Advances in Psychiatric Treatment (Ì998), vol. 4, pp. 18-24

Child psychoanalytic psychotherapyM. Fitzgerald

The goal of psychoanalytic psychotherapy with adistressed child is to alter the child's psychic

structure and function. The technique is based onthe same theory as adult psychoanalytic psychotherapy (see Box 1). The unconscious is central, asis the interpretation of defence, resistance, transference, working through and the reconstructionof earlier life. It differs from adult psychotherapyin that the child's age and level of development are

at all times central to the work. In young childrenthe focus of interpretation is on free play, while withadults it is free association of ideas. In the treatmentof adolescents a combination of techniques, bothadult and pre-adolescent, are used, while for lateadolescents the technique is basically adult technique with attention to issues relevant to that stageof the life cycle.

Modern psychoanalysis

Modern psychoanalysis has expanded our understanding of children and adolescents, as SigmundFreud's original model was excessively reduction-

istic and could not deal with the full complexity ofhuman behaviour. Nevertheless, many of Freud's

fundamental tenets, for example the importance ofthe unconscious, still hold as well as the clinical

Box 1. Child versus adult psychotherapy

Child psychotherapy shares many similaritieswith adult psychotherapy - the unconscious,transference, resistance, etc. but differs inits emphasis on the child's age, level of

development as well as free play being afocus of interpretation.

concepts of transference, countertransference,working alliance and negative therapeutic reaction.

Since Freud, multiple psychoanalytic paradigmshave developed, including Kleinian psychologyand self-psychology. While Freud emphasisedan energy discharge point of view within anatural science framework, more recent workhas also stressed a 'person' point of view within

a hermeneutic framework (see Box 2). Thetwo points of view help us to understanddifferent aspects of psychoanalysis. The energydischarge model can be helpful in partiallyunderstanding obsessional neurosis, as indeedwill increased knowledge of genetics, while theperson-oriented model can give us some help inunderstanding borderline personality disorders(American Psychiatric Association, 1994). Furtherwork needs to be done in reconciling these twoapproaches.

John Bowlby's work on attachment, separation

and loss has implications for psychoanalysis.His concept of the secure base for the child inrelation to the mother would appear to describeusefully the relationship of the child to the childpsychotherapist. John Bowlby was critical ofpsychoanalytic explanations of psychic energy anddrive discharge. He proposed explanations in termsof attachment and emphasised systems theory,information theory and cognitive psychology. Inmodern psychoanalysis the emphasis has movedonto a person or human relatedness paradigm, incontrast to the body paradigm of traditionalpsychoanalysis. Bowlby in particular emphasisedthe importance of the external environment on thechild and believed that much acute and chronicanxiety was due to threats of abandonment by aparent as a means of discipline. He did not givesufficient emphasis to the child's mental set and theeffect of the child's personal fantasies in processing

the external stress. The modern child psychotherapist has to give due weight to internal and externalfactors.

Michael Fitzgerald (Child and Family Centre, Ballyfermot Road (Beside Health Centre) Dublin 10, Republic of Ireland) is an AssociateMember of the British Psychoanalytical Society, and is interested in all aspects of psychotherapy, including outcome research.

Child psydtotherapy APT (1998),vol. 4,p. 19

The new directions in psychoanalysis focus oninterpersonal interactions with a detailed study ofthe interplay between the psyche of the person andthe therapist. This is a two-person psychologicalmodel, therefore there is less focus on drivedischarge and of the person unveiling themself,than in the one-person psychological model. Thefocus is no longer on so-called therapist neutralitybut on building up new meanings with the person.They work together in the new model. The therapistcannot help but reveal himself through his interventions and within this 'bipersonal field';

therefore, the psychotherapeutic dialogue is theoutcome of both parties and not just the product ofthe person. The therapist's interpretation emerges

from reviewing his/her own thoughts, feelings andthe person's input, whether verbal or non-verbal.

The newer models of psychoanalysis posit peopleas seeking human contact, and psychopathology isseen as a result of relational failure. All psychoanalytic treatments are research because eachperson brings something unique that has not beenexactly described previously and which thetherapist has to work with in a creative way withoutimprisoning himself in some theoretical model thatdoes not fit with the individual.

The more recent advances in psychoanalytictheory and technique have led to better modes oftreatment with psychologically vulnerable people.Heinz Kohut pointed out that for vulnerable and'fragmented' people the older psychoanalytic

emphasis on conflict gave insufficient understanding. His self-psychology places the emphasison the person's "experience of others as centres ofinitiative leading to the construction of the self"

(Cohler & Galatzer-Levy, 1988). This has led toconsiderable emphasis being placed on failures ofparental empathy for the child leading to disordersof the self and low self-esteem. The child therapist's

empathy to the child in treatment is therefore ofcritical importance. The older 'antiseptic' technique

or indeed the newer French technique, with itsexcessive focus on language and inadequate focuson affect and the transference, can lead to

Box 2. Modern psychoanalysis

Modem psychoanalysis has shifted its emphasisfrom an energy discharge point of viewwithin a natural science framework to aperson point of view within a hermeneuticframework and the building up of meaningsbetween therapist and patient. Due weightis now given to internal and external factors..

re-traumatisation of people. This is a good exampleof the danger of words (Berman et al, 1996). Theapproach of self-psychology avoids these pitfalls.

Technique

In the 1920s papers on child psychoanalysis basedon work conducted directly with children began tobe published using a modified technique withanalysis of the young child's free play as well asthe spoken word. Anna Freud's (1965,1974) aim was

to help the child understand the meaning of thesymptom and to resolve it in that way rather thantelling the child to give up the symptom. She keptmanagement of the person to a minimum exceptwhere there were seriously harmful forces at work.

Anna Freud summarised her technique as follows:"to analyse ego resistance before id content and to

allow the work of interpretation to flow freely betweenid and ego; to proceed from surface to depth; to offerthe person of the analyst as a transference object for therevival and interpretation of unconscious fantasies andattitudes" (Freud, 1965).

This remains an excellent approach to thetechnique of child psychotherapy. The modernchild and adolescent psychotherapist has tointegrate technical and theoretical developments ina way that is appropriate to the needs of a person.

Melanie Klein, the other great pioneer in thisarea, believed that the infant at birth had a capacityfor some organisation. The most primitive organisation according to her was the paranoid-schizoidposition which is characterised by splitting,projective identification and idealisation. There isa part object relationship where objects (persons)are exploited for what can be got out of them. Thereis a great deal of projection of aggression whichleads the child to experience much persecutoryanxiety. There is also primitive splitting into goodand bad. These ideas are very helpful when dealingwith severely 'damaged' personalities, for example,

borderline personality disorder. The aim is to movethe person onto the depressive position where thereis an integration of love and hate and reparationwith the aim of sparing the object from harm. Hertechnique has been criticised for its emphasis onthe inborn death instinct, for premature deepinterpretations of the unconscious and for excessivefocus on transference interpretations and a relativeneglect of external reality.

Transference

Transference occurs when feelings, attitudes andexperience towards parental figures are transferred

APT(1998),vol.4,p.20 Fitzgerald

by the child onto the therapist in the present. AsYanof (1996) points out the "transference has a

central place in child analysis as it does in adultanalysis". Another part of the relationship involves

the therapist as a new real relationship. Thetherapist pays attention to both. Klein (1932) usedclassical adult technique and interpreted play as anequivalence to free association of ideas in the adult.She emphasised the importance of analysing thechild's negative ideas about the therapist and

pointed out that a child could develop a transferenceneurosis equivalent to that of adults. It took AnnaFreud many years while treating children to cometo the conclusion that they could develop atransference neurosis similar to adults. Althoughit is possible to provide a manualised approach forthe beginner, the experienced practitioner willintegrate the various theories of psychoanalysiscohesively and apply them in a way that best meetsthe needs of the individual. All child psychotherapists will need supervision from time to timethroughout their lives as part of continuingprofessional development.

Defence

Children often show defence activity in a nonverbal way. They may move away from thetherapist, cut short a game or hide a drawing. Thesecan be a defence against some unpleasant feelingor instinctual drive (Yanof, 1996). In the early yearsof psychoanalysis only the id derivative (forexample, aggression) would be interpreted.However, currently these defences would also beconsidered much more in the context of therelationship with the therapist. That is, hiding thedrawing because the child was fearful of criticismby the therapist who in the transference couldrepresent a critical mother or father, or to protectthe therapist from evidence of the child's aggression.

Theory of mind

There has been enormous interest in children's

theories of mind in the past decade. This is ofrelevance to child psychotherapy and interventions. There is still a question as to whetherchildren under the age of five or six years are ableto 'understand' the therapist's interpretations ofconflicts as expressed in play and the child's own

personal worries. The gradual understanding ofmind emerges between four and six years andprovides

"a developmental context for considering children's

capacity for internalisation, their creation of an inner

psychic reality and response to therapeutic intervention"

(Mayes et al, 1996).

Mayes et al (1996) also point out that"significant for psychoanalytic work with children is

the suggestion that only after children are able tounderstand how their own and other's mental states

are constructed and how these states are behind allactions and language can they reflect upon their ownthoughts and mental life".

Some therapists, especially with people withborderline personality disorder, are helping themto understand how other minds function apart fromtheir own. Indeed, a great deal of psychotherapy isabout sorting out what belongs to the child oradolescent and what belongs to other people intheir environment.

Importance of play

Play is central to child analytic psychotherapy. Inplay children symbolise their conflicts and anxieties(Sandier et al, 1980; Segal, 1981).

During the past 10 years child psychotherapistshave seen play as not only giving us an understanding of the child's mind, but also

"that play has its own development promoting

function for the child inside (and outside of) the analyticsetting. It raises the question of what should beinterpreted directly, what interpreted in displacementand what left unsaid" (Yanof, 1996).

Premature interpretations can interfere with thisnew maturation of the child. Timing is always ofcritical importance; beginners tend to interpret tooslowly and more experienced therapists too quicklyand too frequently. When the child psychotherapistis working with the extremely deprived andego-damaged child, as opposed to the neurotic, playcan be psychologically healing and promotepsychological growth in itself.

Indications

This form of treatment is useful to children who areanxious or depressed or in psychological turmoil. Itis also of value to children who are in conflict becauseof physical illness, or who are having difficulty comingto terms with disability. It is helpful in treating childrenwith unresolved grief reactions because of the deathof a parent. These reactions can make the child morevulnerable to depression in later life if not dealt withsatisfactorily. Psychoanalysis can help children whoare having difficulty resolving stress due to someoverwhelming trauma, for example a serious accidentor other traumatic life event.

Child psychotherapy APT(1998), vol. 4, p. 21

In general, people with schizophrenia and autismwould not be treated with psychoanalysis as a first-line treatment.

First session

It is not unusual for a child, coming to their firstsession, to have fears or fantasies about thetreatment. They may feel that they are 'naughty'

and may see it as a punishment. If they have beenmistreated for most of their life, they will havemuch mistrust and very little hope of help. Siblingsmay have mentioned the word 'mad' in relation to

coming for therapy and this can cause the childgreat anxiety. Sometimes they will have been givenother explanations of the visit and are completelyconfused. These prior fantasies or explanationsneed to be explored by the therapist with the child.The major part of treatment is opening up clearlines of communication and openness, and dealingwith fantasies so that the world makes sense to thechild.

General approach to sessions

If the therapist asks themselves the followingquestions, he/she is far more likely to remainfocused on what is important (see Box 3):

(a) What is the link between the end of theprevious session and the beginning of thissession?

(b) What is the affect or anxiety in this session?(c) What is the relationship of this anxiety to:

(i) current preoccupations?(ii) therapist?(iii) childhood experiences?

(d) What is the theme of this session?(e) What is the overall theme of the sessions?

Box 3. General approach to sessions

Links between sessionsThe relationship between affect in the session

to current preoccupation, the therapist andchildhood experience

Themes and core conflicts in sessionsContradictions, transference and counter-

transference as well as analysis of resistance.

(f) What are this person's core conflicts?(g) What are the contradictions in the person's

material today?(h) What are the transference and counter-

transference?What is the link between a dream and thetransference (if relevant)?What is the resistance?

(i)

(j)(See Fitzgerald, 1988.)

Conditions wherepsychotherapy has a role

Abuse

One of the first tasks of healthy development is theacquisition of basic trust which will grow in thechild in a good enough family. Children who arephysically abused, sexually abused or suffer seriousneglect, grow up very mistrustful and fearful ofpeople. Child psychotherapy takes a very long timeto reverse this mistrust of people, and an elementof it probably always persists.

Aggression

Uncontrolled aggression in the classroom is acommon reason for referral for child psychotherapy. Such children tend to have a history ofbeing in a family where there was considerableviolence, or have experienced violent attacks in oroutside the family. There is often marital disharmony or alcoholism in the family. The child maybe part of a very large family where the parents areoverwhelmed by the excessive care-taking needsand not able to meet them. These experiences canleave children feeling very angry and resentful.They take these feelings out on other pupils or onthe teacher in the classroom. In child psychotherapy,the child is helped to understand why they are soangry and aggressive and are helped to see theorigins of their symptoms. The therapist helps thechild to express feelings about experiences in earlierchildhood and to understand them, and thereforeto work through them and resolve them by talkingabout them so that they are not acted out.

Anxiety

A child may present with feelings of anxiety,nightmares, or fear of going out onto the streetalone. This could be because he or she lives with

APT (1998), vol. 4, p. 22 Fitzgerald

extremely anxious, over-protective parents who areconstantly worried about their welfare, telling themthat the world is full of dangers and that all kindof catastrophes could happen. The child hasnightmares of catastrophes, clings to his or herparents and is terrified of any separation fromthem. The child psychotherapist tries to help thechild to see the world as a relatively safe place, andthat there is not 'a catastrophe around everycorner', which is an example of reality testing.

Parasuicide

Children from the age of about 12 years can commitor attempt suicide. For children who attemptsuicide, child psychotherapy is required in additionto some other treatment like family therapy. It maybe because the child is being abused in some way,or they may feel that they are not being treated wellin the family and that some other sibling is beingfavoured. They may express their anger at someoneclose to them for not caring enough for them. Theattempted suicide is then a way of punishing thisperson. The child psychotherapist helps the childto see that this is not an appropriate way ofcommunicating with this other person and helpsthem to communicate in a more direct verbalfashion.

Depression

Childhood depression is not an uncommonpresenting symptom. The father of a child (who wassmall in stature) was tall, athletic and had a verysuccessful athletic career. The father was totallyunaccepting of his son who was not athletic likehimself. The father favoured another son who wasathletic and fulfilled the father's ideal for a son.

Clearly, in this case, work is required with bothfather and child. The child in psychotherapy hadto be helped: to come to terms with his small statureand not to be so angry about it and to express angerdirectly to his father about his inappropriateattitude towards him. The father had to be helpedto accept his son as he was.

In depressed children anger is usually turnedinwards, and helping the child to express this angeroutwards can be beneficial. The child has to be helpedto value the assets that they have, as these can oftenget overlooked by the child when there is excessivefocus on some negative issue, like short stature. Thetherapist must try to help the child to build up apositive self-image and increase their self-esteem.

Some children in families where there is maritalviolence blame themselves and feel inappropriately

that it is caused by something in them that is'bad'. The child psychotherapist helps the child

to differentiate between that which they areresponsible for and that which they are not.

Abdominal pain

A child complaining of tummy pain at 8 o'clock each

morning may do so because they inappropriatelyfear criticism from a teacher, or cannot face theirown perfectionist academic standards. They maysee it as a total disaster if they are not top of theclass. The child experiences conflict which is thenexpressed as abdominal pain. The child psychotherapist helps the child to understand this painand to modify their standards and to see the teacheras he or she is in reality.

Effectiveness of child andadolescent psychotherapy

This is of critical importance to psychotherapists,referrers and policy-makers (see Box 4). It isimportant because of the large numbers of childrenwith emotional and conduct problems: one studyof 200010-year-olds found a rate of 16% (Fitzgerald,1996). Clearly not all these would be candidates forpsychodynamic psychotherapy. Psychodynamicchild psychotherapy is one of the three mostcommonly used therapies, the other two being childbehaviour modification and child cognitive therapy.

Some of the positive effects of psychotherapy arenot seen immediately. Some of the improvementscontinue to arise between 18 months and three yearsafter a child finishes psychotherapy treatment.For children, the overall improvement withpsychotherapy has been put at between 67 and 78%.The spontaneous improvement rate, that is theimprovement rate without treatment, has been putat about 25% (Kolvinef al, 1981). It is likely that childpsychotherapy considerably speeds the rate ofimprovement.

The majority of scientific outcome studiesare behavioural and only about 20% are non-behavioural. Nine per cent of the studies useddynamic psychotherapy. A number of meta-

analyses of controlled studies have been carried out.Weisz & Weiss (1993) found a greater effect size forbehavioural than non-behavioural treatments.Nevertheless, Shirk & Rüssel(1992) have shownconvincingly that it is erroneous for the widerscientific community to be under the impressionthat psychodynamic therapy has been shown to be

C/i /'/</psychotherapyAPT (1998),vol. 4, p. 23

Box 4. Effectiveness of child psychotherapy

Child psychotherapy is effective, with a 68-78% improvement rate compared with a25% spontaneous improvement rate.Intensity of treatment is associated with abetter outcome. Children with disruptivedisorders treated for three years or morehad as good an outcome as those withemotional disorders.

less effective for children than the newer treatments.Eight per cent of the studies showed a negativeeffect of treatment. Effect sizes are similar inmeta-analyses of child and adult psychotherapy.However, there are a number of limitations tometa-analytic studies, including problems withconfounding variables and unrepresentativeness ofmany studies.

Individual psychoanalytic studies

The intensity of psychoanalytic treatment was foundto be associated with a better outcome in a study ofchildren with psychological problems, which hasbeen replicated (Heinicke & Ramsey Klee, 1986). Atthe end of treatment and at two years follow-up

children treated four times a week showed greaterimprovement in self-esteem, adaptation and capacityfor relationships than those treated only once a week.

Children with uncontrolled diabetes have shownsignificant improvement with psychoanalyticpsychotherapy compared with an untreated controlgroup (Moran et al, 1991).

A landmark study of child psychoanalysis of 763cases showed

"child psychoanalysis to be particularly effective for

seriously disturbed children under 12 years sufferingfrom a variety of psychiatric disorders, particularlythose which involve anxiety" (Fonagy & Target, 1996).

Some of the aims of the treatment includedreplacing aggression and violence with a capacityto reflect on interpersonal experience and givinginsight into current and earlier childhood experience. Other aims included giving the child'developmental help', which means removing

obstacles which have interfered with the normalemotional and cognitive development. Thesechildren show multiple symptomatology andfeatures of borderline personality disorder. Thetransference and countertransference were used forthe purpose of interpretation. Outcome was

evaluated in terms of clinically significant changein overall adaptation using the Hampstead ChildAdaptation Measure. Again, those treated four tofive times per week showed greater improvementthan those treated less frequently. Also, those havinglonger treatment showed greater improvement.Children with emotional disorder showedgreater improvement than those with borderlinepersonality disoder.

An important clinical finding in relation toadolescents was that they showed a high attritionrate and benefited as much from less intensivetreatment. Indeed, Anna Freud favoured lessintensive treatment for adolescents because it isimportant for adolescents to become independent from their parents and psychotherapy isdependence-inducing.

The findings with disruptive disorders are veryimportant as they are very frequently referred fortreatment (Fitzgerald, 1996). The study showed thatwhen they were treated intensively for three yearsor more their outcome was as good as for those withemotional disorders. Depressed children wererelatively resistant to psychotherapy and thisfinding is similar to the results of a previous studyby Fitzgerald et al (1994). One of the major unsolvedproblems of child psychotherapy outcome researchis that it is often effective in research studies butless effective in clinical situations. Fitzgerald(1996) has shown that an eclectic mixture ofpsychotherapy showed significant improvement inan out-patient child psychiatric clinic at threemonths follow-up, but that the positive effects haddisappeared at one year follow-up.

In the years after treatment further 'booster'

periods of psychotherapy may be needed as thereis evidence that many forms of treatment may nothave lasting effects (Fitzgerald, 1996).

Conclusion

While child psychotherapy has a considerableamount to offer to many disturbed children thereis little doubt that some children will require multi-modal treatments, for example, children withobsessional neurosis (Fitzgerald & Berman, 1996).It is important for the psychotherapist to keep inmind that about 30% of the variance in relation tothe aetiology of psychopathological problems willprobably be explained by biological factors. Aholistic approach is the only way that makes sense,with the therapist taking internal and externalfactors into account and keeping in mind abiopsychosocial model.

APT(1998),vol.4,p.24 Fitzgerald

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Fonagy, P. & Target, M. (1996) Predictors of outcome in childpsychoanalysis; A retrospective of 763 cases at the Anna FreudCentre, ¡ournalof the American Psychoanalytic Association, 44,27-78.

Freud, A. (1965)Normalityand Pathologyin Childhood.The Writings,Vol.6. New York:International University Press.

(1974)Introduction to Psychoanalysis.London: Hogarth.Heinicke,C. M. & Ramsey Klee, D. M. (1986) Outcome of child

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Klein, M. (1932)ThePsychotherapyofChildren.London: Hogarth.Kelvin, I.,Garside, R.,Nicol, A.,et al (1981)HelpStartsHere.London:

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of mind. Journal of the American Psychoanalytic Association, 44,117-142.

Moran, G. S., Fonagy P., Kurtz, A., et al (1991)A control study ofpsychoanalytic treatment of brittle diabetes. Journal AmericanAcademy ofChildPsychiatry,30,241-257.Sandier,].', Kennedy,~H. & Tyson, R. (198Q)TheTechniqueofChild

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2. The following would be a generally acceptedspontaneous improvement rate:a 95%b 80%c 75%d 25%e 50%.

3. Which of the following is not a key concept ofpsychoanalysis:a transferenceb countertransferencec working throughd conditioninge unconscious

4. Which of the following women were notassociated with child psychotherapy:a Anna Freudb Melanie Kleinc Hermine Hug-Hellmuthd Elizabeth Malcolme Margaret Mahler.

Multiple choice questions

1. Child psychoanalytic psychotherapy would notbe considered as a major choice of therapy forwhich of the following?a autismb anxiety disorderc depressive disorderd grief reactione disruptive disorders.

MCQanswers1abcdeTFFFF2abcdeFFFTF3abcdeFFFTF4abcdeFFFTF

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