Although the empirical knowledge base in psychoanalysis is constantly growing, there has been a paucity of systematic studies in child and adolescent psychoanalysis. More recently, the situation has begun to change.
The importance of empirical work has been stimulated by Peter Fonagy, Mary Target, and colleagues. One example was an early work, a well designed controlled study on the psychoanalytic treatment of diabetes by Moran, Fonagy, et al (1991). Fonagy and Target's 1996 report on 763 cases comparing intensive and non-intensive therapy was a landmark, even with its methodological drawbacks, because it generated enthusiasm among analysts for the worthiness of empirical research. For example, they found that analysis was particularly effective for more seriously disturbed children, a group that “is not that which analysts most frequently identify as ‘good analytic cases.’”
Child and adolescent psychoanalysis has been enriched by its extensive clinical literature dating back to Hug-Hellmuth, Melanie Klein, and Anna Freud, despite the drawbacks of relying only on clinical reports. Analysts, immersed in clinical work, find such reports more valuable than research reports. In fact, many researchers in the field of psychotherapy have observed a disparity between clinicians and researchers in child and adolescent psychotherapy—a gap between empirical results in laboratory settings of mainly manualized behavioral and cognitive treatments and treatment provided in general clinic settings (non-manualized and non-behavioral, including use of dynamic concepts). Unfortunately, psychoanalysis or intensive psychodynamic treatment is not represented in most of these studies. The usual mode of psychotherapy in clinic settings is a once a week treatment, whose efficacy has been questioned by Weiss, et al, in two studies. In fact, Fonagy and Target, in 1994, observed that the usual practice of once a week therapy, in contrast to intensive treatment, may be counterproductive in children and adolescents with disruptive disorders.
Systematic research in psychoanalysis, important as it is, is a formidable challenge, particularly since the goal of psychoanalysis is not just symptom relief. Because many now do believe that it is critical to develop systematic empiricism in the field, an APsaA Research Subcommittee in Child and Adolescent Psychoanalysis has been established, first by the Board's Committee on Child and Adolescent Analysis (COCAA) and later including the Council's Committee on Child and Adolescent Psychoanalysis (COCAP). I am chair of the subcommittee.
Our first task will be to determine the nature of the patient population and the work analysts are carrying out. Previous attempts to survey child and adolescent psychoanalysts have had variable success. In order for the current project to work, institutes will have to actively champion the value of systematic research, bringing the field closer to other scientific fields.
Perhaps the most practical way to begin will be to systematically survey the supervised analyses conducted under the auspices of institutes affiliated with APsaA. Supervised psychoanalyses are particularly useful to study because the educational climate lends itself to a treatment that follows the theoretical ideal of the educational institution and detailed process notes are already being kept. This follows the suggestions of Gabbard, Gunderson, and Fonagy, who propose a “multisite process and outcome study in which all patients under taking psychoanalysis under supervision become subjects in a rudimentary investigation of the outcome of psychoanalytic treatment.”
Hopefully, after initial pilot studies, all institutes will participate, including graduate analysts as well as candidates. Instruments are being finalized that will be used to collect a variety of data describing the patients (demographic, diagnostic, developmental, life stressor, and other factors). Briefer instruments will be used to follow-up with the patients. One question that can be answered is: Are most of the children and adolescents in psychoanalysis the more seriously disturbed ones like those described by Fonagy and Target?
Leon Hoffman, M.D., is vice chair of COCAA, co-chair of COCAP, and director of the Pacella Parent Child Center of The New York Psychoanalytic Institute & Society.
It is important to begin the study of the mechanism of change during psychoanalysis, an area of relative neglect in psychotherapy research. In order to determine what actually occurs during psychoanalytic sessions, in the future we hope to systematically study the narrative reports of individual sessions, using a consistent set of parameters. Certainly, an ideal study would evaluate the process via videotaped recordings of sessions; however, at this nascent stage of our endeavors, such an undertaking is unrealistic.
One of the instruments that can be used is the empirically validated Child Psychotherapy Process Q-set (CPQ) (by Celeste Schneider and Enrico Jones), but as a Likert scale. The CPQ provides a basic pan-theoretical language for the description and classification of therapy process in child treatments. This pan-theoretical instrument is more effective than one in which the therapist is asked about explicit techniques utilized. We will ask our subjects to rate the detailed process notes of a representative session with the CPQ. What analysts actually do in sessions can be correlated with a variety of variables, including the report of their theoretical orientation.
This is important because it has been demonstrated that even when using manuals, therapists do not always do what they say they are doing, and the mutative agent in the therapy may not be what the therapist believes it is. Psychodynamic therapists often apply cognitive behavioral techniques, and the mutative agents in CBT are often psychodynamic factors, labeled with CBT terminology.
The current project is being designed as a series of modules that can be implemented separately or as a whole, including a systematic evaluation module, symptom and adaptive scales that can be used for follow-up, and a process module. If we succeed, the project will provide a great deal of demographic information about the children and adolescents in psychoanalysis, about the nature of the analytic interventions used, and the treatment outcome. This data and the results obtained will also generate a variety of testable hypotheses for further study.