Over the past 10 years, the Committee on Child and Adolescent Analysis (COCAA) has conducted a series of three surveys designed to assess the state of training in child and adolescent psychoanalysis at particular points in time (2002, 2005, 2010). The results of these surveys point to the serious challenges as well as the opportunities for growth within the field of child analysis today. Over the five-year period from 2005 to 2010, both the number of child and adolescent candidates and number of child and analytic cases conducted by these candidates declined significantly Overall, there are 20 percent fewer child and adolescent training cases and 21 percent fewer candidates in child and adolescent training than in 2005. However, from 2002 until 2005, these percentages increased. As a result, when the survey data from 2002 are compared with the 2010 data, there is a more modest, but still significant, decline. The number of child and adolescent candidates has declined by 8 percent and the number of cases these candidates have in analysis is 12 percent less than in 2002. Currently there are 166 candidates with a total of 110 cases in child and adolescent training programs in the Association.
However, candidates clearly continue to want and value child training. A number of metropolitan areas including Boston, Chicago, Michigan-Ann Arbor, New York, and Seattle each have 10 or more active child and adolescent candidates. Many graduate child analysts, including those who do not have large child analytic practices, believe that their child training has been invaluable for all aspects of their work. Child and adolescent training programs have provided their graduates with enhanced understanding of child development and the attendant emotional conflicts of childhood. These graduates can more effectively respond to the needs of all of their patients and have important tools to use in advocating for the welfare of children and in countering trends toward behavior therapy and medication for children.
A variety of factors, ranging from those that emphasize challenges from the external environment (e.g., general economic conditions, difficulty securing third-party reimbursement) to those that stress factors internal to the analyst (countertransference and the absence of conviction about the efficacy of child analysis) are often cited as contributing to the challenges currently facing the field. Keeping both sets of issues in mind is necessary in attempting to further understand the nature of the obstacles to child and adolescent psychoanalysis. Potentially relevant to this understanding is a preliminary study by Leon Hoffman and his colleagues of patterns of child analytic practice in New York City, which was published in the Journal of the American Psychoanalytic Association (JAPA) in 2009. In brief, Hoffman et al. found that although there were relatively few child and adolescent cases in New York City, most of these analyses were conducted by a small group of child analysts. Twenty-four percent (15/63) of child analysts were conducting a substantial portion—73 percent (41/56)—of the reported analyses. Hypothesizing that there has always been a small, active cadre of child analysts treating a majority of child analytic cases and that this group has enabled the field to endure, the authors conclude that “a systematic study contrasting the ”high immersion“ practitioners of C/A analysis with those who do not conduct C/A analysis might provide the field valuable information.”
To the extent that Hoffman et al.'s findings are generalizable, smaller or more geographically isolated child training programs may be particularly burdened by too few people doing too much of the work to “carry the torch.” One particularly creative response to this set of problems has been the development of the Southeastern Consortium for Child Analysis, an alliance developed to provide long-distance child and adolescent training. The Cincinnati Psychoanalytic Institute and the New Orleans-Birmingham Psychoanalytic Center are the formal sponsors of the consortium with potential child candidates applying to and enrolling in the child training program of one of these two institutes. In addition, candidates from other training programs have elected to participate in the weekly seminars when it has seemed advantageous to their training. A group of six candidates, along with one auditor, completed the first year of classes in June 2010. The success of this program has stimulated interest in developing a similar consortium on the West Coast.
Charles E. Parks, Ph.D., is chair of COCAA, secretary of the Association for Child Psychoanalysis, an adult training analyst and child and adolescent supervisor at the Baltimore Washington Institute, and holds faculty appointments at Georgetown and George Washington medical centers.
The development of child-focused analytic training programs in a number of institutes allows candidates to pursue and graduate from child analytic training prior to or in lieu of training and graduation in adult analysis. Based on a carefully conducted four-year pilot study of child-focused training (11 candidates in 4 institutes), BOPS voted in June 2006 to change its training standards so that candidates could be admitted for child analytic training only. These candidates would be eligible for membership and certification in the American Psychoanalytic Association upon graduation. Since then, seven child-focused programs have been developed and approved by COCAA. Currently, there are four candidates in child-focused training. One candidate has graduated from a child-focused program. Importantly, several other candidates have chosen to pursue adult analytic in addition to child analytic training.
…the existing significant body of research that indicates the usefulness of intensive treatment for children is not widely known, even to many child and adolescent analysts.
Recent systematic reviews of the evidence base for psychoanalytic child and adolescent treatments cite a growing research literature on the efficacy of such treatments. Key findings from the literature include (1) beneficial effects of psychoanalytic therapy on a broad range of outcome measures for children with a wide range of psychological disorders, (2) the need for intensive (as opposed to less intensive) approaches to prevent clinical deterioration in some cases, and (3) sustained, or even enhanced, improvement at long-term follow-up, including follow-up in adulthood. In an article published in JAPA in 1996, Peter Fonagy and Mary Target, on the basis of their reviews of the clinical records of 763 psychoanalytic and psychoanalytically-oriented psychotherapy cases from the Anna Freud Centre, found evidence that psychoanalytic approaches to treatment were particularly effective for younger children and for those with more severe emotional and social psychopathology. Importantly, the clinical condition of over 60 percent of the patients with more complex psychopathology deteriorated if they were not treated with intensive psychoanalytic treatment (i.e., three times per week or more). In this review, 80 percent of more neurotic patients benefited significantly from psychodynamic treatments. While more research in both process and outcome in child analysis is essential, the existing significant body of research that indicates the usefulness of intensive treatment for children is not widely known, even to many child and adolescent analysts. Particularly given the increasing emphasis on “evidence-based treatments,” reviews of this research need to be more effectively disseminated to local institutes and beyond.
The annual COCAA-sponsored workshop in January 2011, titled “When Child Analysis Is Indispensable,” involved further exploration of the potential advantages of intensive psychoanalytic treatment through the detailed comparison of therapeutic process and outcome in a four times per week, as opposed to a twice weekly, treatment of two different neurotic patients. This comparison highlighted the centrality of enhanced opportunities for and therapeutic usefulness of work with transferences as they arose in the relationship with the analyst in the four times per week treatment. COCAA is also exploring the possibility of developing a national registry of child analytic cases. Such a registry would begin to provide more information about the nature of current child and adolescent cases and treatment outcomes, including long-term follow-up.
In recent years, COCAA has become increasingly attentive to the need for didactic training in aspects of ethical and professional conduct which arise specifically in work with children and adolescents. Two of the most recent COCAA-sponsored workshops on boundary violations and ethics in work with children and adolescents have been well attended and enthusiastically received. Current plans include developing a sample curriculum in this area with the recommendation that such training be included in the curriculum in the adult as well as child and adolescent programs of each institute. Drawing on clinical material studied in these two workshops, as well as the work of the COPE Study Group on Supervision in Child and Adolescent Analysis, Paula Atkeson and Anita Schmukler have authored a monograph on ethical practice in child and adolescent analysis, providing a much needed contribution to the literature on this important topic.
The future of child psychoanalysis depends on whether Hoffman's small cadre of highly immersed child analysts and teachers can endure. Much of the work outlined above suggests that this small group can be transformed into a larger, more vibrant child and adolescent analytic community. Child analysis has historically played a vitalizing role in the American Psychoanalytic Association. However, an enhanced focus by the entire Association, child and adult colleagues alike, is necessary if we are to take advantage of this time of challenge and opportunity.
Editor's Note: In this issue, this article replaces the regular BOPS column by Colleen Carney and Lee Ascherman.