It is my pleasure to have the opportunity to present my thoughts on the status of child analysis, as chair of the Committee on Child and Adolescent Analysis and as a practicing child analyst. This series of articles includes the task force report that was chaired by Martin Silverman, and an article by Lee and Rima Brauer, who in December 1995 reported on The Survey of Child Analytic Practice. How one defines “crisis” will determine the view of the problems and the possible solutions. For example, just as with adult analysis, for several years the number of candidate applications to our institutes has decreased, accompanied by a gradual attrition of the number of training analysts and supervising child analysts. The number of patients in both adult and child analysis has also been decreasing. This seems to be the result of several factors. Economic pressure due to managed care plans has discouraged many families from working with child analysts because most managed care plans do not authorize more than a total of three visits. Combined with the emphasis on the “biological” basis of childhood disorders that has increased pressure to place more children on medication, lack of public knowledge of psychoanalysis and child psychoanalysis, and the usual negative publicity about our field and Freud lead some to wonder if anyone still practices analysis.
Within our institutes is great variability in the number of candidates, patient availability for candidates, and faculty, and hence the degree of hopefulness that we and our field of child analysis (and adult analysis) can survive. What factors influence this variability in programs and in the availability of analytic candidates and patients? COCAA has developed a phone questionnaire to shed light on those factors that mitigate toward successful programs and happy analysts. The preliminary results were reviewed and collated at the December meeting of The American. This data will be presented to the Board on Professional Standards and widely distributed at the May meeting. I would like to present some of the preliminary findings and impressions now in anticipation of the detailed report.
We conducted a detailed phone interview with the chair of each child analysis program or the chair of the institute, if there was no organized program. The questions were categorized under education, faculty, recruitment of child analysis candidates, case finding, outreach, sharing information, and other ideas of how COCAA might be helpful. We had 100 percent participation. The amount of data was so extensive that our committee was excited, yet overwhelmed. These are some of the data and their implications:
Many institutes have child psychotherapy programs. Their experience has generally been positive in terms of teacher satisfaction and generating some child candidates.
The majority of institutes have not noticed a drop in applications for child analytic training.
There was overwhelming evidence that economic pressures are having an impact on child analysis and on psychotherapy practice and case finding.
Child analytic faculty refer children and adolescents to candidates. However, more than half the respondents said there were no referrals from the general faculty. Most child faculty do not discuss or encourage their adult colleagues to refer child or adolescent cases to candidates.
There were many reasons for the difficulties in case-finding for candidates. One worthwhile suggestion was to discuss with candidates and faculty how to refer a patient in analysis to a child analyst.
The majority of institutes agree that a first case can be a child. Some require a waiver. Pragmatically this seems to imply that an analyzable patient should be taken into analysis regardless of age.
Many institutes have integrated child analytic courses into their core curricula. The interesting finding was the great variability of the extent and nature of the courses. One extreme was the incorporation of all the required child analytic courses into the general curriculum. The other was that there were no courses, or only a child development course. There was also a strong sense by most programs that the candidates wanted specific advanced child analytic courses in addition to those in the core curriculum. Because of this, we decided to hold the COCAA Tuesday Workshop in May on the child analysis curriculum. This could highlight the process of curriculum development and integration.
Institutes have enhanced child analysis in many ways. One way was to invite child analytic courses.
While child analysts are busy in the institutes, clearly we must be more proactive in the community and in communicating with our institute colleagues to enhance child analytic referrals and the education of candidates.
There is an almost unanimous desire for a child analysis international network that could disseminate information and arrange practice and training workshops at the annual meetings. COCAA will consider holding a workshop later in the week of the national meeting that could be better attended and serve part of this function.
One of the questions we failed to ask became clear as we reviewed the data. We did not inquire about child analysts who value their education but prefer not to see children clinically. In child psychiatry there has been long-standing evidence that people stop seeing children as they become more senior. Is this the situation with child analysts and does it help account for the limited number of children in analysis, as found by Brauer in his survey?
This study exemplifies the philosophy and intent of COCAA. As it has evolved, the functions of the committee have broadened from functioning within BOPS as a standard-setting body that enumerated requirements for the education of the child analyst, that reviewed the institutes' appointments of child analytic supervisors, and that participated in site visits in conjunction with the Committee on Institutes. New functions include developing programs in child analysis, enlivening programs on the decline, consultation on curriculum and program issues, and holding workshops at the meetings on topics of interest. The subcommittees of COCAA now consult with a majority of the institutes. The broad representation on the committee from across the country and the growing sense of our function as a stimulant and advocate for child analysis has underlined our sense that our greatest
value lies in our consultative and information sharing functions. Thus this study. In a similar way we have encouraged child analysts and adult analysts to form regional scientific meetings attractive to other professionals in the community to bring community attention to child analysis. Study groups also serve to foster interchange and enhance interest in the field. These activities and the spirit of COCAA as it represents the attitude of BOPS carries our desire to serve as a facilitating body for institutes, our colleagues, and most importantly for the enhancement of the education of our candidates.
COCAA supports the proposals of the Task Force on Child Analysis. We believe that the strengthening of child analysis in our institutes and societies, and its increased visibility in The American through its program and publications will be a shot of adrenaline for analysis. The more children in analysis, the more their parents become sources of adult analysands. The educational value for our candidates is a more integrated understanding of the development of the mind. I believe there will be a greater interest in research possibilities as more analysts see the efficacy of child analysis, and the exciting mental functioning of children.
Samuel E. Rubin is chair of the Committee on Child and Adolescent Analysis.