“Child analysts have a mean of 1.05 child cases in analysis.” This startling statistic appears in the American Psychoanalytic Association's 1990–93 Survey of Psychoanalytic Practice. The report further states, “The striking finding is that the majority of child graduates have no child patients currently in analysis” (italics mine), and that “most of those with cases have only one case in child analysis.” Surely, there is an urgent crisis in the field of psychoanalysis that needs to be addressed if one branch of the field and, by minimal inference, the entire field is to survive.
What is The American doing to address this urgent problem? In 1993, I was asked by Bernard Pacella, then president, and Marvin Margolis, then chair of the Board on Professional Standards, to form and chair a Long Range Planning Task Force on Child and Adolescent Psychoanalysis. In concert with the Executive Committee, which added names to the list of prospective members I compiled, I assembled a group that included experienced child analysts and recent child analytic candidates, recent graduates, and psychoanalysts who do not work directly with children but who appreciate the contribution child analysis and child development have made to psychoanalysis.
We communicated at first by telephone and mail. We have continued to do so since then, but beginning in December 1994 we also met at each scientific meeting of The American. We have examined a number of issues, including the failure of some psychoanalytic practitioners and educators to recognize that children and adolescents can be successfully analyzed, with lasting benefit, and that child and adolescent analysis is as legitimate as the analysis of adults. We have been scrutinizing the ways that adult and child analysis inform and enhance each other, clinically and educationally.
Another issue involves the practice within psychoanalytic education of splitting child analytic training from the basic psychoanalytic curriculum and relegating it to a secondary status. The implicit message is that psychoanalysis consists primarily of the psychoanalysis of adults. Training in the psychoanalytic treatment of children and adolescents requires merely additional training that has to be undertaken after a reapplication procedure and at considerable additional cost in tuition, time away from one's family, and willingness often to undertake yet more supervised cases at a low fee. Postponing child analytic training until the completion of training in the analysis of adults also means that it is usually undertaken after a candidate completes personal analysis, despite the serious educational disadvantages that imposes. It also puts child analytic training in a position of prolonging a candidate's “student” status and of competing with the excitement of “graduation” and moving on to the status of teacher and administrator. This is a practice that can hardly be expected to encourage candidates to undergo child analytic training.
A third issue is the tendency for child analytic training to thrive in some areas but wither in others. Related to this is the serious decline in recent years in the number of child and adolescent analyses being conducted, even by experienced, well-known, highly respected child analysts. This has been documented in the report of APsaA's 1990–1993 Survey of Child Analytic Practice conducted by Lee and Rima Brauer in December 1995.
The history of child analytic training in member institutes of The American, the organizational split between the Association for Child Psychoanalysis, and the antipathy that has existed between adult and child analysis epitomized by the formation of The American and that organization, and the attention paid or not paid to child analytic issues in national meetings of The American and in the major psychoanalytic periodicals, have also been deliberated by the task force.
The task force has made a number of recommendations that have been conveyed to the officers of The American. The most important recommendation has been that The American endorse and do everything possible to implement fundamental changes within its member institutes so that candidates are trained in the theory and practice of psychoanalytic treatment of adults, children, and adolescents. We strongly recommend that our member institutes be encouraged and enabled to offer an integrated psychoanalytic training program in which candidates are trained in the theory and practice of psychoanalysis of people in all stages of life. We have in mind a curriculum that does not merely include child development as an isolated focus, but that truly aims at training candidates to analyze patients of all ages, if that is a candidate's goal.
I am in the process of developing, in consultation with the other members of the task force, a model curriculum that can provide the candidates from the beginning to the end of training with a unified view of psychoanalysis as a body of knowledge and a modality of psychological treatment for all patients. Child, adolescent, and adult analysis would be addressed in every course track and in essentially every course in the basic curriculum. An attempt would be made to include clinical material involving patients in various age groups throughout the curriculum. The ways the technical and theoretical issues dealt with can inform and elucidate, as well as pedagogically complicate and interfere with, training in treating these different groups is given consideration in this model curriculum. This curriculum would include electives and options that would allow a degree of choice of courses, including continuous case seminars, which not all candidates might elect to take. This plan could allow some candidates to graduate with rich exposure to principles of child and adolescent analysis but without interest in analyzing these patients, while other candidates interested in being certified as child and adolescent or as adolescent analysts, in addition to working with adult patients, could do so with a only an additional year or so of classes. Training child and adolescent analysts would be much more candidate-friendly than the current, two-tiered system.
We propose that, in coordination with such a unified, single curriculum of psychoanalytic education, candidates not only be permitted, but strongly encouraged, to begin supervised child and adolescent analytic cases as early as possible in their training. We expect they usually would do so after having first begun a supervised adult case and showing an understanding
of the principles involved. There might be instances, however, when it might be appropriate for a particular candidate to begin working with a particular child as her or his first case, as is already being done in at least six institutes affiliated with The American. No one, of course, would be forced to analyze a child or adolescent. We urge, however, that The American and the administration of each institute of The American sincerely stand behind the recognition that the analysis of a child and the analysis of an adolescent is legitimate psychoanalysis on par with the analysis of an adult.
In this regard, we strongly recommend that The American in its certification process recognize the satisfactory analysis of an adult, a child, or an adolescent as equal in value. We could envisage requiring any three satisfactory cases as fulfilling the requirements for certification as a psychoanalyst, so long as two of them are of adults, i.e., three cases including one child or one adolescent, whether or not the applicant is in full child analytic training. This was recommended by the Certification Committee a long time ago but was not implemented. The system that has prevailed permits an applicant for certification as a psychoanalyst who is engaged in child analytic training to substitute the three supervised child and adolescent cases seen in supervision for the child analytic training in place of one of the adult cases required for certification. This actually penalizes candidates for entering child analytic training and disparages adult analysis.
This needs to be changed. Perhaps the entire process of assessing competence as a psychoanalyst would benefit from reconsideration, including less reliance on numbers and more reliance on other criteria, as some of the members of the task force indicated in our discussion.
The task force also recommends that a strong and sincere effort be made to see that there be more inclusion of child and adolescent material in the proceedings of the scientific meetings and in the papers published in JAPA, not only as separate papers and panels devoted to child and adolescent themes but also in those devoted to general issues of psychoanalytic interest, as well as in the pages of TAP. We urge that serious consideration be given to the appointment of an associate program chair of The American and an associate editor of JAPA and of TAP for child and adolescent analysis. (The editor of JAPA has responded to our suggestion by appointing such a person.) We urge also that strong and sincere efforts be instituted by The American to effect a dialogue and all other appropriate measures that might work toward healing the rift that exists between it and the Association for Child Psychoanalysis. We urge, too, that individual child and adolescent psychoanalysts work within their institutes, societies, communities, and the various activities of The American in the interest of fostering professional and public awareness of the effectiveness and value of child and adolescent analysis, and that studies be undertaken to assess the effectiveness and value of the psychoanalytic treatment of these segments of the population. We have begun to discuss how these efforts might be carried out.
Child analysis is in serious danger. And if one part of the body of psychoanalysis develops gangrene, can that possibly be good for the rest of the organism?
Martin A. Silverman chairs the Joint Task Force on Child and Adolescent Psychoanalysis. He is also clinical professor of psychiatry, training and supervising analyst, and former chair of the Child Analysis section at New York University Medical Center; training and supervising analyst at the New York Psychoanalytic Institute; and past program chair for the Association for Child Psychoanalysis.