When we examine the work of child analysis and child therapy, what do we find that distinguishes these two modes of treatment?
In current discussion of the topic, emphasis is upon frequency of sessions, with the concurrent challenge regarding frequency. In fact, it is the close connection among frequency, analytic stance, and interventions (including interpretation of defenses and transference) that determines whether an analytic process is taking place in work with a child.
One feature that distinguishes work with children is attention to particular developmental issues: delays, lags, fixations. In work with children whose primary symptoms are of neurotic origin, the developmental issues are part of the analysis. A misperception in modern times has been that helping children return to the path of development is the goal of treatment. This notion fails to give sufficient attention to the analysis of neurotic conflicts and may attend more to behavioral manifestations than to internal conflicts and defenses.
Of primary importance is the assessment of the child's difficulties. Neurotic conflicts that are firmly rooted, in a child with good ego strength, are generally most responsive to analysis. In these cases, greater frequency permits more opportunity to interpret defenses and transference. One aspect of assessment for child analysis is the way the child engages with the analyst and the response to early interventions. Internalized conflict and access to imaginative fantasies are crucial.
For children with ego disturbances, psychoanalytic psychotherapy may be the treatment of choice, even when the frequency of meeting is four or five days weekly. This may help the child in developing ego strengths.
In comparing and contrasting such cases, only a careful examination of process notes of many child cases of similar age and pathology in which one child is treated in analysis and another in therapy can demonstrate this perspective.
One aspect of assessment for child analysis is the way the child engages with the analyst and the response to early interventions.
With respect to transference, here is a brief example of two children Anita Schmukler treated.
Two nine-year-old girls had been in treatment for three years, one in analysis and the other in therapy. Both exhibited symptoms related to conflicts with their mothers, both of whom were relatively isolated from their daughters, while also spending a good deal of time away from home in work-related travel.
Karen, bright, curious, and psychologically minded, constructed play in which a good deal of transference references was patent. Gentle, careful work with this material led to some elaboration of her feelings, but she was not able, in her twice-weekly sessions, to work with transference conflicts. Why was analysis not utilized in this case? While in some cases the choice of treatment is based upon psychological problems and ego structure, in this case it was based upon the child's living about 90 minutes from the closest psychoanalyst and her being one of seven siblings, two of whom were physically challenged. Thus, the burden on the family was a consideration in making a recommendation.
Stephanie was in a four-day/week analysis and, at nine, had developed a capacity for insight and work with analytic material. Dealing with similar issues in play to those that Karen had brought, she constructed play in which a large toy cat had a mother who stayed away for “four years” on business trips. In the play, the girl moved with her father and siblings to 213 Main Street.
After examining the associated feelings from many perspectives, Schmukler wondered about the relation between 213 and 212, her office suite. Stephanie looked surprised at first
Anita 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.
Paula 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.
and then, tearfully, said she wished that she lived next door to Schmukler's “real” home so that the analyst could “share in the mothering” and help the little girl to grow.
There were multiple implications for positive and negative transference and these were examined in depth.
Even in 2012, we hear from some colleagues that “child analysis is not real analysis.” In reply, we can suggest that they examine child analytic cases for evidence of work with defenses, transference, object relations, and the multiple perspectives from which we work. Examination of structural change and effective work at termination would also illuminate the study.
…the description of child analysis as simply resolving the interferences to progressive development does not convey the complexity of what takes place in child analysis.
Child analysis involves regression in the context of the transference and analysis of conflict and defense, as well as addressing impediments to development, but the description of child analysis as simply resolving the interferences to progressive development does not convey the complexity of what takes place in child analysis.
Freud did not think that analysis of children, in the depth to which we analyze adults, was possible. In 1909, commenting on Little Hans and the work that his father did with him, Freud wrote:
It was only because the authority of a father and of a physician were united in a single person, and because in him both affectionate care and scientific interest were combined, that it was possible in this one instance to apply the method to a use to which it would not otherwise have lent itself. No one else, in my opinion, could possibly have prevailed on the child to make any such avowals…
So Freud, at least in 1909, could not fathom analysis of transference in a child. His view seems to have affected generations of analysts since that time. Freud's daughter, Anna, developed methods of analyzing children and tried to find compromises between the analytic methods established for adults and the educational approach that children were thought to require. Anna Freud resisted the notion that children could develop intense transference neuroses in the course of analysis.
The intermingling of interpretive work and educational approaches to working with children, in addition to inattention to transference, led many analysts to conclude that child analysis is not “real” analysis. Since many analysts of children present clinical material as if “the play says it all,” with minimal interpretive work, analysis of transference and resistance, and analysis of dreams may lead the listener to suspect that perhaps child analysis is identical with therapy, only with more frequent sessions. This would certainly make one doubtful about recommending a treatment that is so arduous and time consuming, especially if the conviction about the vast potential of analytic treatment is not present.
Melanie Klein also tried to apply methods for adults in working with children. Initially, she tried to use the couch with young children, and looked for free associations in this manner. She soon discovered that this was not a feasible approach, and she evolved a mode of play therapy that was substantively more fruitful. Overall, adult psychoanalysis was the model for working with children, which both delayed progress in the field of child analysis and conveyed an impression that child analysis was not “full analysis.” That construct has influenced generations of clinicians and is worthy of deep and thorough examination.
Today we attend to transference neurosis in children, we work with perceptions of analyst as both transference object and developmental object and both are subjected to analytic scrutiny. We are aware that educational approaches, when they arise, can be subjected to analysis as well.
From this perspective, we can see that the analysis of children and adolescents is, indeed, analysis.