despite evidence that psychoanalysis in practice was an eclectic mix of interventions (5). Although adult psychoanalysis has in many ways integrated this information and become more open to communication with other fields of psychotherapy, its initial state of isolation and its isolation of child and adolescent psychoanalysis results in a double burden for the field of child and adolescent psychoanalysis.

Precedents to This Work

Wallerstein’s work merits special consideration. In his conclusion to the systematic Menninger study of 42 adults in psychoanalysis, Wallerstein (5) wrote,

Much less work has been done on the field of child and adolescent psychoanalysis. Major contemporary systematic research on child and adolescent psychoanalytic treatment dates back to the work of Peter Fonagy (6, 7). Work of Wallerstein’s type—that of systematically following the practices of child and adolescent psychoanalysts—is rare. Some survey work in this vein has been done, however. Abrams (8) reported that each child and adolescent psychoanalyst carried on average 2.2 child and adolescent psychoanalytic cases. Abram’s survey noted some characteristics of the surveyed providers; for example, he noted that child and adolescent psychoanalysts with low caseloads attributed problems to external factors, such as the availability of patients and fees, whereas analysts with high caseloads cited internal causes, such as countertransference, as explanations for low caseloads.

In 2000, the Committee on Child and Adolescent Analysis of the American Psychoanalytic Association began exploring (9) how to implement systematic studies of the process, therapeutic impact, and practice of child and adolescent psychoanalysis. As a first step, the committee decided to document the current practice of child and adolescent psychoanalysts by means of a survey. The committee felt that an empirical description would compel educators and practitioners to address the problems in the field and would stimulate future research.

Of those surveyed, 61 percent (63 of 103) responded. The child and adolescent psychoanalysts in this cohort treated a total of 201 adult, child, and adolescent analytic cases (at a frequency of three times a week or more; mean±SD=3.2±2.6). Of these psychoanalytic cases, only 56 were children and adolescents. Child and adolescent analytic practice was smaller than that observed in Abram’s survey (mean=0.9±1.2). Nearly two-thirds (64%) of child and adolescent psychoanalysts had no child or adolescent analytic cases in treatment. Almost three-fourths (73%) of all the child and adolescent psychoanalyses were conducted by fewer than one-quarter (24%) of the providers (9).

Rationale for This Work

Although these data are important and have been used to suggest child and adolescent psychoanalysis’s challenge to sustain itself (9), to date no work has built on these systematic works to consider the implications beyond those internal to the field. Whereas some (10, 11) have made recent considerable contributions in the field of psychoanalytic child psychotherapy, more work is needed, especially work that advances the valuable data contained in the preliminary empirical work sponsored by the Committee on Child and Adolescent Analysis. If child and adolescent psychoanalysis wants to emerge from its isolation and communicate with the other fields of psychotherapy through a commitment to systematic research and field development, these data have promise.

As a follow-up to the publication of the cross-sectional survey, we undertook a more intensive study of child and adolescent psychoanalysts and their way of practice. The aim of the project was to clarify key factors concerning the field in relation to other contemporary psychotherapies. We expected to find that, in contrast to the traditional perspective of child and adolescent psychoanalysts as being doubly isolated both within psychoanalysis and from the other fields of contemporary psychotherapy, child and adolescent psychoanalysts would have many similarities with providers of the broader range psychotherapies.

Methods

Survey and Interview

The research group developed a semistructured interview that was divided into three parts. To reduce bias, the interview was conducted by a research assistant who was not involved in the data analysis and was not known to the subjects. The interviews were transcribed for review later in the data analysis. The interview parts consisted of demographic and factual questions about practice and education, questions eliciting descriptions of three patients (preferably a child, an adolescent, and an adult), and questions about the psychoanalyst’s personal life.

The first part of the interview included demographic and professional questions, economic factors, current family situation, current and past family responsibilities, makeup of the family of origin, illness in self and family, illness in the family of origin (particularly depression), and economic variables such as the ability to accept lower fees. Questions concerning psychoanalysts’ conceptualizations of important principles and practice of child and adolescent psychoanalysis included the nature of primary professional identification, the value of a developmental framework, and how psychoanalysts used a developmental framework in practice. Questions also concerned the nature of child and adolescent psychoanalysts’ practice (both adult psychoanalysis and child and adolescent psychoanalysis, individual psychotherapy not conducted within an analytic frame, family work, medication, teaching, research, etc.), utilization of child and adolescent psychoanalytic principles in professional work (psychotherapy, other treatment, teaching in other venues, and other aspects of the psychoanalysts’ career), psychoanalysts’ age and gender, and the nature of psychoanalysts’ practice.

Psychoanalysts were also asked about the value of their analytic education, satisfaction or dissatisfaction with size of their practice, promoters of or impediments to development of a child and adolescent psychoanalytic practice, and the importance of mentors and identification models (including enablers and those who obstructed progress). The survey also addressed psychoanalysts’ attitudes toward parents of children and adolescents (view of parents as integral participants in the treatment or not, as supportive, or as those who obstruct [i.e., have to work around them]). Theoretical and technical attitudes when working with children, with their parents, and with adults were also surveyed. Child and adolescent psychoanalysts were finally asked how they imagine their child and adolescent analytic education affected work other than child and adolescent psychoanalysis, how the motivation to develop a large child and adolescent psychoanalytic practice develops, and what their conviction was about the value of analysis.

In the second part of the interview, analysts were asked about some of the patients they treated at any point in their career, focusing on one session or one anecdote. Analysts were asked to describe three such patients, preferably a child, an adolescent, and an adult.

In the third part of the interview, analysts were asked about their own personal lives. Questions concerned how analysts decided that they wanted to work with children and adolescents and what analysts’ experiences and attitudes toward play, games, and activities were. Psychoanalysts’ earliest memories of playing, interests (reading habits, movies, sports, etc.), and personal experiences with children and adolescents were all explored. Analysts were asked for a description of life with their family of origin and current family; about the nature of their friendships; and about lifestyle, ways of coping with stress, anxiety, success, and so forth. Analysts’ degree of optimism or pessimism were also explored and developed.

Selection of Subjects and Confidentiality

The sample was one of convenience. It consisted of analysts known to the senior author (Hoffman). None of those interviewed were supervised by or had any clinical or administrative relationship to the senior author. The nature of the interviewee’s practice, including the number of child and adolescent psychoanalytic patients, was not known beforehand and was not a basis for selection as a subject in this study. Of 25 subjects, five declined to participate. The interviews were recorded with a high-level recording device. All subjects signed informed consent. A follow-up letter of acknowledgment was sent to subjects with an offer to withdraw from data analysis if they so wished. No subject wanted to be removed from the data analysis. To protect confidentiality, subjects’ names and other identifying data were removed from the transcripts. Narrative material is presented in the form of disguised vignettes or quantitative data. The institutional review board of the New York Psychoanalytic Society and Institute approved the project.

Data Analysis

Grounded theory (12) is a qualitative approach to generating theory grounded in data that has been used in psychoanalytic studies (13). In comparison with other methods, it provides an operational structure that enhances construct validity without sacrificing flexibility or rigor. In addition, it enables the examination of the frequency at which certain ideas are expressed and the identification of what aspects are most salient and pervasive. The process includes collecting data, coding, developing concepts and categories, and returning to the data to refine, develop, elaborate, and exclude (constant comparison). Collection and analysis of data occur in tandem, referring to each other repeatedly. As patterns emerge, data are reexamined, and categories are redefined and elaborated. All three authors were engaged in this process. To reduce bias, the first and second authors independently applied the grounded theory analysis. In addition, the senior author, who had preexisting relationships with the subjects, did not participate in the initial step of developing themes, constructs, and categories. Analysis was conducted to the point of thematic saturation. After this initial step, the senior author reviewed both raters’ products and identified consistent themes between the two raters. The analysis was finalized in a consensus outcome through the contributions of all three authors.

Results

Demographic Characteristics

The age of the cohort mirrored the age distribution found in the cross-sectional survey (9). The average age of the sample was 62.7 years (range=48–78 years). There were 13 men and seven women. Six child and adolescent psychoanalysts were also both adult and child psychiatrists, 10 were also adult psychiatrists but not child and adolescent psychiatrists, and four were in other mental health professions. Sixty-two percent were from New York City.

Practice

The total number of patients in the sample was 67. This was spread among the 20 subjects to yield an average of 3.35 analytic patients per child and adolescent analyst (compared with 3.2 in the 2009 cross-sectional survey; 9). The number of child and adolescent patients in the sample who were in psychoanalysis was 10; when spread among the 20 subjects, this yielded an average of 0.5 patient per child and adolescent analyst (compared with 0.9 in the 2009 survey and 2.2 in Abrams’ 1979 survey [8]). In terms of other activities, virtually all the child and adolescent psychoanalysts participated in a variety of administrative, clinical, supervisory, and consultative activities (at psychoanalytic institutes, other training programs, clinics, and schools). In addition, almost all conducted psychotherapies with children, adults, and children.

Qualitative Findings

Active, flexible work with parents, including addressing ruptures in treatment.

Grounded theory analysis revealed a most important finding regarding how child and adolescent psychoanalysts work with parents. There was a clear repeated idea and concept among the child and adolescent psychoanalysts concerning the value of helpful, flexible work with parents. Typical responses, amalgamated to disguise subjects’ identities, follow.

A few of the child and adolescent psychoanalysts in this cohort were directly critical of this education, but most did not express a direct critique of their child and adolescent analytic education, which virtually ignored teaching them how to work with parents. However, other child and adolescent psychoanalysts in this group did learn that working actively with parents was central (and even preceded) work with the child.

What was most striking was that in their current work, in contrast to what they were taught, virtually all the child and adolescent analysts reported learning for themselves, outside of their formal education, that active work with the parents is essential to working psychotherapeutically or psychoanalytically with children.

In addition, virtually all these analysts believed that work with the parents was modified or minimized when working with adolescents older than age 15 or so. When discussing ruptures in treatment and how to resolve them, this group reported that the successful or unsuccessful resolution of the rupture depended on work with the parents and not with the child. However, a few analysts reported instances with adolescents in which ruptures could be resolved with the adolescent him- or herself.

Therapeutic relationship, insight, and other findings.

Grounded theory analysis demonstrated that virtually all of the child and adolescent analysts believed that the relationship between analyst and child (or various technical terms such as developmental object) is the crucial mutative agent in the treatment: “The actual relationship that develops between me and the child helps the child grow and develop. The relationship with me which the child develops is very special and very important to the child.”

Several analysts also discussed how a child learns to understand his or her motivations without necessarily achieving cognitive insight: “Children do demonstrate that they understand something. It is not like the insight expressed by an adult. They will communicate in their play and activity that they have understood something.”

A fourth and final shared concept concerned the value of training in child and adolescent psychoanalysis in better understanding adult patients. Child and adolescent analysts felt that their training in child and adolescent analysis and development helped them to see their adult patients form a perspective on their early development. The necessary flexibility required when working with children often translated into a more flexible approach in their work with adults: “When a woman patient was talking to me about her battles with her co-workers last week, I could picture how she had described herself as an eight-year-old arguing with her friends.”

Finally, in terms of the other items addressed in the Background section, such as the role of mentors, promoters of or impediments to development of a child and adolescent analytic practice, impact of family life, and financial obligations, no generalizable themes emerged from the qualitative analysis.

Discussion

In this exploratory study of 20 child and adolescent psychoanalysts, we found that the actual practice of child and adolescent psychoanalysis (treatment intensity of three or more times a week) is very similar to the practice of other contemporary psychotherapies. Contemporary child and adolescent psychoanalysts value an active, flexible engagement with the family system, respect the importance of the therapeutic relationship, and understand the active process of therapeutic growth beyond classic models of insight. We also found that child and adolescent psychoanalysts use their work to inform their other psychotherapy work, suggesting that those in the field may be interested in productive communication and the flexible application of the strengths of one field to serve the development of another.

The finding regarding child and adolescent psychoanalysts’ perceptions of family work has clear parallels not only with family and systems therapists but more generally with the larger realm of cognitive-behavioral and other therapists who are comfortable giving supportive directives, psychoeducation, and developmental guidance. This is a significant departure from traditional characterizations of child and adolescent psychoanalysts. Many child and adolescent psychoanalysts reported having been taught in their formal training that psychotherapeutic work with parents is limited to gathering information and maintaining a rapport with parents to allow the analysis to continue. Counseling, parent guidance, and therapy, supportive or otherwise, was not advocated. If ever done, it was done despite the analyst’s better judgment. Sometimes parents were not seen by the analyst but referred to someone else.

A few of the subjects responded that working with parents was a central part of their education, and this shift suggests the importance of studies such as this one. Much in alignment with the findings of Wallerstein’s Forty-Two Lives in Treatment (14), the contemporary practice of child and adolescent psychoanalysis diverges from the traditional curriculum. Unfortunately, we did not ask how these analysts teach their students the importance of working with parents of children in therapy or analysis. In fact, we could not find any references in the literature to either anecdotal or systematic data with respect to comparing how one practices and how one teaches. It remains to be seen whether this conviction regarding the importance of working with parents is systematically taught with the same rigor and intensity as the technical aspects of working with a child.

Most psychoanalysts also felt that the relationship between analyst and child was the most crucial mutative agent (a variety of terms were used to describe this relationship, including the “real” relationship and the analyst as “developmental object”), and, finally, a fair number stressed the importance of the childhood version of the concept of insight as a mutative agent. The child and adolescent psychoanalysts’ theme of applying the lessons of their work in child and adolescent psychoanalysis with different patient populations and in different modalities suggests that there is a willingness among child and adolescent psychoanalysts to communicate with other fields of contemporary psychotherapy.

Conclusions

This project, which began almost 15 years ago, was envisioned as an attempt to answer the following questions: “Why has child and adolescent psychoanalysis remained small and isolated since its creation?” and “Will its future see greater growth and integration within the practice of contemporary psychotherapy, or will it become further isolated?” Despite this study’s significant limitations—that it used a convenience sample rather than a randomly chosen sample and that this cohort of child and adolescent analysts had very similar education and very similar theoretical orientations—the message is very clear that child and adolescent psychoanalysts are not much different from providers in other fields and are open to growth and flexible, even (and perhaps especially) when growth implies some loosening of the restrictions of the traditional adult psychoanalytic curriculum.

This study’s findings can inform recruitment and education in child and adolescent psychoanalysis. The inclusion of younger providers who are more flexible and open to integrating the skills and strengths of other psychotherapies into child and adolescent psychoanalytic work may not only result in recruitment and training of those who more accurately reflect practice in the field but may also promote further integration between child and adolescent psychoanalysis and the other fields of psychotherapy. This may be a key strategy to reduce the isolation of child and adolescent psychoanalysts and to promote the field’s development in tandem with the contemporary psychotherapies. More broadly, this study demonstrates that systematic research may be applied to child and adolescent psychoanalysis to promote its growth and advancement in the contemporary context and become integrated with the broader array of available psychotherapies.