In the January 2022 issue of Psychiatric News, psychiatrist Claire Zilber describes the Collaborative Care Model (CoCM) in which a case manager and psychiatrist team up with the primary care physician taking charge of the patient's overall care. Dr. Zilber touts this model as “the more ethical approach to (psychiatric) resource allocation” because the most good is done for the most people, in contrast, she says, to psychiatrists practicing psychoanalysis, where the immense time investment in one person is inappropriate.
How do psychoanalysts respond to such a statement? We know that psychoanalysis can be a life-changing therapy as a result of the healing power within a powerful ongoing relationship. Psychoanalysis is also an illuminating research instrument into human emotional life. In fact, many patients enter psychoanalysis after disappointing results in less intensive therapies.
Those of us who practice psychoanalysis find that organizational psychiatry, including child and adolescent psychiatry, manifests a lack of interest in the forces at play within the mental and emotional lives of patients. Too many psychiatric approaches still focus on defining causes of mental and emotional distress only via medical, genetic, neurologic, and behavioral models, minimizing the exploration of the power and complexity of patients' subjective lives.
Edwin Land, inventor of the Polaroid camera, observed that often problems are not hard to solve; the hardest job is usually to define a problem clearly and well. Subsequently, solutions often suggest themselves. A clinically informed understanding of a patient's subjective world is most important in trying to understand the nature of a person's problems. A liaison group of child and adolescent psychoanalysts has worked intensively with colleagues at the American Academy of Child and Adolescent Psychiatry (AACAP) over the past twenty-five years. In that way they have made inroads in promoting the restoration of the psyche to psychiatry.
In the 1990s, which U.S. president George H.W. Bush declared the Decade of the Brain in a show of support for neurological research, Rachel Ritvo and Paulina Kernberg lobbied successfully for AACAP to create a Psychotherapy Task Force, which Dr. Ritvo then chaired. American Psychoanalytic Association (APsaA) members Lee Ascherman, Lawrence Hartmann, and Shirley Papilsky served on the task force. Their report was published in 1999 in the Journal of Psychotherapy Practice and Research. A policy statement was subsequently drafted supporting psychotherapy as a core competence in the training of child and adolescent psychiatrists; this was revised in 2014 and is again under revision to reflect recent advances in research supporting psychodynamic treatments as evidence-based. In 2012, the Journal of the Academy of Child and Adolescent Psychiatry (JAACAP) published a practice parameter for psychodynamic psychotherapy with children. Paulina Kernberg's initial draft was completed after her death by Helene Keable and Rachel Ritvo.
After the task force disbanded, a formal psychotherapy committee, with enhanced staffing and meeting times, continued to advocate for psychodynamic psychotherapy as an efficacious treatment modality for children and adolescents. In an invited editorial in JAACAP in celebration of AACAP's 60th year in 2013, “Past Imperfect, Future Tense: Psychotherapy and Child Psychiatry,” Rachel Ritvo and Judith Cohen pointed out that psychodynamic psychotherapy was historically the foundational frame of AACAP's early organization. Since that time, several APsaA and ACP members of AACAP have sponsored programs and panels at annual meetings, supporting the value and efficacy of psychoanalytic theory in clinical work with children and adolescents.
A twenty-two-year series of panels at AACAP annual meetings, focused on psychoanalytic concepts, was organized by Nathaniel Donson and sponsored by AACAP's Psychotherapy Committee.
Beginning in 2000, AACAP's Program Committee supported a fifteen-year series of clinical case conferences called “Contributions from Child Psychoanalysis,” each with a DSM subtitle. Using case material presented and discussed by child and adolescent psychoanalysts, and balanced by contributions from non-analytic members
of the child and adolescent psychiatry (CAP) community, the efficacy and richness of analytic work with young children and adolescents once again became embedded in annual AACAP meeting programs. Panel participants in that series included Judy Yanof, Susan Coates, Kerry and Jack Novick, Martin Silverman, Penny Hooks, Helene Keable, Roy Aruffo, Robert King, Alexandra Harrison, Ted Shapiro, Lee Ascherman, Horatio Hojman, Mali Mann, Dan Jacobs, Arthur Farley, Tim Dugan, and Efrain Bleiberg. Topics ranged widely and included discussions of gender identity disorder, adoption, leaving home for college, obsessive compulsive disorder, supervision, and work with families.
In 2017, Martin Drell, Maya Hubert, and Nathaniel Donson discussed the value of the psychoanalytic constructs of enactment and transference/countertransference in working with provocative children on inpatient units. In the same year, a six-year series, “Integration of New Developmental Research in Infant Mental Health in Psychotherapy in Children and Adolescents,” was begun in which Arietta Slade, Beatrice Beebe and Martin Drell, Alexandra Harrison, Daniel Schechter, Joshua Sparrow, Efrain Bleiberg, Andrew Meltzoff, Regina Pally, and Judith Cohen discussed the uses of psychoanalytically oriented developmental infant research in later clinical work with children and adolescents. These panels stressed the importance of parent-infant attachment, relationship-based therapies, and evidence-based parenting strategies. The 2021 panel considered the value of Susan Donner's analytic dyadic play therapy with a preschool child with autistic features, with Charles Zeanah providing a research discussion and Lynda Phillips stressing the value of mentalization.
Beginning in 2020, a second series of panels, called “Models of the Mind” after John Gedo and Arnold Goldberg's seminal work and chaired by Nathaniel Donson and Timothy Rice, discussed psychodynamic work with children and adolescents. This series was specifically intended to provide the AACAP audience with psychoanalytic
models for understanding more about the mental lives of their patients. Each panel was entitled “The Continuing Clinical Value of Psychoanalytic Models of the Mind: Developmental, Relational and Psychodynamic Perspectives: …,” with a DSM diagnostic subtopic. Panelists and discussants, all child and adolescent analysts, commented on topics ranging from work with disruptive children in inpatient and outpatient settings to work with gender-expansive children. The first panel offered a comparison of analytic treatment and traditional child psychiatric care with clinical presentations of two children by Timothy Rice and Joseph Wise, discussed by Efrain Bleiberg, Peter Daniolos, and Stanley Leiken.
Too many psychiatric approaches still focus on defining causes of mental and emotional distress only via medical, genetic, neurologic, and behavioral models, minimizing the exploration of the power and complexity of patients' subjective lives.
The 2021 subtopic was “Relational Trauma, Mourning, and Other Clinical Puzzles in Two Gender-Expansive Preschool Children.” Nathaniel Donson and Stanley Leiken presented a brief consultation and a full analysis. Susan Donner commented from a developmental perspective, highlighting the tasks of preschool children and the role of the therapist as a developmental object. From a relational perspective, Cecil Webster integrated the clinical material with a contemporary vantage on gender identity. Lee Ascherman's psychodynamic perspective focused on loss, trauma, mourning, and identity development in relation to transference, countertransference, and adaptations of technique. In two related panels at the 2022 Toronto AACAP meeting, Sandra Meyerovitz, Elizabeth Tuters, and Ella Roglaska, all members of the Canadian psychoanalytic community, discussed Danette Graham's analysis of four-year-old Susie from developmental, relational, and psychodynamic perspectives. Beverly Stoute, in a clinical case conference, explored the role of ethno-cultural toys in children's play and addressed the use of toys and play to foster meaningful dialogue around race and identity.
In 2018, AACAP's Psychodynamic Faculty Initiative (PsyFI) was launched as the Psychodynamic Faculty Training and Mentorship Initiative. PFTMI is a faculty development mentorship program to bring ongoing training and recognition to CAP faculty members who are teaching psychodynamics. A second goal of the program is to lay a foundation for creating a psychodynamic faculty community within AACAP to anchor the continued presence of psychodynamic and psychoanalytic knowledge within AACAP.
Under the leadership of Rachel Ritvo, PsyFI began with a donation to AACAP from the Samuel and Lucille B. Ritvo Charitable Fund. It was conceived as a program similar to APsaA's Teacher's Academy. With the capacity to select up to six CAP mentees per year, to date PsyFI has received forty-two applications and selected twenty-six mentees. Each mentee is matched with a mentor, either a psychoanalyst or a child and adolescent psychiatrist who demonstrates a sustained interest and teaching experience in psychodynamics.
Each mentee develops a year-long project to enhance psychodynamic training, didactics, and/or supervision within their department. Each mentorship year begins with a planning day held during AACAP's annual meeting in October. This approach was organized on the model of Yale's Psychoanalytic Research Training Program (RTP). As with RTP, the intent of the AACAP initiative is to support participants as they develop their local programs through consultations and discussions provided within the mentor-mentee pair. The project thus pairs junior CAP faculty members with senior psychoanalysts and psychiatrists to support curriculum development informed by psychoanalytic principles. Psychoanalysts from both APsaA and the Association for Child Psychoanalysis have generously participated as mentors including Lee Ascherman, Sergio Delgado, Timothy Dugan, Susan Donner, Mali Mann, Tim Rice, Craigan Usher, Ayame Takahashi, and Daniel Schechter.
The mentorship program evokes an awareness among younger CAP faculty that psychodynamics is more than just one more variation of psychotherapy. This was discussed in a November 2021 JAACAP article by Michael Shapiro, who stressed that “a broader and more accurate definition of psychodynamic is a way of thinking in multiple clinical contexts.” A psychodynamic perspective informs the construction of developmentally informed bio/psycho/social diagnostic formulations and treatment planning, strengthens the therapeutic alliance, and aids in the management of transference/countertransference enactments. It is anticipated that ongoing funding will be obtained, and, for the foreseeable future, the program will continue to develop a community within AACAP for psychodynamic psychiatrists and psychoanalysts. A variety of listservs serve communication and dissemination of educational materials. Most recently an independent listserv was formed: .
Dr. Norbert Rieger, a child psychiatrist, came from fascist Germany in 1939 to Camarillo, California, where he became director of the children's inpatient unit at the local California State Hospital. In his years there, he changed a troubled institution
into an active treatment center for severely disturbed children. He was an optimistic and courageous clinician who fought valiantly against the backward mental health system in California.
When he passed away in 1985, he left behind a charitable foundation allocating funds for organizations in the United States and Israel, with funds specifically designated for AACAP. He was immensely grateful for AACAP having accepted him, a young immigrant, into its membership. These funds have underwritten two AACAP Rieger Awards each year since 1990 for the best JAACAP article and for the best service program. A third annual award was added in 2001 for the best psychotherapy paper submitted to the AACAP psychotherapy committee, which has subsequently given the award to nineteen AACAP members. Each winner is offered a reading at annual AACAP meetings. The list of winners includes both analysts and non-analyst members of AACAP: Rex McGehee, Vernon Rosario, Candice Good, Barbara Milrod, Rachel Seidel, Helene Keable, Lenore Terr, (three-time winner) Daniel Schechter, Ann Alaoglu, John Burton, Michael Shapiro, Sergio Delgado, Gilbert Kliman, Susan Donner, Beverly Stoute, and Leon Hoffman.
Through the work of dedicated psychoanalysts, psychoanalysis remains alive at the American Academy of Child and Adolescent Psychiatry. To retain its presence and rebut accusations of inappropriate expenditure of time and effort in the service of our patients, continuity of this work is needed. We encourage other child and adolescent analysts to get in touch with us if you are interested in participating in this important work in years to come.
Rachel Z Ritvo, M.D., is a graduate of the Baltimore Washington Psychoanalytic Institute in adult, adolescent, and child psychoanalysis, an ABPN board-certified child and adolescent psychiatrist, an Assistant Clinical Professor at GWU Medical School, and retired from thirty-three years of private practice.
Nathaniel Donson, M.D., an analyst-psychiatrist, is a psychiatric consultant at the Youth Consultation Service Institute for Infant and Preschool Mental Health in East Orange, New Jersey, and a faculty member of the Columbia University Psychoanalytic Center for Training and Research.
Timothy Rice, M.D., is Associate Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai in New York City. He is Director of Inpatient Psychiatry and of Medical Student Education in Psychiatry for Mount Sinai Morningside and West.
Stanley J. Leiken, M.D., is a Distinguished Life Fellow of AACAP and a Clinical Professor of Psychiatry at UCLA School of Medicine. He has been in private practice of child and adult psychiatry and psychoanalysis for over sixty years.