Child and adolescent analysis tends to be characterized by a variety of aspects of psychoanalytic theory and technique, including: establishing an alliance and atmosphere of safety; attention to conscious and unconscious affect, motivation, and action; transference and countertransference issues; play, interpretation, non-interpretive elements, work with parents, and others.
We work very hard on day-to-day process and interventions, trying to understand internal and external worlds of the youngsters and their development. There are a variety of well-known criteria one considers when contemplating tapering off or termination.
However, we have become increasingly curious about several issues. What happens to these children and their parents in later years? Bluntly, how do we know our efforts are of value in the long run? What factors are mutative in a positive sense, and what might be deleterious? And there are additional questions. What kinds of children and parents come into analysis? What do these treatments teach us about development, about transference and countertransference, and about the influence of the environment, e.g., parents and other factors? And why is there not more information about the outcome process? The above discussion introduces our effort to respond to Leon Hoffman’s request to describe our ongoing research on outcome in child and adolescent psychoanalysis. For some time now, we have been slowly gathering cases of child and adolescent analyses around the country and interviewing the patients and their parents at least two years after termination.
We are aware research in these areas is extremely complex. Such exploration clearly benefits from various strategies, including epidemiological, prospective and retrospective, statistical, narrative, case reports, anecdotal, and open-ended approaches. To this end, we very much hope this discussion might encourage others to explore aspects of child and adolescent analysis that interest them, and thus enhance our understanding of this remarkable field.
In adult analysis, some outcome studies do exist, e.g., Arnold Pfeffer , Nate Schlessinger and Fred Robbins . One of the major findings from those two studies involved the notion that the major transference manifestations of the analyses were repeated in the follow-up interviews, although with more self-awareness, regulation, and insight. This suggested a conscious and unconscious self-analytic function had been achieved via the analysis. There are also individual long-term cases in the adult analytic literature, for example, patients of Freud (e.g., Sergei Pankejeff [“The Wolfman”] and the poet HD), Winnicott, and others.
From the Issues in Child and Adolescent Psychoanalysis Editor
This is the fifth article in our series on child and adolescent analytic and psychodynamic practices. In the prior issues of this series, we have described two short-term psychodynamic psychotherapies with children (childhood anxiety and externalizing disorders); and have described work in the community by a child and adolescent analyst.
In this issue Paul Holinger and Robert Galatzer-Levy begin a two-part article describing the follow-up of child analytic cases. Holinger and Galatzer-Levy stress the dearth of follow-up studies in child and adolescent analysis. They very rightly stress the complexities of follow-up studies. Among their questions, they wonder how follow-up studies can help us understand more about development, transference and countertransference, and about the influence of the environment, e.g., parents and other factors. And, most importantly, they wonder why is there not more information about the outcome process?
Finally, they hope their work can encourage others to participate in this very important endeavor.
—Leon Hoffman
Child analysis has less literature on outcome. There are several individual long-term outcome descriptions: e.g., Herbert Graf (“Little Hans”), Peter Heller , “Frankie,” (Berta Bornstein, 1949; Sam Ritvo, 1966), Helen Beiser , and “Susie” (Sam Weiss, 2000). Jonathan Cohen and Bert Cohler’s book The Psychoanalytic Study of the Lives Over Time brought together several additional cases. There also exist some larger long-term studies of psychoanalytic psychotherapy, (e.g., Peter Fonagy and Mary Target , Fonagy et al. , Nick Midgley et al. , which tended to show that, over time, those children who were most troubled seemed to gain the most (Galatzer-Levy et al., 2000). Interestingly, there is little in the child/adolescent literature that links the analysis with the later self-reports of the analysand; one exception is Midgley et al. (see below). Perhaps most remarkably, given the importance of the work with parents in child/adolescent analysis, there are almost no data on the parents and their reactions to the analysis and their changes and relationships with the analyst.
Midgley et al. utilized the long-term outcome study of child and adolescent psychoanalysis from the Anna Freud Centre as described by Target and Target and Fonagy. Midgley’s group interviewed 27 adults who were referred as children and adolescents to the Anna Freud Centre and received intensive treatment (4-5 times per week). A qualitative approach was utilized, but issues of transference and countertransference were explicitly not explored. Rolf Sandell and Sandell and Alex Wilczek suggested outcome studies can beneficially focus on “the patient’s subjective experience of the state of having changed—or not.” Within this conceptualization, it is somewhat startling to note Midgley et al.’s finding: “Over a third of those who took part in this research suggested the therapy they had received as children had had little impact on their lives, or had been a waste of time.” Furthermore, several participants reported “the sense that the analysis had a negative impact on their lives as children … and made certain aspects of their lives (at the time) worse. Interestingly, nearly all those who made such comments were women who had been in therapy as latency-age children or adolescents.”
What are we to make of this relative lack of information? Our training and concepts? The effort it takes to do both the analytic work and the research? Arrogance? Fear? Resistance? However, as Schlessinger and Robbins have reported (1983; personal communication), in their follow-up interviews of nearly 40 adult analysands, they experienced no adverse reactions and many reports of appreciation from patients for having an opportunity to rethink their analyses and sometimes get back into a helpful treatment with the same or different analyst.
Our basic strategy currently is to find child/adolescent analytic cases that have terminated/tapered off at least two years prior, and interview the patients and their parents. Unlike most studies mentioned above, the follow-up interviewer is blind to the analysis per se. These are open-ended interviews, and we ask the patients and their parents about their reactions to the analysis, subsequent lives, and anything else they may want to talk about.
What information do we hope to gain from this study? This includes: What issues tend to bring parents and children into treatment; how do patients and parents experience the treatment; what did patients and parents feel helped or did not help in the treatment; further understanding of the dynamics of the transferences and character structure of the patients and parents over time; nature of the “termination,” and subsequent contact by patients and/or parents with the treating analyst; any subsequent treatment of patients and parents; enhanced understanding of child, adolescent, and adult development in general; medication use; experience of the follow-up process; and more.
We will describe the protocol and preliminary data in more detail in the next issue of TAP. Institutional Review Board (IRB) approval has been granted for this study by the Chicago Institute for Clinical Social Work IRB Board.
Editor’s Note:
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