In the course of discussing questions that arise in the supervision of child and adolescent analysis, our COPE Study Group on Supervision of Child and Adolescent Analysis found that questions about boundary issues occur frequently and often are perplexing. Our study group's lively discussions increasingly focused on the complexity of defining boundary problems in child and adolescent work. We found ourselves unclear in many instances about what constituted a true boundary violation as distinguished from boundary crossings, boundary intrusions, and enactments. In our meetings, we set about clarifying our thinking, not only about formal distinctions but, more importantly, how to work with material presented by our child and adolescent analytic patients which could lead the analyst into boundary difficulties.
Several characteristics unique to child and adolescent analysis make boundary issues more complex than issues that arise in the conduct of adult psychoanalysis. The first difference is that in child analysis, the analyst is also working with parents, and is often in contact with nannies, teachers, physicians, and other significant adults in the child's life. Within this complex system, boundary issues can readily arise. The second difference is that the child and adolescent communicate important material through action rather than words. While “using your words” is an important outcome of analysis, the child and adolescent express thoughts and feelings not only in play but also in actions directed toward the analyst. Third is the pressure for the analyst to regress arising from the immaturity of the child and the developmental level of the impulses the child is expressing in action. Lastly, the analyst serves as a new developmental object for the child which can raise technical questions including the question of when it might be appropriate to serve a protective function for the child in certain situations.
We found ourselves unclear in many instances about what constituted a true boundary violation as distinguished from boundary crossings, boundary intrusions, and enactments.
Thus there are many instances in child and adolescent treatment that unless worked with in a thoughtful and insightful manner, could give rise to boundary issues. An illustrative example is the issue of the child and the analyst touching. This can happen in a game of tag, when the child may dive into the analyst's lap, or when the adolescent hovers too closely to the analyst indirectly expressing erotic impulses. The analyst needs to quickly think, is this behavior a communication that may facilitate treatment or does it need to be limited as too stimulating for both the child or adolescent and the analyst? How far should the analyst let this behavior unfold, when should the analyst limit it and how should that be done? The analyst considers the transference meaning of these actions and the impact of the analyst's response in the context of the patient's specific conflicts and his/her developmental stage. The analyst also needs to be clear as to why he/she has chosen a particular technique in the moment. Clearly, an adolescent seeking physical contact presents a different issue than a young child's doing so. Most important of all, is that the analyst be fully aware of his/her counter-transference to these behaviors in order to make the most appropriate choice in how to work with this kind of material.
While we all agree that we want to help our patients move to “use their words,” there is no one right way to work with the issue of physical contact. The discussions in our
Paula G. Atkeson, Ph.D., is a training and supervising analyst, and supervisor of child analysis, at the Baltimore Washington Institute for Psychoanalysis. Atkeson is one of the founders and governing board members of the Jenny Waelder Hall Center for Children.
Anita G. Schmukler, D.O., is a training and supervising analyst and child supervisor at the Philadelphia Center for Psychoanalysis; supervisor of child analysis at the Psychoanalytic Institute of NYU, the Western New England Psychoanalytic Institute, and the Cincinnati Institute of Psychoanalysis.
study group of various considerations and approaches indicate that each case in all its complexity needs to be individualized within a general ethical context to facilitate the analytic treatment.
Since the purpose of our study group is to examine dilemmas of supervision, we addressed this material in that context. In multiple cases, we examined what transpires when a candidate is beset by difficulties in identifying and working with ethical and boundary issues. Frequently a candidate, perhaps because of unresolved conflicts, responds to a parent with deference and fails to protect the child's privacy. Also, we hear of candidates' anger with parents and their failure to recognize transferential issues. Ethical dilemmas are often the consequence of such situations.
Given our exposure to such dilemmas in child training, our extensive discussions of them and our educational mission, our study group has developed a three-session Curriculum on Ethical Practice in Child and Adolescent Analysis. We hope to address areas that may not be covered in case conferences and yet are a crucial part of training in analytic work with children. Further, we are in the process of developing the curriculum and associated material into a casebook for ethical practice in child and adolescent analysis. This will have applicability for child analytic candidates, for the community of child analysts, and for all persons involved in the psychotherapeutic treatment of children.