Outcome in Child and Adolescent Psychoanalysis—Part II

In a previous issue, we presented an overview of outcome studies in child and adolescent psychoanalysis [See “Issues in Child & Adolescent Psychoanalysis,” TAP 53/1, page 25]. We were interested to learn what happens to these children and parents in later years and what impact the analytic process had on them—positive and negative. Among the issues that emerged was the paucity of outcome information (especially with respect to the parents of the children) and the variety and complexity of investigating this area.

This article is a brief response to Leon Hoffman’s request to highlight some preliminary results of our ongoing research on outcomes of child/adolescent analysis. Some of the goals of this work were noted in the prior article. Here we will first discuss the process of the study and then some of the preliminary findings.

Interview Process

A short summary of the process of contacting and interviewing the patients and parents follows. As noted previously, we contacted the patient/parents at least two years after termination of the 4-5 times per week analysis. Most patients and parents had already given consent to participate as part of an institute clinical/research initiative, when the researchers made the first current contact; occasionally, the original analyst made contact. All subjects completed the IRB-approved consent forms. Interviews were conducted either in person or by phone.

The interviewers were blind to most of the content and process of the analysis, so they would be less biased as they interviewed the patient and parents. All interviewers were graduates of APsaA institutes, all were certified, and most were child and adolescent psychoanalytic graduates. All subjects agreed to be recorded; if recording equipment was unavailable,

the interviewer took notes. The interviewer asked about the patient/parents’ experience of the analysis, with questions following from this information. The patient/parents were told this was not an evaluation of the analysis, patient, or parents. The patients were interviewed between 2-6 times, and the parents 1-2 times.

Various Demographics

Thus far, there have been a total of eight patient/parents contacts. Four of the patients were female, four male. Seven of the analysts were male, and one was female; the female analyst treated a female patient. In all eight contacts we were able to interview all the parents (one case was a single-parent family, with only the mother available). In six contacts we were able to interview the patient. In two cases, the patients decided not to be interviewed (one female, one male).

From the Issues in Child and Adolescent Psychoanalysis Editor

In this issue Paul Holinger and Robert Galatzer-Levy conclude their two-part series describing the follow-up of child analytic cases. In the first article, Holinger and Galatzer-Levy stressed the dearth of follow-up studies in child and adolescent analysis. [See “Issues in Child & Adolescent Psychoanalysis,” TAP 53/1, page 25.] In this issue they describe the outcome data of cases in which eight children and adolescents had been seen 4-5 times a week. Among their very interesting and important findings, I would like to stress one:

“The patients were very impaired initially, both with respect to their internal world as well as their behaviors. Anxiety, depression, obsessions and compulsions, problems with anger, suicidality, sleep, eating, and other issues were interfering with their development and at times putting their lives at risk. Given the interview data and the general outcome of these current students and professionals, it would appear that the analyses contributed positively to their development.”

This is an important message for the mental health community. An intensive, lengthy analytic treatment can be very helpful to children and adolescents with severe emotional problems. In fact, one of their patients said “that she was very happy with herself, and that treatment worked because it was longer than her previous therapies.”

Hopefully, more of us can engage in this significant work.

—Leon Hoffman

Interestingly, in several cases the parents thought the patient would be reluctant to be interviewed, but in fact they were very willing; in the two cases of patients who were not interviewed, the parents had thought they would be willing. Additionally, sometimes the patients felt their parents would not agree to be interviewed, but the parents welcomed the opportunity. In other words, both parents and patients often misread the other’s feelings about participating.

Three patients were 6 years old or less when starting analysis (two males, one female); three were 7 through 12 years (two females, one male); and two were 13 through 15 years (one female, one male). The ages of the patients at the interviews were as follows: two were 17 through 18 years (two females); and four were 23 or older (three males, one female); the two patients who were not interviewed were 23 through 27 years (one male, one female). (Throughout this article data is presented as group summaries to protect subjects’ privacy.)

Presenting Problems and Diagnoses

These were rather troubled children and parents with referral diagnoses including ADHD, Asperger’s, autism, antisocial personality disorder, schizophrenia, bipolar illness, and depression. Seven of the eight patients came from intact families, i.e., lived with both parents. One patient was a father-loss case, one patient was adopted, and one was a fraternal twin.

The presenting problems were varied and severe. These included: unable to attend school and/or asked to leave; regressed in bowel and bladder; depressed; suicide attempts, hospitalizations, suicidal ideation; cutting; obsessive-compulsive symptoms; anger, temper tantrums, impulsivity; delinquent behavior and trouble with the law.

The initial diagnoses by the analysts included: major depression; OCD; anxiety disorders (including selective mutism); eating disorders; and personality disorders (including conduct disorder).

Treatment

All patients were seen 4-5 times per week. The parents were usually seen every 1-2 weeks initially, shifting to once a month and often less as treatment continued. The analyses lasted between 3-5 years. Nearly all analysis tapered off at the

end, e.g., two sessions per week, to once a week, to once a month, etc.

Three of the patients were on medications at various times during the treatment: antidepressants, stimulants (Ritalin), anti-anxiety agents, and sleep medications. One was on antidepressants throughout treatment, with, according to parents and patient, dramatic positive results.

Dreams and transference were prominent aspects of treatment. However, they tended to appear later in treatment, with discussions initiated by the analyst. Dreams initially tended not to be reported spontaneously, but dream work became more part of the treatment over time subsequent to the analyst asking about dreams. Transference work occurred in all treatments, but often most apparent in the latter half of the analysis. Prior to that, “play” and work in displacement dominated, and transference interpretations were often met with “Let’s just play, doc!” or with an outstretched hand: “Talk to the hand, not to the head!”

The creativity and variety in the play and interactions between patient and analyst were rather striking. The “play” included puzzles, drawing, board games, baseball and basketball, TV and movies, computers, a variety of activities using the analysts’ office contents and furniture, and even the dogs of one analyst.

Post-Analysis

Five of the eight patients had post-termination contact with their analyst. Three had occasional sessions over a period of years, and two returned for once a week sessions for several months. Of these five, two also saw other therapists briefly, but returned to their initial analyst. Three patients did not see their analyst post-termination; one of them noted she was very happy with herself, and the treatment worked because it was longer than her previous therapies.

Five of the eight parent-couples, usually mothers, and the single mother made post-treatment contact with the analyst. The reasons varied widely: talk with the therapist about their own issues; get referrals for themselves or other family members or friends; update the analyst on the development of the patient; and so on. Two mothers continued about once a month contact for years.

In general, the mothers manifested more investment in the treatment than the fathers, and fathers often saw the analyst far less during treatment. Some parents made significant psychological progress during the treatment, and some did not. Regarding the latter, one father during the outcome interviews remained convinced his son should have followed the professional path he (father) had urged all along, rather than the interest his son chose—despite the fact his son was performing spectacularly in the field of his own choice and enjoying it. Most parents expressed vivid gratitude about the treatment.

General Outcome

During the follow-up interviews, two patients were still students and doing well, and the other six were working in various professions. According to the patients and/or their parents, they felt successful and busy. Their professions included: teaching, medicine, digital media, car sales/mechanics, business management, and policing. Of the five who were out of school and over 23 years old, four had been in long-term relationships (two married, one has a child); we had no relationship information about one.

Aspects of the severe pathology which brought the children into treatment could now be seen in modulated and adaptive (rather than debilitating) form in some of their professional work. For instance, in one patient, early marked obsessive-compulsiveness now found a home in fine, delicate medical work; and in another patient, remnants of extreme fear of anger and criticism in childhood were recognizable in his adult work of sophisticated police and security work.

Many of the patients, particularly those who started analysis before 6 years old or in latency, could barely remember why they had come initially or what the problems were. However, at follow-up, all the patients tended to show a high level of self-awareness and self-reflection. They seemed capable of understanding their character structures with the liabilities which led to treatment and also their assets and potentials. They also knew when they needed help with either past issues which reemerged or current obstacles.

This raises the question Nathan Schlessinger and Fred Robbins addressed concerning the reemergence and recognition of transference and character issues in the process of the follow-up interviews. With most patients, we did not have enough interviews with individual patients to show the same kind of process (remobilization and self-analysis of the transference with the interviewer) that Schlessinger and Robbins found. What we did find similar were evolved sophisticated capacities for self-understanding and self-reflection. These were seen in younger as well as older patients we interviewed, though it tended to be more pronounced the older the patient.

Summary

Research in psychoanalysis is as complex and varied as the field itself. This preliminary study represents an effort to address questions surrounding the paucity of outcome information in child/adolescent analysis and to highlight a few themes that may have a bearing on our clinical work.

First, this current effort suggests patients and parents are willing to be interviewed and discuss the treatment and outcome. All the parents involved in the treatments talked with us, as did six of the eight patients. As Schlessinger and Robbins reported, no adverse effects were noted and most patients and parents said they were grateful for the opportunity to reflect on the process. However, we do not know why two of the eight patients ultimately did not participate.

Second, the patients were very impaired initially, both with respect to their internal world as well as their behaviors. Anxiety, depression, obsessions and compulsions, problems with anger, suicidality, sleep, eating, and other issues were interfering with their development and at times putting their lives at risk. Given the interview data and the general outcome of these current students and professionals, it would appear the analyses contributed positively to their development.

Third, there were both differences and similarities evident in the analytic process itself from patient to patient. Differences: There was a wide variety of ways analysts worked to connect with the children and adolescents, and the creativity was remarkable. Also, the length of treatments varied considerably as did the post-termination contact. While all analyses involved the parents, the amount of contact was quite variable. The use and perceived benefits of medications also varied.

Similarities: The terminations almost always involved a tapering from 4-5 times per week to fewer, over time. In addition, since its inception, the field of child/adolescent analysis has grappled with the mutative aspects of analyses. Donald Winnicott , Jose Valeros , Helen Beiser , Phyllis Tyson] , and many others have wrestled with such questions. In these eight analyses, the following issues were all prominent and seemed essential: the analytic relationship and play; the interpretation of affect, childhood antecedents and transference; and work with the parents.

Fourth, the issue of post-termination contact with the analyst deserves mention. More than half of the patients made post-termination contact with their analysts. Perhaps most strikingly, 75 percent of the parents made post-termination contact with the analyst. Some of these contacts lasted for years. This would seem to highlight the importance of the parent work and the need to seriously consider re-examining the significance of these relationships and work.

Finally, we would like to express our gratitude to Leon Hoffman for his encouragement of this project, to the patients and parents who shared their experiences with us, and to our many colleagues who are participating in various ways throughout this venture.