The Handbook of Child and Adolescent Psychotherapy

Psychoanalytic Approaches

Monica Lanyado, Ann Horne, Monica Lanyado, Ann Horne

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134691845
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This Handbook provides a comprehensive guide to the practice and principles of child and adolescent psychotherapy around the world.
Contents include:
* a brief introduction to the child psychotherapy profession, its history and development
* a review of the theory underlying therapeutic practice
* an overview of the varied settings in which child psychotherapists work
* analysis of the growth of the profession internationally
* an examination of areas of expertise around the world
* a summary of current research
Contributors are experienced practitioners from within a diverse range of schools and approaches and so provide a well-rounded picture of child and adolescent psychotherapy today. The Handbook of Child and Adolescent Psychotherapy will be an essential resource for professional psychotherapists, students of psychotherapy, social workers and all professionals working with disturbed children.

1 Introduction

Ann Horne and Monica Lanyado

The psychoanalytic tradition, with its emphasis on the importance of childhood experience, is now just over one hundred years old. Early papers on work with child patients began to appear about eighty years ago (Hug-Hellmuth 1912; Sokolnicka 1920; Freud, A. 1926; Klein 1927). Trainings in child and adolescent psychotherapy began in the UK in the 1930s and 1940s, consolidating in 1949 in the formation of the Association of Child Psychotherapists, which today accredits courses and sets standards for membership of the profession. As a young profession, operating mainly within the National Health Service in the UK, child and adolescent psychotherapy has not only survived but has reached a maturity.

Nevertheless much of what child psychotherapists actually do remains a matter for specialist professional journals, The Child Psychotherapist and the Problems of Young People and the later Extending Horizons being notable exceptions here (Daws and Boston 1977/81; Szur and Miller 1991). There are at least three important influences that have encouraged this phenomenon. Behind such a reality there lie concerns about maintaining confidentiality while writing about troubled and vulnerable young people – an issue addressed at the end of this chapter. There has also been the development of a variety of approaches to working with children, adolescents and their families – the initial understanding of the child’s internal world and the unconscious processes at work in the positions he adopts in relation to his environment, very much the keystone of early child guidance work, came under pressure in many clinics with the advent of family therapy and behavioural and cognitive approaches. Although psychoanalytic work continued to develop in child and family mental health settings (especially in London), it was of necessity slower, longer-term work than that ofother interventions, and (until fairly recently, see Chapter 9) less amenable to the research instruments then available. Publication in other than specialist psychoanalytic journals was therefore rare. Finally, one has to consider the impact of numbers and geography: child and adolescent psychotherapists are not numerous, there being less than 300 practising or in training in the UK. These are unequally spread across the country, most being not only in London but in north-west London, within reach of the four London training schools and the psychoanalytic world of that area. The actual influence, in terms of consultation, teaching and the continuing evolution of applied work and ideas has, in contrast to the numbers of practitioners, been surprisingly great.

It seemed, therefore, timely to respond to our publisher’s invitation to join their handbook series at a point when debate within the profession has become more open, when research tools are more sophisticated, when the availability of child psychotherapists and psychoanalytic thinking about children grows, both in the UK and internationally, and when public outrage about violent and disturbed children lives uneasily in a society that still gives its children few rights and finds it difficult to take seriously child mental well-being.

The handbook

This handbook is designed for several types of reader. For those who are already training or working as child psychotherapists the value will probably lie mainly in the chapters on work of specialist interest, although many of the other contributions will offer creative ideas and sparks to further thinking. For the reader in allied professions, we hope at the same time to offer an introduction to the profession that not only helps to locate it in its historical and present context but also enables an appreciation of some of the practices involved in a psychoanalytic approach to understanding and working with distressed and ‘stuck’ children and young people. Some chapters are therefore deliberately written to be accessible to a general audience and the authors have responded to that brief – this is especially true of the section introducing the theoretical foundations.

While we recognise that there can be dangers in pitching a book at several levels, we felt it important to use this opportunity to present the profession of Child and Adolescent Psychotherapy as it is now. Our year of publication, after all, marks the fiftieth anniversary of the establishment of the Association of Child Psychotherapists. It is frequently the case that practice moves ahead of theory, and practitioners are at times reluctant to share what they actually do outside (or even within) the profession, as innovations may be viewed as radical or not conforming to established theoretical tradition. We have been fortunate in our contributors: many, like the authors of Chapters 22 and 24, are quiet experts who, in writing for the first time together on their subject, present important developments in theory and practice. Our hope, therefore, would be that the more generalised introduction will then make accessible some of the excitement and potential in recent thinking about practice, and that the general reader will also find much in the more specialised chapters to enhance practice in other professions as well as to facilitate understanding of why and how the child psychotherapist is working in a specific field.

We have also included writers from a variety of theoretical backgrounds: Contemporary Freudian, Independent, Jungian and Kleinian. Although there has in recent years been much movement away from the bitterness of argument and theoretical polarisation experienced in the 1940s (King and Steiner 1991; Daws 1987), there remain important differences amongst theoretical schools, leading to divergence in technique. A by-product of the handbook may therefore be the explication of approaches taken for granted in a particular training school but possibly less available in others. In general, however, we have gathered experienced writers with proven interest and expertise in specific areas. This multi-authored approach should give the reader a sense of the diversity within the profession, and of a vibrant profession able to discuss, differ and develop, while sharing clear underlying principles.

Structure

The book is structured in five main parts but each chapter, particularly those in the final part, can be read in its own right. The first part introduces the theoretical foundations of the work and is the most generalised section of the entire book. Throughout, authors have used straightforward language to introduce important ideas and concepts. Most useful for the nonpsychoanalytic reader who may wish to follow up the suggestions for further reading, these introductory chapters also provide plentiful references for those readers who wish to have more detailed knowledge.

The theoretical section is followed by five chapters about the child and adolescent psychotherapist in practice. These comment on family and cultural context, explore the nature of the relationship between child and therapist and the clinic setting in which this occurs, and includes an overview of research. Psychotherapy is a particularly difficult area to research. An increasing number of highly relevant and useful studies are now being conducted, partly because qualitative research, which allows for the complexity and interactive nature of what is being studied in psychotherapeutic terms, is becoming more generally acceptable in research circles. This is an increasingly important area of development for the profession. The varied settings for direct and applied work are outlined in Part III and set the context for later chapters. The importance of membership of the multi-professional team is stressed in descriptions of the role of the therapist in the community, in residential settings, in hospital in relation to physical illness, and when children are in specialised in-patient therapy units. Child and adolescent psychotherapists in different parts of the world have also been approached to present as accurately as possible the international spread of this work.

The fourth part of the book describes the diversity of treatment models offered by child and adolescent psychotherapists. The tradition of intensive psychoanalysis (of four-or five-times weekly duration) with which the profession began retains its rightful place; the principles, however, have become applied and developed in once-weekly work, probably the norm for most treatments. In addition, consultative work applies psychoanalytic principles to enable colleagues in a variety of settings to make sense not only of the young people with whom they work but also of their own responses and feelings. Psychoanalytically informed group work is also a developing area for the profession. The fascinating new area of parent–infant psychotherapy is another arena in which there is a great increase in interest, bringing together the advantages of early intervention, the skills of careful observation which are central to our training, and research in parent–infant developmental psychology.

The final section of the book describes areas of special clinical interest: trauma, deprivation, delinquency, violence, sexual abuse and sexually abusive behaviour, gender identity problems, eating disorders, work with refugees, autism and disability. These chapters provide a mixture of an overview of ways of working with these specific problems as well as some of the theoretical thinking behind them. They are rich in case illustrations as well as thought-provoking, and provide an intimate and impressive view of how far the profession has come in adapting classical psychoanalytic practice, originally developed for the treatment needs of mainly neurotic patients, to the more complex nature of a child and adolescent psychotherapist’s work today.

Historical developments

Although the lasting impetus to the establishment of the profession of Child and Adolescent Psychotherapy comes from the theoretical interest and practice of both Anna Freud and Melanie Klein (Daws 1987), there are other influences, both earlier and parallel, which helped found the structure for psychoanalytic work with children and young people. In Vienna, Hermine Hug-Hellmuth (or Hug von Hugenstein) combined her experience as a teacher with her growing interest in psychoanalysis, publishing her first monograph in 1912 and a paper on child analysis in 1921 (MacLean and Rappen 1991). Indeed, in a masterly account of the history of child analysis (or of psychoanalysts working formally with children), Geissman and Geissman elaborate Hug-Hellmuth’s early contributions, concluding: ‘Her work, buried for sixty years, is being unearthed at last: and that work was the invention of child psychoanalysis’ (Geissman and Geissman 1998: 71).

MacLean and Rappen interestingly delineate, in Hug-Hellmuth’s approach, factors adopted by Anna Freud (work with latency children; the educational role of the analyst; the preliminary period establishing a therapeutic alliance) and decried by Klein; and points developed by Klein (interpreting the negative transference; the use of play; distinguishing the educational from the analytic role) and criticised by Anna Freud (MacLean and Rappen 1991). Her influence on both is rarely acknowledged.

Other psychoanalysts engaged in thinking about and working with children and young people at much the same time as Anna Freud and Melanie Klein were Eugenie Sokolnicka in France and, slightly later, Sophie Morgenstern (Geissman and Geissman 1998). The tradition of ‘child analysis’, however, remains in a slightly contentious relationship to psychoanalytic psychotherapy, and the reader wishing to explore the former further is directed to Geissman and Geissman for an excellent history.

In the 1920s the child guidance movement, begun in the USA, reached the UK. The first specially trained psychodynamic workers with children in the child guidance multi-professional teams were the psychiatric social workers (PSWs). Following the establishment of the first child guidance clinics in the UK (by Emanuel Miller and Noel Burke in London and the Notre Dame Clinic in Glasgow) the ‘Mayflower ladies’ – the first PSWs – went out to the USA to be trained by colleagues there. This interest in gaining particular expertise in work with children and young people grew amongst the early professions in the new clinics – psychologists, psychiatrists (originally specialists in Psychological Medicine) and social workers. Although there was a stimulating ethos of interest in applying psychoanalytic and child development understanding to children, many clinics remained voluntary, reliant until the advent of the National Health Service in 1948 upon jumble sales and donations to keep going. This picture of committed enthusiasm by professionals, yet a backcloth of it being difficult for society to take seriously child mental health issues, remains with us.

At University College, London, the 1920s saw the first courses in child development and observation, run for social workers and teachers. Cyril Burt was appointed to the experimental post of Child Psychologist by London County Council (Urwin and Hood-Williams 1988). It was during this period of early excitement that Dr Margaret Lowenfeld established in 1928 the Children’s Clinic for the Treatment and Study ofNervous and Delicate Children:

Here Lowenfeld’s wartime experience and research observations had already led her into the belief that, in addition to environmental considerations, there were processes inherent in children themselves which would enable them to find more adaptive solutions. For Lowenfeld the key to these possibilities was play.

(Urwin and Hood-Williams 1988: 42–3)

This developed in 1931 into a one-year training course and, in 1935, into a three-year ‘training in psychopathology and psychotherapy with children and leading to a diploma’ (ibid.: 89). The first child psychotherapy training was thus established at Lowenfeld’s Institute of Child Psychology.

Melanie Klein’s move to England in 1926 greatly influenced the British psychoanalytic world not only through her theoretical exploration of the internal world of the infant and the very early mother–infant relationship but through her practice of child psychoanalysis and her belief in the availability of very young children to psychoanalysis through the analytic play technique that she developed (Klein 1955). The ‘symposion on Child Analysis’, held by the British Society in 1927, demonstrates the split already evident between the followers of Klein and those of Freud’s daughter, Anna, in Vienna (Klein 1927). Klein’s influence led the Psychoanalytic Society to develop its own criteria for training in child analysis, beginning with the supervised analysis of two adult patients, and followed by supervised work with a pre-latency, a latency and an adolescent, all while the candidate was in full analysis.

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Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• Foreword
• Acknowledgements
• 1 Introduction
• Part I Theoretical foundations
• Part II The child and adolescent psychotherapist in practice
• Part III The child and adolescent psychotherapist in different therapeutic environments
• Part IV The diversity of treatments
• Part V Special clinical interests
• Appendix: Further information
• Index