Child Psychoanalytic Psychotherapy Research Articles

Dual citizenship and wicked problems: a leadership stance in child and adolescent psychoanalytic psychotherapy

ABSTRACT This paper raises and addresses issues to do with leadership and child psychotherapy, beginning with a report on a systematic review of papers about leadership in the Journal of Child Psychotherapy (JCP). The authors establish that leadership is expressed implicitly rather than as an important issue in its own right with relevance to clinical work, service development and the ongoing viability of psychoanalytic child psychotherapy. When reviewing the limited literature available, the authors classify them into five types of article: tribute to leaders past; clinical leadership; threat to survival and call to action; organisational leadership; and exemplary papers describing professional leadership. The authors query why the leadership literature is sparse and inexplicit and respond by using the theme of ‘dual citizenship’ to explore the issue from a psychoanalytic and organisational perspective. The psychoanalytic perspective explores tensions and barriers that may be profession-specific in relation to leadership. The organisational perspective explores the wider literature on leadership, starting with the concept of ‘wicked problems and clumsy solutions’. The authors introduce and describe a ‘leadership stance’ that is compatible with psychoanalytic practice in context. This requires opening up leadership activity to the same scrutiny and reflective practice as clinical work, which provides ways of containing organisational and career anxieties and perplexing clinical problems. This paper is a call to action in regard to integrating leadership into the training and the profession.

Integrating professional identities: an ethnographic study of psychoanalytic child psychotherapy in a children’s social care setting

ABSTRACT The importance of child and adolescent mental health services (CAMHS) collaborating with other agencies is of paramount concern for children with complex difficulties, including children in care. However, there is a lack of research exploring the role of child and adolescent psychoanalytic psychotherapists in multi-disciplinary and multi-agency work surrounding these children. Aims: to develop a theory of how child and adolescent psychoanalytic psychotherapists function within a social care setting, including how they position themselves in a multi-disciplinary and multi-agency environment. Methods: an ethnographic case study design, consisting of participant observation supplemented by interviews. Findings: grounded theory analysis identified that the child psychotherapists balanced three elements of their professional identity: discipline-specific identity; CAMHS team member identity; child’s care network member professional identity. To be effective in their role, the child psychotherapists needed to integrate the elements of their professional identity. The findings have implications for understanding the contribution of child psychotherapists in this field, particularly how to integrate into multi-disciplinary and multi-agency settings, whilst retaining their distinctive professional identity.

Kinship care: uncannily close for comfort?

ABSTRACT This paper explores the impact of kinship care upon the child, as observed through the clinical lens of child psychoanalytic psychotherapy. It acknowledges the social care and policy landscape, which retains a widely held belief that kinship care is a preferable option to foster care. In the light of this belief, the paper also draws attention to the internal and external dynamics inherent in the complexities of this arrangement as presented in the child’s psychotherapy and the parallel parent work. Clinical vignettes are used to illuminate the often unconscious, painful and confusing thoughts, feelings and fantasies experienced by both the child and the kinship parent. Psychoanalytic ideas relating to Freud’s ‘The Uncanny’ and Winnicott’s paper ‘Mirror-role of the mother and family in child development’ are used to underpin the clinical material and reflections. The paper culminates in emphasising the need for practitioners to be attentive to these dynamics, and to provide robust support for the kinship parents, in processing their kinship experience and the intergenerational traumas it may stir up.

Measuring health-related quality of life measures in children: lessons from a pilot study.

There is a debate in the health outcomes literature regarding who the most appropriate respondent is when assessing children’s health-related quality of life (HRQoL). In some cases, parent-proxy may be the only practical option where children are unable to self-complete an HRQoL questionnaire. However, children’s self-reported values may be preferable because HRQoL is subjective and represents the respondent own perception of health. We collected the youth version of the EQ-5D-3L as part of a feasibility study comparing psychoanalytic child psychotherapy with usual care for children aged 5-11 years with treatment resistant conduct disorders. The questionnaires were completed at baseline and 4-month follow-up by the child via face-to-face researcher administration, and by one parent as a proxy respondent. We present percentages of completion at each time-point and investigate the level of agreement between child and proxy-respondent on the child’s health. About two thirds of children (65.5%) were able to complete the EQ-5D-Y at baseline and 34.4% at follow-up. Children and primary carers were mostly concordant regarding overall child’s health. Parents reported more problems in ‘doing usual activities’ and ‘feeling worried, sad or unhappy’ and fewer problems with ‘pain’ and ‘looking after oneself’ than children did. The reports regarding ‘mobility’ were very similar between children and proxy-respondents. The assessment of quality of life by children using selfreport questionnaires is possible with the help of a face-to-face researcher, providing evidence that children should be asked to self-complete HRQoL questionnaires in trial studies.

The Tiger Skin on the Bannister (and Other Stories): Internal Dialogues and Parallel Autobiographical Process in a Reading of Wilfred Bion’s The Long Weekend, 1897–1919: Part of a Life

ABSTRACT This essay presents excerpts from a reading of the section ‘England’ in Wilfred Bion’s autobiography The Long Weekend, 1897–1919: Part of a Life. Findings are now presented alongside a series of the reader’s own memories that were evoked, at varied speeds, both during and after the reading process. Drawing on the fields of infant observation and child psychoanalytic psychotherapy, the essay demonstrates how exercising an observational stance to the reader's own subjective material and subsequent, reflexive internal dialogues contributed to penetrating layers of meaning of the book. Furthermore, it aims to show how a reading of an autobiography unexpectedly enabled a powerful, parallel creative process within the reader.

The psychoanalytic psychotherapy endeavour in the Greek public sector

The paper maps the services that provide psychoanalytic psychotherapy for children, adolescents and adults in the Greek public sector, the research projects that contribute to the development of psychoanalytic research, along with the training in psychoanalytic psychotherapy available in Greece. It underlines the lack of adequate psychotherapeutic services available to the Greek population, an unfortunate fact considering the troubled times that the Greek society has been through in the recent years (socio-economic crisis, refugee crisis, etc.). Finally, it discusses one of the prominent problems psychoanalytic psychotherapists in Greece face, that is the absence of official recognition of the specialty or title of ‘psychoanalytic psychotherapist’, as a psychotherapist is not a registered profession in Greece.

‘Sea of trapezoids’: the analytic setting and virtual treatment during a pandemic

ABSTRACT The Covid-19 global pandemic has, for the moment, upended the traditional setting for analysing transference and countertransference dynamics, vital components to the work of psychoanalytic child psychotherapy. The physicality of the customary treatment setting provides a basis for the experiences of containment and understanding, along with the corresponding and familiar technical considerations within that setting. The absence of these fixed physical elements when transferring cases to virtual and other non-conventional settings points to a new set of technical challenges. How do we understand projective identification, transference and countertransference with children when the modified setting does not inherently afford a child the physical means to make contact with the consulting room as a container? What resources do we have as clinicians for persevering through the psychoanalytic process, in the face of the current global uncertainties? In this paper, I outline some of the theoretical underpinnings in psychoanalytic child psychotherapy that elucidate the challenges to the work I have encountered with my child patients during the pandemic, and explore the clinical implications stemming from those challenges.

Modifications of the therapeutic setting during the Covid-19 pandemic: thoughts based on the Greek experience with latency children and adolescents

ABSTRACT The paper reflects on the authors’ observations regarding the handling of the Covid-19 pandemic within the context of child and adolescent psychoanalytic psychotherapy in Greece. The specific conditions in Greece during the first general lockdown are described, and the necessary modifications to the therapeutic framework with latency children and adolescents are discussed. During the lockdown, the authors continued to meet with their patients online, a framework that had both advantages and limitations. The authors share their thoughts about the ways they tried to keep the connection with their patients alive, in the face of the first wave of the coronavirus crisis.

Clinical Assessment of Prementalizing Modes of Psychic Functioning in Children and Their Parents in the Context of Trauma

ABSTRACTAs psychoanalytic psychotherapy for children depends on their capacity to mentalize, it is essential to integrate this dimension in their psychological assessment. Mentalization refers to the capacity to identify and comprehend the mental states (feelings, thoughts and intentions) underlying and explaining one’s own behaviors and those of others. This vital ability, which develops during the first five or six years of life in the context of a secure parent-child attachment, is often impaired in children subjected to neglect and maltreatment. Based on rigorous and systematic clinical observations made in youth protection and child psychiatry services, the authors suggest that the children in these settings, along with their parents, frequently present a prementalizing mode of psychic functioning. Further, the authors propose operationalizing the teleological, psychic equivalence, and pretend modes as they might be observed in older children and their parents. To this end, they begin by identifying behaviors, attitudes, and relational patterns potentially linked to each of these modes within a theoretical framework. Next, they describe the characteristics of these children’s narratives, play, and artistic productions. Lastly, three clinical vignettes are used to illustrate how the prementalizing modes are manifested. The results of this clinical assessment can guide the choice of techniques to be used in child psychotherapy.

TIGA-CUB-manualised psychoanalytic child psychotherapy versus treatment as usual for children aged 5–11 with treatment-resistant conduct disorders and their primary carers: results from a randomised controlled feasibility trial

Background: Parenting programmes are recommended for conduct disorders in 5–11 year olds, but ineffective for 25–33%. A feasibility trial was needed to determine whether a confirmatory trial of second-line, manualised short-term psychoanalytic child psychotherapy (mPCP) versus treatment as usual (TaU) is practicable.Method: This was a two-arm, pragmatic, parallel-group, multi-centre, individually-randomised controlled feasibility trial with blinded outcome assessment. Child–primary carer dyads were recruited from National Health Service Child and Adolescent Mental Health Services and mPCP delivered by routine child psychotherapists.Results: Thirty-two dyads (50% of eligible, 95% CI 37 to 63%) were recruited, with 16 randomised to each arm. Eleven (69%) completed ≥50% of 12 week mPCP and 13 (81%) ≥1 session. Follow-up was obtained for 24 (75%) at 4 months and 14/16 (88%) at 8 months. Teacher follow-up was 16 (50%). Manual adherence was good. Baseline candidate primary outcomes were 37.4 (SD 11.4) and 18.1 (SD 15.7) on the Child Behaviour Checklist/Teacher Report Form externalising scale and 102.8 (SD 28.4) and 58.8 (SD 38.9) on the total score. Health economics data collection was feasible and the trial acceptable to participants. Conclusion: Recruitment, teacher follow-up and the manual need some refinement. A confirmatory trial is feasible, subject to funding of research child psychotherapists.

TIGA-CUB \u2013 manualised psychoanalytic child psychotherapy versus treatment as usual for children aged 5\u201311 years with treatment-resistant conduct disorders and their primary carers: study protocol for a randomised controlled feasibility trial

BackgroundThe National Institute for Health and Care Excellence (NICE) recommends evidence-based parenting programmes as a first-line intervention for conduct disorders (CD) in children aged 5–11 years. As these are not effective in 25–33% of cases, NICE has requested research into second-line interventions. Child and Adolescent Psychotherapists (CAPTs) address highly complex problems where first-line treatments have failed and there have been small-scale studies of Psychoanalytic Child Psychotherapy (PCP) for CD. A feasibility trial is needed to determine whether a confirmatory trial of manualised PCP (mPCP) versus Treatment as Usual (TaU) for CD is practicable or needs refinement. The aim of this paper is to publish the abridged protocol of this feasibility trial.Methods and designTIGA-CUB (Trial on improving Inter-Generational Attachment for Children Undergoing Behaviour problems) is a two-arm, pragmatic, parallel-group, multicentre, individually randomised (1:1) controlled feasibility trial (target n = 60) with blinded outcome assessment (at 4 and 8 months), which aims to develop an optimum practicable protocol for a confirmatory, pragmatic, randomised controlled trial (RCT) (primary outcome: child’s behaviour; secondary outcomes: parental reflective functioning and mental health, child and parent quality of life), comparing mPCP and TaU as second-line treatments for children aged 5–11 years with treatment-resistant CD and inter-generational attachment difficulties, and for their primary carers. Child-primary carer dyads will be recruited following a referral to, or re-referral within, National Health Service (NHS) Child and Adolescent Mental Health Services (CAMHS) after an unsuccessful first-line parenting intervention. PCP will be delivered by qualified CAPTs working in routine NHS clinical practice, using a trial-specific PCP manual (a brief version of established PCP clinical practice). Outcomes are: (1) feasibility of recruitment methods, (2) uptake and follow-up rates, (3) therapeutic delivery, treatment retention and attendance, intervention adherence rates, (4) follow-up data collection, and (5) statistical, health economics, process evaluation, and qualitative outcomes.DiscussionTIGA-CUB will provide important information on the feasibility and potential challenges of undertaking a confirmatory RCT to evaluate the effectiveness and cost-effectiveness of mPCP.Trial registrationCurrent Controlled Trials, ID: ISRCTN86725795. Registered on 31 May 2016.

Discussing the therapeutic setting in child and adolescent psychoanalytic psychotherapy

The aim of this paper is to contribute to a debate on the particular characteristics of the therapeutic setting in child and adolescent psychoanalytic psychotherapy and its differences from the setting in adult therapy. In our opinion, there is a fundamental difference between these two, as in child and adolescent psychotherapy two distinct aspects co-exist and in some areas, overlap. In this paper, we attempt to delineate these two aspects, following Green’s division of the analytical setting into the active matrix and the casing. We propose that in child and adolescent psychotherapy the therapeutic contract, the active matrix, concerning the necessary conditions for making a therapy psychoanalytic – namely, the therapist’s free-floating attention and the patient’s free associations – is agreed between the therapist and the child/adolescent. We argue that in contrast, the contract regarding the casing – the timings of sessions, the fees and so on – is agreed primarily with the parents or carers of the child/adolescent. Ruptures and possible modifications in both the matrix and the casing of the setting are discussed through the presentation of clinical material.

The impact of parental participation in the child's psychoanalytic therapeutic process

In child psychoanalytic psychotherapy, including parents or guardians in the process is not a random or indifferent factor. The literature is restricted and not conclusive regarding the approach to be followed. Our aim was to analyze the impact of parental participation in the therapeutic process of a school-age child, who began psychotherapy because he presented behavioral problems and relationship difficulties in school. We performed a naturalistic, descriptive, longitudinal study that followed the Systematic Case Study method. The psychotherapy lasted for 160 sessions with the patient and 25 interviews with the parents. We identified that the interviews with the parents had an effect on the therapeutic process, observable in the sessions after these interviews, both in the therapist and in the child. We conclude that the psychopathological state of the child, the family dynamics, therapist’s characteristics and experience are important factors and capable of contributing to different effects, in each case.

20/20 Hindsight: A 25-year programme at the Anna Freud Centre of efficacy and effectiveness research on child psychoanalytic psychotherapy

Objective: This paper describes the evolution of methods of enquiry—through 25 years of work, with Professor Peter Fonagy and many other colleagues—of research and theorizing about child and adolescent therapy outcomes. Method: The work has focused on measuring psychoanalytic outcomes, but with an increasing interest in discovering therapeutic elements across treatment modalities. Results: Headline findings are described, with lessons from the ups and downs of developing (a) retrospective, follow-up, and prospective outcome studies, and (b) measures of child and family functioning. Issues of manualizing and measuring treatment process are discussed, together with the fruitfulness of mixed-method (quantitative and qualitative) process and outcome research with young people and families. Conclusions: Using the dilemmas, experiences, and findings ‌‌of our group as examples, growing points and well as growing pains for the field are suggested.

Child psychoanalytic psychotherapy: a single case study

Child psychoanalytic psychotherapy is a specific approach to the treatment of emotional, social and behavioural problems in children. There are hundreds of modalities of psychotherapy, and this continues to increase. The vast majority has not been investigated using controlled (or other types of) studies and not all of these methods are based on explicit etiological or therapeutic theories of change. A gap exists that should be filled between psychotherapeutic research and clinical practice. Based on these assumptions, the present study sought to analyse the first year of the psychotherapeutic process of a boy aged seven who was referred for psychotherapy. A descriptive study was performed, based on a single case study design. The participants were the child and his therapist and the main measure was the Child Psychotherapy Q-Set–CPQ, a procedure used to analyse the psychotherapeutic process in 3–13-year olds. The results show the main elements of the psychotherapy process, describing characteristics of the child, of the therapist and the dyad interaction.

The Intersubjective Nature of Play Development and Its Role in Child Psychoanalytic Psychotherapy.

Playing is a vital activity in childhood. It is important to psychological development, in both cognitive, emotional, and social dimensions. It has a core role to the young child’s mental health. In the clinical setting, play has had an important function, enabling a way of communicating with the child, and a privileged way for creation of meanings and expression of feelings, affects, fears, angry, difficulties, etc. In this article, I highlight the intersubjective nature of play development, its impediments and its crucial role in child psychoanalytic psychotherapy.

A study of process in psychoanalytic psychotherapy with children: the development of a method

Objective: The aim of this article is to present the development of a method of analysis of the process of psychoanalytic psychotherapy with children (MAPPP-C) that is relevant for the study of the psychotherapy process from the perspective of the object relations theory. The process was studied by analysing changes in child patients' anxieties, defence mechanisms, object relations and unconscious phantasies, in each psychoanalytic psychotherapy session and throughout their entire psychotherapy. Method: MAPPP-C is both a qualitative and quantitative method of analysis of child psychoanalytic psychotherapy processes. This article will describe the stages in the de-velopment of the method, how the indicators were determined, the units of analysis in the study, the development of analytical codes, the training of raters in this method and inter-rater reliability and agreement tests. Results: This article describes the tasks that compose MAPPP-C, examples of its application and presents some hypotheses that arose from the analysis of the pilot study. Discussion: The preliminary results show that MAPPP-C is a method that allows one to assess the psychotherapist's interventions and the patient's responses in order to enable the analysis of the psychotherapeutic process. The results of the reliability test of the method will allow it to be applied to other types of psychoanalytic psychotherapy with both children and adults.

Predictors of discharge in child psychoanalytic psychotherapy

This empirical study was based on the analysis of the results of a study about dropout predictors among in child psychoanalytic psychotherapy. The objectives were to characterize the sample of children discharged from psychoanalytic psychotherapy, examine the association between sociodemographic/ clinical variables and child psychoanalytic psychotherapy discharge, and determine predictors of discharge in child psychoanalytic psychotherapy. This quantitative, descriptive and retrospective study analyzed the clinical records of 600 children treated in three institutions that offer graduate courses in psychoanalytic psychotherapy in Porto Alegre, Brazil. The analysis of clinical records revealed that 24.2% of the child patients were discharged from treatment. Neurological assessment and treatment duration were predictors of discharge in child psychoanalytic psychotherapy. The predictors of discharge and dropout may coincide, but they are not the same. In this sample, the construction of the therapeutic alliance and the understanding of the reasons why children need psychotherapy by their parents or guardians may explain our findings.

A psychoanalytic child psychotherapy contribution to generic assessments.

Psychoanalytically trained child and adolescent psychotherapists have applied psychodynamic thinking to family work, consultations and brief work for some time. Findings from a research project in which the author investigated the processes involved in generic assessments undertaken by herself and what actually takes place are presented. A description of some skills and techniques used by the author are also described.

Psychoanalytic psychotherapy for children and adolescents with severe depressive psychopathology: Preliminary results of an effectiveness trial.

This waitlist-controlled field study aimed to evaluate the effectiveness of psychoanalytic short- and long-term psychotherapy for children and adolescents by using a prospective design. The presented analyses focus on the self- and parent-reported levels of depression and the therapists' ratings of the patients' level of functioning. Thirty-five children and adolescents (aged 4-21 years) and their parents who entered psychoanalytic therapy in private practices in northern Germany participated in this ongoing study. At the time of data analysis, the wait-list control group comprised 17 patients. Data were collected from therapists, parents, and from the patients themselves. Questionnaires were administered at the beginning and the end of treatment, as well as up to 5 points in time during therapy. Follow-up took place at 6 and 12 months after therapy. Depression levels were measured with the self- and parent-reported screening questionnaire Child Depression Inventory, and quality of life with the KIDSCREEN. Patients received, on average, 97 sessions of therapy (range: 25-205). Overall, patients showed pronounced impairments at the commencement of outpatient therapy. At the end of therapy, there was a significant reduction in depression in the treatment group (parent report: d = 0.88, p < .001; patient report d = 0.68, p ≤ .003). The wait-list control group, which received minimal treatment, displayed a slight, but not statistically significant, symptom improvement in the patient report (d = 0.07, p ≤ .503), but a significant improvement in the parent report (d = 0.49, p ≤ .008). The results suggest that psychoanalytic therapy is successful in alleviating depressive pathology and improving quality of life for a significant number of depressed children and adolescents.