SPECIAL ARTICLE Psychoanalysis and Child and Adolescent Psychiatry THEODORE SHAPIRO, M.D., AND AARON ESMAN, M.D.
Abstract. This report describes psychoanalytic advances in theory and practice as well as changes in knowledge about determinants of behavior from infancy through adolescence. These changes influence how dynamic psychotherapy is conducted. Mother-infant research, affect development, object relations separationindividuation theory, and newer concepts of regulation of self-esteem are explored as they affect treatment strategies. The authors also review countertransference transference and psychoanalytic reconstruing of adolescence as a stage and their influence on how therapy is conducted. Finally, the authors propose using a dynamic formulation as a means of determining where or when the therapist intervenes. J. Am. Acad. Child Adolesc. Psychiatry, 1992, 31, 1:6-13. Key Words: dynamic therapy, child and adolescent therapy, psychoanalysis, dynamic formulation. We are witness to a changing world in which child and adolescent psychiatrists have shifted from what had been a one-treatment strategy to a multitreatment armamentarium that includes a variety of psychotherapies (behavioral therapy, cognitive therapy, group therapy , family systems therapy, etc). This situation challenges the psychodynamically oriented therapist to consider ways in which recent psychoanalytic theory and research influence the general child and adolescent practitioner and in which so-called "standard" practices of dynamic psychotherapy can and should be modified. This question has broad implications for the survival in clinical practice of psychoanalytic principles and for the conduct of inquiries into how children fall ill and how symptoms evolve . Some recent reviews of the subject evoke the image of a practitioner of dynamic child therapy who seems like a caricature of a classical analyst (e.g., Zeanah et al., 1989) still bound by the impediments of outworn theory as though nothing has happened since Freud wrote at the turn of the century. In fact, there have been 100 years of evolution in the thinking of analysts, and more recent ferment with respect to changing models of development, symptom formation, and therapeutic approach. Among these changes, the influence of the interpersonal sphere on intrapsychic variation, including the new appreciation of transference and countertransference in the psychotherapy of children will be highlighted. The ways in which early dyadic influences encroach on development of self and ego and participate in the formation of symptoms will also be elaborated. Recent empirical data suggest that these issues serve, as much as the triadic interactions of the oedipal constellation, as a watershed in mental Accepted July 26, 1991. Dr. Shapiro is Professor of Psychiatry. Professor of Psychiatry in Pediatrics. and Director. Child and Adolescent Psychiatry. Cornell University Medical College-Payne Whitney Clinic. New York, N.Y. Dr. Esman is Professor of Clinical Psychiatry and Director ofAdolescent Services, Cornell University Medical College-Payne Whitney Clinic. Reprint requests to Dr. Shapiro , Cornell University Medical College-Payne Whitney Clinic, 525 East 68th St.• New York, NY 10021. 0890-8567/92/3101-006$03.00/0 © 1992 by the American Academy of Child and Adolescent Psychiatry.
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development, with consequent implications for structuralization of the mind in accord with cognitive and neurophysiological change . Ego psychological phenomena from the standpoint of explorations into early object relations models, narcissistic self-regulation and actual childhood histories. with some stress on the impact of severe insults in early childhood ranging from incest to other traumas that may lead either to difficulty or at times to resilience will also be examined. Some attention will be paid to the ways in which memories are structured in the mind and to the recent understanding of procedural versus declarative memory, and how these affect Freud's (1914) well-known triad of remembering, repeating, and working through. Recent work on affect development as a determinant of motive has shown how children learn to designate their feelings and regulate their emotions as well as how feelings restructure meaning (Emde, 1991; Lewis, 1991; Stern, 1985). The authors shall also consider how a psychodynamic framework continues to be useful in structuring clinical data before one embarks on any mode of therapy, including pharmacotherapy and family therapy. The authors propose that the use of the dynamic formulation as a guidepost (along with DSM-III-R) is a reasonable means of determining where to dispatch efforts to where things hurt most or to where efforts are most likely to yield effect (Shapiro, 1990). In short, the authors shall try to bring together some of the evolving models and data derived from psychoanalytic propositions and studies to demonstrate that they represent a dynamic flux and not a static canon of fixed procedures. Some of the modifications in theory and praxis derive from work with adults, whereas some come from reconceptualizations about development derived from analytically informed direct observation of infants and children in naturalistic and experimental settings. Psychoanalysts and dynamic therapists have always held a tripartite view of the phenomenology and meaning of symptoms. The descriptive level holds closely to Freud 's trenchant vision of the distinction between hysterical symptoms and neurological lesions as a necessary precursor to understanding meaning. We must thus first describe well. This holds in the dynamic framework too. Anna Freud's J.Am. Acad. Child Adolesc. Psychiatry, 31:1, January 1992
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(1963) careful analysis of the symptoms of childhood along developmental lines led to her warning that treatment should be considered only if children or adolescents are stopped in their developmental path for too long or tarry at an earlier stage than is appropriate in one of the developmental lines, creating problems in adaptation. This essential developmental viewpoint allows for transient, even necessary, symptom formation as part of the maturational course. Behind the descriptive picture of what is observed, a dynamic flux of intrapsychic forces is assumed that permits the inference that symptoms have meaning; moreover, what is consciously displayed is, it is assumed, the result of the interaction of forbidden wishes and the protective forces of the ego at the behest of conscience and superego and external prohibitions. These external prohibitions are imperfectly internalized rulelike structures, which derive in part from the child and in part from the parent. The third level of organization involves the reconstruction or construction of what "must have happened" to generate these symptoms and descriptive pictures. This is the genetic level of thinking, which derives largely from Freud 's view of trauma as etiological, a notion that is currently in center stage as the role of incest and other traumas on symptom formation is reconsidered. Corollary to this last postulate is Freud's notion that the oedipal conflict is nuclear and a consequence of the fact that we grow up in families (or equivalent caretaking social organizations) in which the child has to resolve the primary wish to be loved and identifies with mother and/or father even as wishes are frustrated. Fundamentally, the point of view of analysis from its onset has been retrospective and reconstructive, but it has simultaneously given rise to a major enterprise of forward looking developmental research. This began with the early designation of a genetic field theory by Spitz (1959) and his students (Emde, 1990), followed by the separation-individuation process as espoused by Mahler (1975) and her colleagues and by Bowlby's (1982) ethological integration of psychoanalysis and object relations theory, which has become known as attachment theory. This latter conceptualization has beenoperationalized by the experimental "strange situation" designed to measure security of attachment during the second year of life (Ainsworth et al., 1978). These ideas have received further support from the seminal nonanalytical work of Sameroff (1975) who argued and demonstrated that, while there may be a continuum of reproductive casualty that can be demonstrated in early development, by the time the child is of school age, a continuum of caretaker and social casualty must also be examined. This idea parallels the cautionary notion of Anthony (1987), Garmezy and Phipps-Yonas (1984), and others that it is not only the genes that make the child, but the nonshared environment as well (Plomin, 1989; Reis and Klein, 1987). The concept of resilience or invulnerability or of "superkid" or the "dandelion child" of Anthony (1987) derives from a peculiar interaction among intrapsychic structuring and the realities of the child's expanding world. Thus; there has been a major feedback loop among dynamic psychotherapists and the academic research schools that has grown out of some of these early dynamic conceptual frames. There J.Am.Acad.ChildAdolesc.Psychiatry, 31:1, January1992
have been many false byways, but there have also been validated studies of this interaction between theory and practice and these have, in tum, influenced our view of children, just as they have influenced activities with children in the psychotherapeutic endeavor. Anthony's (1969) earlier lament that research and psychotherapeutic clinical practice are two worlds apart may no longer be valid; bridges have been made. Indeed, it may be said that developmental research has been in more positive relationship to psychoanalysis than the tendency seen in biological research to become increasingly separate and mutually disparaging. Many early psychoanalytic studies took libido theory too literally, leading to emphasis on such events as toilet training as though they were potentially traumatic, rather than emphasizing the broader scope of interactive events that have repercussions on the developing mind (Erikson, 1956). There was a tendency to see pathological characteristics in what can now be seen as variability in response patterns. Only recently have we begun to gather the kind of information that permits us to consider dynamic cognitive structuring as it affects play and language in the light of the contemporary psychodynamic view that communication, language, and play are central modes of interaction and determinants of how we know each other. Development and Dynamic Psychiatry
For example, it is now believed that attempts to understand what is going on psychologically in autistic and the developmentally disabled children must take into account their intrinsic incapacities. This is different from the earlier view in which symptoms were seen as simply parallels to other dynamic compromises or of "primitive" developmental stages. Such children's presumed views of the world (from an analytic vantage point) must be looked at not as compromise formations but as functions of the ways in which their disability leads to a particular pattern of responsiveness. The work of Hobson (1990), Shapiro (1973), and others all suggest that in autism and other developmental disabilities with cognitive components the oedipal roots of these disabilities are trivial. These may indeed be "prestructural" children in the sense that they cannot lend the nuance of meaning to their expression, and meaning must be inferred from the repetitiousness of their behaviors and the limitations of their cognitive capacity. Hobson's (1990) idea of the unique theory of mind of the autistic child leads to a particular sense of self that accounts for his unusual interaction. Shapiro and Hertzig (1991) offer similar conclusions emphasizing the integrative failures in affective and cognitive development that lead to the personal social failures described. Using the model ofa biological disorder, Tourette's syndrome, Cohen (1991) has teased apart the effect on the self of movements occurring without volition and how these effects are represented. This leads to a central question in recent work in analytic understanding of development: What are the reciprocal roles of mother and infant before language and how does their interaction structure later development? In extreme cases like autism, biological factors are limiting, but in other cases closer to the usual, there may be a desire to ask how
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mother-infant interactions color future interactions and the potential for dynamic treatment. These interactions have been well studied by this time, and the studies have had a major feedback effect on the way in which therapy is done (Greenspan, 1989; Solnit, 1987; Zeanah et al., 1989). Winnicott's (1975) earlier caveat that "there is no such thing as a baby," only a mother-infant dyad, has been taken seriously by investigators such as Stem, Emde, and others, and has given power to the arguments of the object relations school of psychoanalysis that minimizes the traditional drive-defense relationship in favor of an interactional two-person or three-person model that has implications for therapy. Indeed, Pine (1985) and others suggest that the therapeutic process is analogous to a resumption of development. The organization of later adult mental structures is founded to some degree on the ways in which the child experiences the world at each stage of development. These ideas have led us to the concept of a much better formed nuclear ego even in the first months of life that engages the world early, as opposed to the model of an undifferentiated infant who reacts passively (Zeanah et al., 1989). Self-psychologists, too, emphasize this readiness to interact (Tolpin, M. 1986). According to this modem concept, the infant begins to organize the experiences with caretakers in significant and meaningful ways right from the start. Stem's (1985) idea of a core-self with a variety of stages in its development is certainly relevant to recent ideas about inborn ego nuclei, self-representation, and the significant role of parenting on early mental structuring. Among adult analysts, Loewald (1978) has been preeminent in his insistence that the drives as well as self and object representations evolve out of the internalization of early motherinfant interaction patterns; that, indeed, it is these interactions, rather than the objects themselves, that are internalized forming the nuclear elements of psychic structure. One may also credit Hartmann as an earlier ego psychologist for his notion of ego nuclei as an even earlier precursor. The implications of such models for therapy are many-one can look more concretely now to early interaction as molding current behavior. Concurrent treatment of mothers and fathers whose fantasies about their children may have continuing impact on the child patient can also be seriously considered. Bowlby's integration of ethological models and object relations theory has become a prototype of the influence of newer psychoanalytic ideas on clinical practice. His idea of the early interactions between mother and child has given rise to a series of paradigms such as the strange situation developed by Ainsworth et al. (1978), where the security of attachment-that is the capacity of the child to use the mother as a secure home base for exploration-becomes the advance herald of later developmental competence. Even more striking are the consequences of observations that security of attachment is predictive of later psychopathology or healthy adaptation, and that such inferences can be made even from exploring the intrapsychic musings of the motherto-be or the mother than has been treated in a particular way by her own mother. Main et al. (1985) and others have developed schedules of inquiry that code surface answers to routine questions in such a way that one Can determine 8
whether a mother's view of her child will lead to secure attachments with .their salutary effects on the next generation. From a psychoanalytic perspective Cramer and Stem (1988) and others have instituted similar concepts into a mother-infant treatment program where neither behavioral modeling nor shaping procedures are used. Instead, the therapist interviews the mother interacting with her child and learns about her fantasies of her baby and how those views influence the infant's symptomatic behavior. These workers find that, at least in well selected cases, such nondirective depth exploration can significantly improve interactions and alleviate early infant disorders such as vomiting, excessive aggression, and avoidant interaction. New Views of Transference-Countertransference
Other interactional variables that have become important in work with children find their expression in the recently heightened psychotherapeutic emphasis on transference and, particularly, countertransference. For many years after Anna Freud (1946), most dynamic psychotherapists thought that full-blown transferences did not occur or could not be interpreted in young children because of their ongoing fluid relationship to parents. Therapists of the Kleinian school have, however, always believed the reverse: i.e., that a full transference neurosis occurs in children and can be interpreted as such from the outset of treatment. Sandler et al. (1980) have elucidated the distinctions among different types of transference-' 'Transference of habitual ways of relating, of current relationships, of past experiences, and transference neuroses" (p. 78). In this context, it has been recognized that young children do bring fairly well structured fantasies and play themes to the consulting room, which can be understood and carefully interpreted as transference phenomena (Neubauer, 1987). Any of these can elicit significant countertransference responses (Chused, 1988). This applies not only to children but to adolescents as well. Recent work by Jacobs (1991) and others focusing on the fantasies of the therapist in interaction with the adult patient has proved pertinent to work with children and adolescents. Fantasies of rescue (Esman, 1988), the wish to outdo the parents of the children in our charge, the rageful attitude toward parents who abuse, the regressive pull of playing with a child, the joy of being with an adolescent when one's own adolescence is barely completed, all have significant impact on the ways in which we deal with our patients (Esman, 1990a; Schowalter, 1986). Case Example Jane, a 17-year-old girl of unusual charm and intelligence had been in psychotherapy for a year with a young psychiatrist who had begun working with her when Jane was hospitalized because of a mild suicidal act. Jane was an extremely responsive patient-bright, insightful, and hard working. The therapist was aware of her identification with the patient and had succeeded in maintaining an appropriately neutral but empathic stance throughout. As the academic year drew to a close, Jane became increasingly preoccupied with thoughts of college, with her conflict about leaving home, and the like. One day, she J. Am. Acad. Child Adolesc. Psychiatry, 31:1, January 1992
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began to speak about her friends-those, she said, whom she feared she might never see again once she went away. She went on in this vein for some time; her therapist recognized that this was a veiled reference to the anticipated termination of the treatment and the patient's feeling ofloss, but she' 'couldn't find a way to interpret it, so I just listened to her." It was not until, in supervision, she was helped to recognize her own feelings of loss, her own deep pleasure in the work with this rewarding patient, and her reluctance to acknowledge the impending end of the relationship that she was able to "find a way" to make the connection explicit. Marshall (1979) has developed a typology of countertransference reactions, depending on their source (the patient's unconscious or the therapist's) and the extent to which the therapist is capable of awareness of these feelings and can use them to further his or her understanding of the patient. Lesser (1971) has examined the special countertransference issues arising in work with children with sensory handicaps, stressing, again, the roles of rescue fantasy and of the difficulty many therapists experience in helping such children because of their own unconscious revulsion and anxiety. This transference-countertransference matrix must be seen in light of the activity that must occur between young patients and adult therapists. The fact that we must play along with, interact, provide foils for play, or become participant observers can be most distressing and/or too satisfying. The recent scrutiny in adult therapies of enactments and what object relations theorists call projective identification leads to new possibilities for viewing our interactions . We may now ask "Am I reacting to the child's play or to an unconscious fantasy?"; "Am I feeling what I am feeling because of my own unanalyzed unconscious fantasies?"; "Do I feel this way because of my response to the child's parents?" This heightened interest in countertransference reactions is consistent with a radical questioning of the concept of the therapist as an external observer, one which is being replaced by a more interactional view that permits observation of the child in a field of play with the therapist as adult and as projected object. These multiple images aid therapists to understand the significance of their own emotions and fantasies in the play.
Emotions and Interaction Emde (1990), following Klein (1976) but also exhorting us from the experimentalist vantage, calls for the establishment of a "wego" as well as an " ego" for dynamic therapy. He encourages a revival of an interpersonal view, examining the interactional framework of the development of self and its influence on the ways in which we perceive. Social psychologists such as Mead et al. (1934) have long talked of man's development in the social matrix. This was also implied by Freud's early notion (derived from Darwin) that long caretaking for small iminature broods contributes to neurosogenesis. Certainly Sullivan's (1953) interpersonal theory rests on this premise. Only recently, however, has such empirical research as that of Emde demonstrated how the affective tone of the interaction of the child and mother J. Am. Acad. Child Ado/esc. Psychiatry, 31: 1,January 1992
determines a sense of "basic trust" that can be demonstrated at the end of the first year of life (Erikson, 1956; Sorce et al., 1985). Emde and others have shown that even at the crawling stage when faced with an apparent dropoff, a 9month-old pretoddler will crawl farther if the mother has a "come hither" look. Similarly, by age 3, children already have some internalized prohibitions and rules that govern behavior that can be construed as nuclei of the superego . Clearly, the internalized defensive organizations and rationalizations that are evident in childhood can be found well before the resolution of the oedipus complex. We also have direct evidence that by 2 to 3 years, children can dissimulate (Lewis, 1989) or make up stories as to why they shouldn't follow the rules; thus, we can recognize that intrapsychic conflict is already presaged by these preoedipal behavioral constellations. Even more significantly, we can determine how parents provide double signals similar to the double bind that leads to our understanding that 3-year-olds have a firm grasp of various signal systems from parents and can segregate their compliance. All these capacities offer continuing evidence for clinicians that affects modulate behavior and that social interactions determine affective dispositions. Surely clinicians have also known these facts from their own encounters with children, but empirical studies reinforce and validate these clinical experiences. They compel us to take greater and more careful account ofthe child's environment even in the toddler years. Parents must be seen more frequently and persistently to determine the nature of the child's actual experience and for us to decipher what is happening despite what we are told. The isolation from the parents of the traditional Kleinian therapist seems no longer tenable. Moreover, the dynamically informed psychotherapist might well consider the value of parent counseling coincident with work with the child or adolescent. As we learn more about how children develop, the impact of caretaking cannot be ignored. Even though early on Anna Freud did see parents and advised others to do likewise in psychoanalysis, there was a tendency to use the parents only as sources of information. Recent data suggest that some work with parents is indicated, paralleling work with children. Recent studies on emotion in infants and children increasingly regard affects not merely as drive derivatives but as basic inborn propensities available from birth. These affects develop and serve as motivating structures, determining our resort to one or another behavioral pattern, as well as our use of emotionally tinged ideas as regulators of behavior. The child who is constantly prohibited during the "terrible twos" is likely to experience such constraint as an intrusion on his quest for autonomy. He or she will respond by turning the passive into the active (identifying with the aggressor), becoming naysayers, and opposers. This negativism, based on miscarried autonomy seeking, may then skew character organization . Although such preoedipal organizations develop as clearcut trends, these may still be reorganized as the child approaches the 5th to the 7th year (Shapiro and Perry, 1976). Hierarchic reorganizations, as described by Werner (1940), accompany the evolution into middle childhood (or "latency" as Freud called it). Concrete operational thought 9
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arises as the oedipus complex has come to its full flowering. Indeed; the interaction and study of cognition and emotional development permits us to break through to a new view of latency and adolescence. These may be biogenetic shifts on the basis of brain and psychic structure reformation. These new organizations take hold as the determining constellations of overt behavior but also are represented as unconscious fantasies. The fantasies are organized as unconscious structures, but they may also be organized in action patterns and as affective dispositions (Shapiro, 1975). There is a direct relation between the thinking of some cognitive psychologists and Freud's ideas about repeating as a way of remembering. We know from studies of children that they may have procedural knowledge, i.e., they may know how to do things, but not be able to tell you how they do it (Clyman, 1991). For example, they have evidence of grammatical understanding in their early utterances without knowing what a noun or a verb is. This understanding has had its reciprocal effect in regard to how dynamic psychotherapists look at the enactments that are seen in child therapy. These enactments, these play sequences, may not be organized as conscious thoughts. There is a similar split offered by cognitive psychologists between episodic and semantic memories, with evidence that the former are stored as visualization and not verbal thoughts. It is by putting these entities into a language format that the psychotherapist attempts to restructure existing patterns and to have an impact on the child's ego organization. Indeed, verbal propositions have an organizing effect on behavior as do interactional factors (Shapiro, 1991). Moreover, children who are more action oriented may not have access to their emotions as signals, thus, the therapist should direct attention to naming feelings as a means of short circuiting impulsive action. These early preverbal action patterns also are seen in analytic propositions derived from Winnicott and others, bringing new attention to nonverbal aspects of the therapeutic situation. Work with adult borderline and narcissistic disorders has led to the formulation of a construct known as the "holding environment" (Model, 1976). This nonverbal aspect of treatment is now seen as paramount in creating the therapeutic alliance that was earlier looked at as the induction phase in child therapy (A. Freud, 1927). Certainly, work with children presages the practice of providing a safe and congenial medium for exchange where fantasies can then be viewed in relation to overt behavior. As Abrams (1988) puts it, adults in psychoanalysis engage in "characteristic modes of relating, a transference consolidation, the revival of earlier pathogens and the effects of knowing (insight). Children in addition use the setting for new experiences in the service of emerging development organizations" (p. 260). Clearly, the same is true is psychotherapy. For example: J. Was a lti-year-old Asian-American girl who came to treatment after a suicide attempt. Depressed, tearful; and self-reproachful, she came from a deprived and depriving family, with a psychotic and hemiplegic mother and are" mote, harried father. Her life was joyless and focused entirely and compulsively on academic achievement. In her psychotherapy, she poured out tearful complaints about her family life, her sense of obligation and guilt; and her social 10
isolation. The therapist's role was that of a neutral but empathic partner in J.'s self-examination and growth. The patient described her therapy as "the best relationship I've ever had." Gradually, she began, with the therapist's support, to experiment with typical adolescent social interactions and dating, becoming less compulsive with her school work, gaining self-esteem, and ultimately finding it possible to leave home to go to college. Adolescent Development and Therapy
Recent analytic work with adolescents has also given rise to new questions concerning the classical rule of abstinence and neutrality. Although adolescents do not need another authority to lead them or another parent figure in their milieu, work with adolescents in an dynamic setting has certainly led to a loosening of bondage to the concept of neutrality construed as total abstinence (Franklin, 1990). Instead, most therapists who work with adolescents have advocated the building of a primary relationship that will permit the expression of ideas, fantasies, and concerns that can be used in the ensuing work. This approach is based on increased understanding of the concerns of adolescents and the reemphasis on the specific conflicts that are special to this age period. Consolidation of relationships, sharing with peers, and normalization of inner experience through the awareness that other adolescents have similar concerns have been noted as central to adolescent experience (Esman, 1985; Shapiro, 1985a). Sullivan's "chumship" in the juvenile period is an earlier statement of this idea. With this view in mind, we may look at the positive accruals of healthy adolescence as those that "normalize" internal demons. The reassurance that the adolescent experiences when she or he learns that other adolescents share his or her inner thoughts is only possible if the individual can relate those thoughts to others. Therapeutic relationships provide surrogate experiences of this genre. Lest this freedom to express becomes an invitation to wanton license, the therapist may provide the assurance that thinking does not necessarily lead to doing. Contrariwise, some thoughts and wishes may become realities in time if ego support is available to provide appropriate opportunity. The therapist in this setting becomes the needed peer who permits freedom of thought. On the other hand, he or she does not join in on the new freedom but maintains an appropriate and optimal therapeutic distance. Psychoanalytic work with adolescents has also heightened our awareness of their need to resolve the conflictual attachment to the same sex parent ("negative oedipal relationship"); to come to terms with the deidealization of early parent images, and to reformulate a realistic ego ideal (BIos, 1985). BIos (1967) has further illuminated the analogy of adolescence with the separation-individuation process, occurring at a time when biological maturity and sexual procreative powers are at their height, but when, paradoxically, modern industrial society imposes an unnatural prolongation of the process (Esman, 1990b). These ideas have trickled down into psychotherapeutic approaches with adolescents, leading to the possibility of less intense and more focused modes of treatment, and to support for ego growth during this formative period. Curiously enough, the sexual revoluJ.Am.Acad. Child Adolesc.Psychiatry,31:1, January1992
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tion and other .so-called revolutions that are supposed to further emancipate adolescents have led to new problems that dynamic psychotherapies have addressed. The same problems of intimacy and relation to objects are found, despite the fact that children and adolescents are more sexually active than in earlier times (Esman, 1990b; Ginsberg et aI., 1972). Such knowledge and reemphasis has been integrated by the larger community of those who work with adolescents. For example, we know that it is not sufficient to provide condoms for safety in this period of fear of AIDS. Moreover, we fail our adolescents if we provide information on the mechanics of sexual behavior without addressing the environment of safety in which mature intimacy can be integrated with sexuality. Ever since Freud, psychoanalysis has been at the forefront emphasizing these integrations. Erikson was an inaugural spokesman for this developmental point of view from the side of the ego. Similarly, the hospital treatment of adolescents has been enriched by the psychodynamic notion that it is not sufficient to medicate adolescents without observing their response to the milieu, their resistant phase, their engagement, and the necessity to work through the aspects of damage, dependency, and loss that emerge in the course of hospitalization (Rinsley, 1971). The psychoanalytic emphasis on meaning has helped to make child and adolescent psychiatrists increasingly aware of the importance of the meaning of medication to the patient and the family and of the interaction between medication and the doctor-patient relationship in the pharmacological treatment of child and adolescent disorders (Schowalter, 1989; Shapiro, 1985b). Diagnosis and Dynamic Formulation
Ever since the publication of DSM-III and now with the impending appearance of DSM-IV, the new descriptive diagnostic scheme has preoccupied clinicians. However, dynamic psychiatrists have alerted us to the importance of an Axis in which dynamic factors can be coded. Unfortunately, this has not yet been achieved. In lieu of such a dimension, others have proffered a dynamic formulation, both for adult and child work (Perry et aI., 1987; Shapiro, 1989). Such formulations enrich our views of children and adolescents and enlarge our understanding of treatment aims. Since the adolescent is at a radical change point in biology and caught in an interpersonal and family flux at a time when his own personality may be at a crossroad, such a formulation seems paramount. As Cantwell (1980) stated, DSM-III is a book of disorders, it is not a book that describes children. The dynamic formulation can tell us something about how each child shapes his or her environment and how this environment, in tum, shapes the child even as he or she is responding to bodily changes. Recent work by Hauser (1991) has advanced our understanding of how adolescent development proceeds in line with ego integration and the surgent and regressive forces that determine the next step into young adulthood. This work is consistent with Offer's demonstration (Offer and Sabshin, 1984; Offer and Offer, 1975) that the classical analytic concept of " normal adolescent turmoil" requires extensive revision (Oldham, 1978). J.Am.Acad. Child Adolesc.Psychiatry,31:1, January1992
Hauser and others interested in childhood adaptation take us back to our repetitive tendencies to have our lives unfold in what seem to be patterns even if some patterns are discontinuous and nonlinear. It is the patterned behavior that the psychotherapist must capture in concepts and ultimately in words. As Freud (1910) noted in his paper on "Wild Psychoanalysis," if we discover universals that underlie disorder, merely tell ing the patient about them does not promote change. It is the careful dynamic work with the patient that creates the climate of trust, the transference enactments, and potential experiences that lead to conviction. This conviction and the will to change are the aims of dynamic therapies now as then-but we have broadened the scope of techniques to that end, using new data from normal development, adult dynamic therapy and analysis, and from experimental therapeutic ventures. Conclusion The past 25 years have produced new models that enhance our view of and the armamentarium for dynamic therapy. Infant-parent observation, theory of attachment and object relations theory, and self-psychological ideas about selfesteem have been absorbed into ego psychological views of human interaction as it influences psychic structure. These models have had significant effect on therapeutic work, with increasing interest in biological determination of temperament in interaction with caretaking. Most recently, the role of affects as behavioral motivators and modulators of interaction must be considered in the transferencecountertransference dyad and triad in the therapy of children. Adolescence is well established as a developmental epoch in our postindustrial world. The unique problems of this stage have required changes in our understanding of how adolescents act and interact. We add to our treatments new ideas about individuation, sexual freedom, struggles for independence and normalization of experience as dynamic factors in behavioral organization, sexuality and expression of intimacy. Dynamic psychotherapy has been enriched by these new advances in knowledge from psychoanalytic experience, just as psychoanalytic ideas have influenced direct observation. The new dynamic therapists are freer to be themselves with children and adolescents. They are likely to be more flexible in their integration of work with parents and other family members in the therapeutic process. They will be cognizant of the levels of cognitive and language development of their child patients and their impact on communicative processes in the treatment work. They will be alert to the nuances of transference and their varied meanings. They will probably be less ambitious in their goals and more likely (especially with adolescents) to accept limited results and to appreciate the growth enhancing value of symptomatic improvements. Still, they will be always cautious that they are engaged in endeavoring to learn about how the child or adolescent mind is organized and how the meaning of enactments can be interpreted for therapeutic aims and gains. The diagnostic formulation uniformly applied, regardless of a psychiatrist 's orientation, is a tool that will aid clinicians in the appropriate choice of therapy and disposition. It will
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also provide a sense of stepwise solutions as interventions are staged and, finally, provide an overview that encompasses many points of view.
References Abrams, S. (1988), The psychoanalytic process in adolescent children. Psychoanal. Study Child, 43:245-261. Ainsworth , M. D., Blehar , M. D. & Waters, E. et al. (1978), Patterns of Attachment: Assessment in the Strange Situation and at Home. Hillsdale , NJ: Laurence Erlbaum Associates. Anthony, E. J. (1969), Research as an academic function of child psychiatry. Arch. Gen. Psychiatry, 21:385-391. - - (1975), In: Explorations in Child Psychiatry, ed. E. J. Anthony. New York: Plenum Press, pp. 147-1 84. - - (1987), Children at high risk for psycho sis growing up successfully. In: The Invulnerabl e Child, ed. E. J. Anthony & B. Cohler. New York: Guilford Press . Bios, P. (1967), The second individu ation process of adolescen ce. Psychoanal. Study Child, 22:162-186. - - (1985), Son and Father: Before and Beyond the Oedipus Complex. New York: The Free Press. Bowlby , J. (1982), Attachment and Loss, Volume I, 2nd Edition . New York: Basic Books . Cantwell , D. (1980), The diagnostic process and diagnostic classification in child psychiatry-DSM III. J. Am. Acad. Child. Adolesc. Psychiatry, 19:345-355. Chused, J. F. (1988), The transference neurosis in child analysis. In: The Psychoanalytic Study of the Child, eds. P. B. Neubauer, A. J. Solnit et al. New Haven: Yale University Press, pp. 51-82. Clyman, R. B. (1991 ), Th e procedural organization of emotions: a contributi on from cognitive science to the psychoanalytic theory of therapeutic action. J. Am. Psychoanal. Assoc. [suppI.] 39:349- 382. Cohen , D. (1991), Tourette' s syndrome: a model disorder for integrating psychoanalytic and biological perspectives. Intenational Review of Psychoanalysis, 18:195-210. Cramer, B. & Stem, D. (1988), Evaluation of changes in mother- infant brief psychotherap y. Infant Mental Health Journal, 9:20-45. Emde, R. (1990), Play narratives in 36-month-old children: early moral de velopment and famil y relation ships. Pychoan al. Stu dy Child, 45:129-155, 1990. - - (1991), Positive emotion s for psychoanalytic theory : surprises from infancy research and new direct ion s. J. Am. Psychoa nal. Assoc . [Suppl.] 39:5-43. Erikson: E. (1956), The problem of ego identity. J. Am. Psychoanal. Assoc., 4:56-121. Esman, A. (1985), A developmental approach to the psychotherapy of adolescents. Adolesc. Psychiatry, 12:119-133. - - (1988), Rescue fantasies . Psychoanal. Q., 56:263-270. - - ( I 990a), Countertransference with children and adolescents. In: Directions in Psychiatry, ed. F. F. Flach. New York: Hatherle igh Comp any, Ltd. - - (1990b), Adolescence and Culture. New York: Columb ia University Press. Franklin , G. (1990), The multiple meanings of neutrality. J. Am. Psychoanal. Ass oc., 38:195-220. Freud, A. (1927), Four lectures on child analysis. In: The Writings of Anna Freud, Volume I . New York: International Universities Press, 1974 pp. 3-72. - - (1946 ), The Psycho-An alytical Treatment of Children. New York: Internat ional Universities Press. - - (1963), The concept of developmental lines. Psychoanal. Study Child, 18:245-265. Freud , S. (1910), Wild psychoanalysis. In: The Complete Psychological Works of Sigmund Freud, Standard Ed., Volume 12. London: Hogarth Press, pp. 2 19-230. - - (19 14), Rememberin g Repeating and Working Through , In: The Complete Psychological Works of Sigmund Freud, Stand ard Ed., Volume 12. London: Hogarth Press pp. 145-156. Garmezy, N. & Phipps-Y onas, S. (1984), An early crossro ad in research on risk for schizophreni a: the Dorado Beach Conferen ce. In: Children At Risk For Schizophrenia: A Longitudinal Perspective,
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eds. N. F. Watt, E. J. Anthony, L. C. Wynne & J. E. Rolf. New York: Cambridge University Press. Ginsberg, G., Frosch, W. & Shapiro , T. (1972), The new impotence. Arch. Gen. Psychiatry, 26:218-220. Greenspan, S. (1989), The Development of the Ego: Implications f or Personality Theory, Psychopathology and the Psychotherapeutic Process. Madi son, CT: International Universities Press. Hauser, S. ( 199 1), Adolescents and Their Families. New York: Free Press. Hobson, P. (1990), On psychoanalytic approaches to autism. Am. J. Orthopsychiatry, 60:324-336. Jacobs, T. (1991), The Use of the Self. Madison, CT: Int. Univ. Press. Klein, G. (1976), The resolution of experienced incompatibility in psychological developm ent. In: Psychoanalytic Theory: An Exploration ofEssentials. New York International Universities Press, pp. 163-209. Lewis, M. (1989), Deception in 3-year olds. Developmental Psychology, 25:439-443. - - (1991), Social knowled ge and social development. J. Am. Psychoanal. Assoc., [Suppl.] 39:46-73. Lesser, S. (1971), Sensory -handic apped children. In: Basic Handbook of Child Psychiatry, ed. 1. Noshpitz, Volume 3. New York: Basic Books, pp. 652-663. Loewald, H. (1978), Instinct theory, object relations and psychic structure formation. J. Am. Psychoanal. Assoc., 26:493- 506. Mahler, M., Pine, F. & Bergmann, A. (1975), The Psychological Birth of the Human Infant. New York: Basic Books. Main, M., Kaplan, N. & Cassidy, J. (1985), Security in infancy, childhood and adulthood : a move to the level of representation. Monogr. Soc. Res. Child Dev. [Serial 209] pp. 66--106. Marshall , R. (1979), Countertransference with children and adolescents. In: Countertransference, eds. L. Epstein & J. Feiner. New York: Aronson, pp. 407-444. Mead, G. H. (1934), Mind, Self and Society. Chicago: University of Chicago Press. Model, A. (1976), The " Holding Environment " and the therapeutic action of psychoanalysis. J. Am. Psychoanal. Assoc., 24:285-307. Moran, G. (1987), Some Functions of Play and Playfulne ss: A Developmental Perspective. In: The Psychoanalytic Study of the Child, eds. P. B. Neubauer & A. J. Solnit. New Haven: Yale University Press. Neubauer, P. B. (1987), The Many Meanings of Play: Introduction. In: The Psychoanalytic Study of the Child, eds. P. B. Neub auer & A. J. Solnit, New Haven: Yale University Press. Offer, D. & Offer, J. (1975), From Teenage to Young Manhood: A Psychological Study. New York: Basic Books. - - Sabshin, M. (1984), Normality and the Life Cycle. New York: Basic Books. Oldham , D. (1978), Adolescent turmoil: a myth revisited. Adolesc. Psychiatry, 6:267-279. Perry, S., Cooper, A. & Michels, R. (1987), The psychod ynamic formulation: its purpose, structure and clinical applicat ion. Am. J. Psychiatry, 144:543-550. Pine, F. (1985), Developmental Theory and Clinical Process. New Haven: Yale University Press. Plomin, R. (1989), Environment and genes. Determinants of beha vior. Am. Psychol, 44:105-111. Reis, D. & Klein, D. (1987), Paradigms and pathogenesis: a familycentered approach to problems of etiology and treatment of psychiatric disorders. In: Family Interaction and Psychopathology Series Methods and Findings, ed. T. Jacob. New York: Plenum Publi shers. Rinsley, D. (197 1), Theory and practice of intensive residential treatment of adolescents. Adolesc. Psychiatry, 1:479-509. Sameroff, A. J. (1975), Early influences on development: fact or fancy? Merrill-Palmer Quarterly of Behavior and Development, 2 1: Sandler, J., Kennedy , H. & Tyson, R. (1980), The Technique of Child Analysis. Discussions with Anna Freud. Cambridge : Harvard University Press. Schowalter, J. (1986), Countertransference with children: review of a neglected concept. J. Am. Acad. Child Psychiatry, 25:40-46. J. Am. Acad. Child Adolesc. Psychiatry, 3 I: I, January 1992
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- - (1989), Psychodynamics and medication. J. Am. Acad. Child Adoles c. Psychiatry, 28:681-684 . Shapiro, T. (1973), Language development in young schizophrenic children: direct observation as constraint on constructions in analy sis. Psychoanalysis and Contemporary Science, 2:175-187. - - (1975) , Childhood neurosis: the past 75 years: Psychoanalysis and Contemporary Science, 4:453-477. - - (1985a), Adolescent language: it's use for diagnosis , group identity, values and treatment. In: Adolescent Psychiatry, ed. M .Sugar. Chicago: University of Chicago Press, pp . 297-311. - - (1985b), Developmental considerations in psychopharmacology: the interaction of drugs and development. In: Psychopharmacology, 2nd Edition, ed. J. Wiener. New York: J Wiley, pp. 51-68. - - (1989) , The psychodynamic formulation in child and adolescent psychiatry. J. Am. Acad. Child Psychiatry, 28:675-680 . - - (1991), Words and feelings. J. Am. Psychoanal. Assoc., [Suppl.]39:324-348. - - Perry , R. (1976) , Latency revisited: the significance of age 7+-1. Psychoanal. Study Child, 31:79-105. - - Esman, A. (1985), Psychotherapy with children and adolescents: still relevant in the 1980s. Psychiatr. Clin. North Am., 8:909-921. - - Hertzig, M. (1991) , Social deviance in autism: a central integrative failure as a model for social non-engagement. Psychiatr. Clin. North Am.
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Sol nit, A. J. (1987), A Psychoanalytic View of Play . In: Psychoanal. Study Child, eds. P. B. Neubauer & A. J. Solnit. New Ha ven : Yale Uni versity Press . Sorce, J. F., Emde, R., Campos, J. & Klinnert, M. D. (1985), Maternal emotional signaling: its effect on the visual cliff behavior of l-yearolds. Developmental Psychology, 21:195-200. Spitz, R. (1959), A Genetic Field Theory of Ego Formation. New York : International Universities Press . Stern, D. N. (1985), The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. New York: Basic Books. Sullivan, H. S. (1953), The Interpersonal Theory of Psychiatry . New York: W. W. Norton. Tolpin, M . (1986) , The Self and Its Self Objects: A Different Baby. In: Progress in Self-Psychology, Volume II, ed. A. Goldberg. New York: Guilford Press. Werner, H. (1940) , Comparative Psychology of Mental Development. New York: International Universities Press . Winnicott, D. W. (1975), Anxiety Associated with Insecurity. In: Through Pediatrics to Psychoanalysis. (Collected Papers), London: Hogarth Press, p. 99. Zeanah, C. H., Anders, T . F., Seifer, R. & Stem, D. N. (1989), Implications of research on infant development for psychodynamic theory and practice. J. Am. Acad. Child Psychiatry, 28:657-668.
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Abstract. This report describes psychoanalytic advances in theory and practice as well as changes in knowledge about determinants of behavior from infancy through adolescence. These changes influence how dynamic psychotherapy is conducted. Mother-infant research, affect development, object relations separationindividuation theory, and newer concepts of regulation of self-esteem are explored as they affect treatment strategies. The authors also review countertransference transference and psychoanalytic reconstruing of adolescence as a stage and their influence on how therapy is conducted. Finally, the authors propose using a dynamic formulation as a means of determining where or when the therapist intervenes. J. Am. Acad. Child Adolesc. Psychiatry, 1992, 31, 1:6-13. Key Words: dynamic therapy, child and adolescent therapy, psychoanalysis, dynamic formulation. We are witness to a changing world in which child and adolescent psychiatrists have shifted from what had been a one-treatment strategy to a multitreatment armamentarium that includes a variety of psychotherapies (behavioral therapy, cognitive therapy, group therapy , family systems therapy, etc). This situation challenges the psychodynamically oriented therapist to consider ways in which recent psychoanalytic theory and research influence the general child and adolescent practitioner and in which so-called "standard" practices of dynamic psychotherapy can and should be modified. This question has broad implications for the survival in clinical practice of psychoanalytic principles and for the conduct of inquiries into how children fall ill and how symptoms evolve . Some recent reviews of the subject evoke the image of a practitioner of dynamic child therapy who seems like a caricature of a classical analyst (e.g., Zeanah et al., 1989) still bound by the impediments of outworn theory as though nothing has happened since Freud wrote at the turn of the century. In fact, there have been 100 years of evolution in the thinking of analysts, and more recent ferment with respect to changing models of development, symptom formation, and therapeutic approach. Among these changes, the influence of the interpersonal sphere on intrapsychic variation, including the new appreciation of transference and countertransference in the psychotherapy of children will be highlighted. The ways in which early dyadic influences encroach on development of self and ego and participate in the formation of symptoms will also be elaborated. Recent empirical data suggest that these issues serve, as much as the triadic interactions of the oedipal constellation, as a watershed in mental Accepted July 26, 1991. Dr. Shapiro is Professor of Psychiatry. Professor of Psychiatry in Pediatrics. and Director. Child and Adolescent Psychiatry. Cornell University Medical College-Payne Whitney Clinic. New York, N.Y. Dr. Esman is Professor of Clinical Psychiatry and Director ofAdolescent Services, Cornell University Medical College-Payne Whitney Clinic. Reprint requests to Dr. Shapiro , Cornell University Medical College-Payne Whitney Clinic, 525 East 68th St.• New York, NY 10021. 0890-8567/92/3101-006$03.00/0 © 1992 by the American Academy of Child and Adolescent Psychiatry.
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development, with consequent implications for structuralization of the mind in accord with cognitive and neurophysiological change . Ego psychological phenomena from the standpoint of explorations into early object relations models, narcissistic self-regulation and actual childhood histories. with some stress on the impact of severe insults in early childhood ranging from incest to other traumas that may lead either to difficulty or at times to resilience will also be examined. Some attention will be paid to the ways in which memories are structured in the mind and to the recent understanding of procedural versus declarative memory, and how these affect Freud's (1914) well-known triad of remembering, repeating, and working through. Recent work on affect development as a determinant of motive has shown how children learn to designate their feelings and regulate their emotions as well as how feelings restructure meaning (Emde, 1991; Lewis, 1991; Stern, 1985). The authors shall also consider how a psychodynamic framework continues to be useful in structuring clinical data before one embarks on any mode of therapy, including pharmacotherapy and family therapy. The authors propose that the use of the dynamic formulation as a guidepost (along with DSM-III-R) is a reasonable means of determining where to dispatch efforts to where things hurt most or to where efforts are most likely to yield effect (Shapiro, 1990). In short, the authors shall try to bring together some of the evolving models and data derived from psychoanalytic propositions and studies to demonstrate that they represent a dynamic flux and not a static canon of fixed procedures. Some of the modifications in theory and praxis derive from work with adults, whereas some come from reconceptualizations about development derived from analytically informed direct observation of infants and children in naturalistic and experimental settings. Psychoanalysts and dynamic therapists have always held a tripartite view of the phenomenology and meaning of symptoms. The descriptive level holds closely to Freud 's trenchant vision of the distinction between hysterical symptoms and neurological lesions as a necessary precursor to understanding meaning. We must thus first describe well. This holds in the dynamic framework too. Anna Freud's J.Am. Acad. Child Adolesc. Psychiatry, 31:1, January 1992
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(1963) careful analysis of the symptoms of childhood along developmental lines led to her warning that treatment should be considered only if children or adolescents are stopped in their developmental path for too long or tarry at an earlier stage than is appropriate in one of the developmental lines, creating problems in adaptation. This essential developmental viewpoint allows for transient, even necessary, symptom formation as part of the maturational course. Behind the descriptive picture of what is observed, a dynamic flux of intrapsychic forces is assumed that permits the inference that symptoms have meaning; moreover, what is consciously displayed is, it is assumed, the result of the interaction of forbidden wishes and the protective forces of the ego at the behest of conscience and superego and external prohibitions. These external prohibitions are imperfectly internalized rulelike structures, which derive in part from the child and in part from the parent. The third level of organization involves the reconstruction or construction of what "must have happened" to generate these symptoms and descriptive pictures. This is the genetic level of thinking, which derives largely from Freud 's view of trauma as etiological, a notion that is currently in center stage as the role of incest and other traumas on symptom formation is reconsidered. Corollary to this last postulate is Freud's notion that the oedipal conflict is nuclear and a consequence of the fact that we grow up in families (or equivalent caretaking social organizations) in which the child has to resolve the primary wish to be loved and identifies with mother and/or father even as wishes are frustrated. Fundamentally, the point of view of analysis from its onset has been retrospective and reconstructive, but it has simultaneously given rise to a major enterprise of forward looking developmental research. This began with the early designation of a genetic field theory by Spitz (1959) and his students (Emde, 1990), followed by the separation-individuation process as espoused by Mahler (1975) and her colleagues and by Bowlby's (1982) ethological integration of psychoanalysis and object relations theory, which has become known as attachment theory. This latter conceptualization has beenoperationalized by the experimental "strange situation" designed to measure security of attachment during the second year of life (Ainsworth et al., 1978). These ideas have received further support from the seminal nonanalytical work of Sameroff (1975) who argued and demonstrated that, while there may be a continuum of reproductive casualty that can be demonstrated in early development, by the time the child is of school age, a continuum of caretaker and social casualty must also be examined. This idea parallels the cautionary notion of Anthony (1987), Garmezy and Phipps-Yonas (1984), and others that it is not only the genes that make the child, but the nonshared environment as well (Plomin, 1989; Reis and Klein, 1987). The concept of resilience or invulnerability or of "superkid" or the "dandelion child" of Anthony (1987) derives from a peculiar interaction among intrapsychic structuring and the realities of the child's expanding world. Thus; there has been a major feedback loop among dynamic psychotherapists and the academic research schools that has grown out of some of these early dynamic conceptual frames. There J.Am.Acad.ChildAdolesc.Psychiatry, 31:1, January1992
have been many false byways, but there have also been validated studies of this interaction between theory and practice and these have, in tum, influenced our view of children, just as they have influenced activities with children in the psychotherapeutic endeavor. Anthony's (1969) earlier lament that research and psychotherapeutic clinical practice are two worlds apart may no longer be valid; bridges have been made. Indeed, it may be said that developmental research has been in more positive relationship to psychoanalysis than the tendency seen in biological research to become increasingly separate and mutually disparaging. Many early psychoanalytic studies took libido theory too literally, leading to emphasis on such events as toilet training as though they were potentially traumatic, rather than emphasizing the broader scope of interactive events that have repercussions on the developing mind (Erikson, 1956). There was a tendency to see pathological characteristics in what can now be seen as variability in response patterns. Only recently have we begun to gather the kind of information that permits us to consider dynamic cognitive structuring as it affects play and language in the light of the contemporary psychodynamic view that communication, language, and play are central modes of interaction and determinants of how we know each other. Development and Dynamic Psychiatry
For example, it is now believed that attempts to understand what is going on psychologically in autistic and the developmentally disabled children must take into account their intrinsic incapacities. This is different from the earlier view in which symptoms were seen as simply parallels to other dynamic compromises or of "primitive" developmental stages. Such children's presumed views of the world (from an analytic vantage point) must be looked at not as compromise formations but as functions of the ways in which their disability leads to a particular pattern of responsiveness. The work of Hobson (1990), Shapiro (1973), and others all suggest that in autism and other developmental disabilities with cognitive components the oedipal roots of these disabilities are trivial. These may indeed be "prestructural" children in the sense that they cannot lend the nuance of meaning to their expression, and meaning must be inferred from the repetitiousness of their behaviors and the limitations of their cognitive capacity. Hobson's (1990) idea of the unique theory of mind of the autistic child leads to a particular sense of self that accounts for his unusual interaction. Shapiro and Hertzig (1991) offer similar conclusions emphasizing the integrative failures in affective and cognitive development that lead to the personal social failures described. Using the model ofa biological disorder, Tourette's syndrome, Cohen (1991) has teased apart the effect on the self of movements occurring without volition and how these effects are represented. This leads to a central question in recent work in analytic understanding of development: What are the reciprocal roles of mother and infant before language and how does their interaction structure later development? In extreme cases like autism, biological factors are limiting, but in other cases closer to the usual, there may be a desire to ask how
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mother-infant interactions color future interactions and the potential for dynamic treatment. These interactions have been well studied by this time, and the studies have had a major feedback effect on the way in which therapy is done (Greenspan, 1989; Solnit, 1987; Zeanah et al., 1989). Winnicott's (1975) earlier caveat that "there is no such thing as a baby," only a mother-infant dyad, has been taken seriously by investigators such as Stem, Emde, and others, and has given power to the arguments of the object relations school of psychoanalysis that minimizes the traditional drive-defense relationship in favor of an interactional two-person or three-person model that has implications for therapy. Indeed, Pine (1985) and others suggest that the therapeutic process is analogous to a resumption of development. The organization of later adult mental structures is founded to some degree on the ways in which the child experiences the world at each stage of development. These ideas have led us to the concept of a much better formed nuclear ego even in the first months of life that engages the world early, as opposed to the model of an undifferentiated infant who reacts passively (Zeanah et al., 1989). Self-psychologists, too, emphasize this readiness to interact (Tolpin, M. 1986). According to this modem concept, the infant begins to organize the experiences with caretakers in significant and meaningful ways right from the start. Stem's (1985) idea of a core-self with a variety of stages in its development is certainly relevant to recent ideas about inborn ego nuclei, self-representation, and the significant role of parenting on early mental structuring. Among adult analysts, Loewald (1978) has been preeminent in his insistence that the drives as well as self and object representations evolve out of the internalization of early motherinfant interaction patterns; that, indeed, it is these interactions, rather than the objects themselves, that are internalized forming the nuclear elements of psychic structure. One may also credit Hartmann as an earlier ego psychologist for his notion of ego nuclei as an even earlier precursor. The implications of such models for therapy are many-one can look more concretely now to early interaction as molding current behavior. Concurrent treatment of mothers and fathers whose fantasies about their children may have continuing impact on the child patient can also be seriously considered. Bowlby's integration of ethological models and object relations theory has become a prototype of the influence of newer psychoanalytic ideas on clinical practice. His idea of the early interactions between mother and child has given rise to a series of paradigms such as the strange situation developed by Ainsworth et al. (1978), where the security of attachment-that is the capacity of the child to use the mother as a secure home base for exploration-becomes the advance herald of later developmental competence. Even more striking are the consequences of observations that security of attachment is predictive of later psychopathology or healthy adaptation, and that such inferences can be made even from exploring the intrapsychic musings of the motherto-be or the mother than has been treated in a particular way by her own mother. Main et al. (1985) and others have developed schedules of inquiry that code surface answers to routine questions in such a way that one Can determine 8
whether a mother's view of her child will lead to secure attachments with .their salutary effects on the next generation. From a psychoanalytic perspective Cramer and Stem (1988) and others have instituted similar concepts into a mother-infant treatment program where neither behavioral modeling nor shaping procedures are used. Instead, the therapist interviews the mother interacting with her child and learns about her fantasies of her baby and how those views influence the infant's symptomatic behavior. These workers find that, at least in well selected cases, such nondirective depth exploration can significantly improve interactions and alleviate early infant disorders such as vomiting, excessive aggression, and avoidant interaction. New Views of Transference-Countertransference
Other interactional variables that have become important in work with children find their expression in the recently heightened psychotherapeutic emphasis on transference and, particularly, countertransference. For many years after Anna Freud (1946), most dynamic psychotherapists thought that full-blown transferences did not occur or could not be interpreted in young children because of their ongoing fluid relationship to parents. Therapists of the Kleinian school have, however, always believed the reverse: i.e., that a full transference neurosis occurs in children and can be interpreted as such from the outset of treatment. Sandler et al. (1980) have elucidated the distinctions among different types of transference-' 'Transference of habitual ways of relating, of current relationships, of past experiences, and transference neuroses" (p. 78). In this context, it has been recognized that young children do bring fairly well structured fantasies and play themes to the consulting room, which can be understood and carefully interpreted as transference phenomena (Neubauer, 1987). Any of these can elicit significant countertransference responses (Chused, 1988). This applies not only to children but to adolescents as well. Recent work by Jacobs (1991) and others focusing on the fantasies of the therapist in interaction with the adult patient has proved pertinent to work with children and adolescents. Fantasies of rescue (Esman, 1988), the wish to outdo the parents of the children in our charge, the rageful attitude toward parents who abuse, the regressive pull of playing with a child, the joy of being with an adolescent when one's own adolescence is barely completed, all have significant impact on the ways in which we deal with our patients (Esman, 1990a; Schowalter, 1986). Case Example Jane, a 17-year-old girl of unusual charm and intelligence had been in psychotherapy for a year with a young psychiatrist who had begun working with her when Jane was hospitalized because of a mild suicidal act. Jane was an extremely responsive patient-bright, insightful, and hard working. The therapist was aware of her identification with the patient and had succeeded in maintaining an appropriately neutral but empathic stance throughout. As the academic year drew to a close, Jane became increasingly preoccupied with thoughts of college, with her conflict about leaving home, and the like. One day, she J. Am. Acad. Child Adolesc. Psychiatry, 31:1, January 1992
PSYCHOANALYSIS AND CHILD AND ADOLESCENT PSYCHIATRY
began to speak about her friends-those, she said, whom she feared she might never see again once she went away. She went on in this vein for some time; her therapist recognized that this was a veiled reference to the anticipated termination of the treatment and the patient's feeling ofloss, but she' 'couldn't find a way to interpret it, so I just listened to her." It was not until, in supervision, she was helped to recognize her own feelings of loss, her own deep pleasure in the work with this rewarding patient, and her reluctance to acknowledge the impending end of the relationship that she was able to "find a way" to make the connection explicit. Marshall (1979) has developed a typology of countertransference reactions, depending on their source (the patient's unconscious or the therapist's) and the extent to which the therapist is capable of awareness of these feelings and can use them to further his or her understanding of the patient. Lesser (1971) has examined the special countertransference issues arising in work with children with sensory handicaps, stressing, again, the roles of rescue fantasy and of the difficulty many therapists experience in helping such children because of their own unconscious revulsion and anxiety. This transference-countertransference matrix must be seen in light of the activity that must occur between young patients and adult therapists. The fact that we must play along with, interact, provide foils for play, or become participant observers can be most distressing and/or too satisfying. The recent scrutiny in adult therapies of enactments and what object relations theorists call projective identification leads to new possibilities for viewing our interactions . We may now ask "Am I reacting to the child's play or to an unconscious fantasy?"; "Am I feeling what I am feeling because of my own unanalyzed unconscious fantasies?"; "Do I feel this way because of my response to the child's parents?" This heightened interest in countertransference reactions is consistent with a radical questioning of the concept of the therapist as an external observer, one which is being replaced by a more interactional view that permits observation of the child in a field of play with the therapist as adult and as projected object. These multiple images aid therapists to understand the significance of their own emotions and fantasies in the play.
Emotions and Interaction Emde (1990), following Klein (1976) but also exhorting us from the experimentalist vantage, calls for the establishment of a "wego" as well as an " ego" for dynamic therapy. He encourages a revival of an interpersonal view, examining the interactional framework of the development of self and its influence on the ways in which we perceive. Social psychologists such as Mead et al. (1934) have long talked of man's development in the social matrix. This was also implied by Freud's early notion (derived from Darwin) that long caretaking for small iminature broods contributes to neurosogenesis. Certainly Sullivan's (1953) interpersonal theory rests on this premise. Only recently, however, has such empirical research as that of Emde demonstrated how the affective tone of the interaction of the child and mother J. Am. Acad. Child Ado/esc. Psychiatry, 31: 1,January 1992
determines a sense of "basic trust" that can be demonstrated at the end of the first year of life (Erikson, 1956; Sorce et al., 1985). Emde and others have shown that even at the crawling stage when faced with an apparent dropoff, a 9month-old pretoddler will crawl farther if the mother has a "come hither" look. Similarly, by age 3, children already have some internalized prohibitions and rules that govern behavior that can be construed as nuclei of the superego . Clearly, the internalized defensive organizations and rationalizations that are evident in childhood can be found well before the resolution of the oedipus complex. We also have direct evidence that by 2 to 3 years, children can dissimulate (Lewis, 1989) or make up stories as to why they shouldn't follow the rules; thus, we can recognize that intrapsychic conflict is already presaged by these preoedipal behavioral constellations. Even more significantly, we can determine how parents provide double signals similar to the double bind that leads to our understanding that 3-year-olds have a firm grasp of various signal systems from parents and can segregate their compliance. All these capacities offer continuing evidence for clinicians that affects modulate behavior and that social interactions determine affective dispositions. Surely clinicians have also known these facts from their own encounters with children, but empirical studies reinforce and validate these clinical experiences. They compel us to take greater and more careful account ofthe child's environment even in the toddler years. Parents must be seen more frequently and persistently to determine the nature of the child's actual experience and for us to decipher what is happening despite what we are told. The isolation from the parents of the traditional Kleinian therapist seems no longer tenable. Moreover, the dynamically informed psychotherapist might well consider the value of parent counseling coincident with work with the child or adolescent. As we learn more about how children develop, the impact of caretaking cannot be ignored. Even though early on Anna Freud did see parents and advised others to do likewise in psychoanalysis, there was a tendency to use the parents only as sources of information. Recent data suggest that some work with parents is indicated, paralleling work with children. Recent studies on emotion in infants and children increasingly regard affects not merely as drive derivatives but as basic inborn propensities available from birth. These affects develop and serve as motivating structures, determining our resort to one or another behavioral pattern, as well as our use of emotionally tinged ideas as regulators of behavior. The child who is constantly prohibited during the "terrible twos" is likely to experience such constraint as an intrusion on his quest for autonomy. He or she will respond by turning the passive into the active (identifying with the aggressor), becoming naysayers, and opposers. This negativism, based on miscarried autonomy seeking, may then skew character organization . Although such preoedipal organizations develop as clearcut trends, these may still be reorganized as the child approaches the 5th to the 7th year (Shapiro and Perry, 1976). Hierarchic reorganizations, as described by Werner (1940), accompany the evolution into middle childhood (or "latency" as Freud called it). Concrete operational thought 9
SHAPIRO AND ESMAN
arises as the oedipus complex has come to its full flowering. Indeed; the interaction and study of cognition and emotional development permits us to break through to a new view of latency and adolescence. These may be biogenetic shifts on the basis of brain and psychic structure reformation. These new organizations take hold as the determining constellations of overt behavior but also are represented as unconscious fantasies. The fantasies are organized as unconscious structures, but they may also be organized in action patterns and as affective dispositions (Shapiro, 1975). There is a direct relation between the thinking of some cognitive psychologists and Freud's ideas about repeating as a way of remembering. We know from studies of children that they may have procedural knowledge, i.e., they may know how to do things, but not be able to tell you how they do it (Clyman, 1991). For example, they have evidence of grammatical understanding in their early utterances without knowing what a noun or a verb is. This understanding has had its reciprocal effect in regard to how dynamic psychotherapists look at the enactments that are seen in child therapy. These enactments, these play sequences, may not be organized as conscious thoughts. There is a similar split offered by cognitive psychologists between episodic and semantic memories, with evidence that the former are stored as visualization and not verbal thoughts. It is by putting these entities into a language format that the psychotherapist attempts to restructure existing patterns and to have an impact on the child's ego organization. Indeed, verbal propositions have an organizing effect on behavior as do interactional factors (Shapiro, 1991). Moreover, children who are more action oriented may not have access to their emotions as signals, thus, the therapist should direct attention to naming feelings as a means of short circuiting impulsive action. These early preverbal action patterns also are seen in analytic propositions derived from Winnicott and others, bringing new attention to nonverbal aspects of the therapeutic situation. Work with adult borderline and narcissistic disorders has led to the formulation of a construct known as the "holding environment" (Model, 1976). This nonverbal aspect of treatment is now seen as paramount in creating the therapeutic alliance that was earlier looked at as the induction phase in child therapy (A. Freud, 1927). Certainly, work with children presages the practice of providing a safe and congenial medium for exchange where fantasies can then be viewed in relation to overt behavior. As Abrams (1988) puts it, adults in psychoanalysis engage in "characteristic modes of relating, a transference consolidation, the revival of earlier pathogens and the effects of knowing (insight). Children in addition use the setting for new experiences in the service of emerging development organizations" (p. 260). Clearly, the same is true is psychotherapy. For example: J. Was a lti-year-old Asian-American girl who came to treatment after a suicide attempt. Depressed, tearful; and self-reproachful, she came from a deprived and depriving family, with a psychotic and hemiplegic mother and are" mote, harried father. Her life was joyless and focused entirely and compulsively on academic achievement. In her psychotherapy, she poured out tearful complaints about her family life, her sense of obligation and guilt; and her social 10
isolation. The therapist's role was that of a neutral but empathic partner in J.'s self-examination and growth. The patient described her therapy as "the best relationship I've ever had." Gradually, she began, with the therapist's support, to experiment with typical adolescent social interactions and dating, becoming less compulsive with her school work, gaining self-esteem, and ultimately finding it possible to leave home to go to college. Adolescent Development and Therapy
Recent analytic work with adolescents has also given rise to new questions concerning the classical rule of abstinence and neutrality. Although adolescents do not need another authority to lead them or another parent figure in their milieu, work with adolescents in an dynamic setting has certainly led to a loosening of bondage to the concept of neutrality construed as total abstinence (Franklin, 1990). Instead, most therapists who work with adolescents have advocated the building of a primary relationship that will permit the expression of ideas, fantasies, and concerns that can be used in the ensuing work. This approach is based on increased understanding of the concerns of adolescents and the reemphasis on the specific conflicts that are special to this age period. Consolidation of relationships, sharing with peers, and normalization of inner experience through the awareness that other adolescents have similar concerns have been noted as central to adolescent experience (Esman, 1985; Shapiro, 1985a). Sullivan's "chumship" in the juvenile period is an earlier statement of this idea. With this view in mind, we may look at the positive accruals of healthy adolescence as those that "normalize" internal demons. The reassurance that the adolescent experiences when she or he learns that other adolescents share his or her inner thoughts is only possible if the individual can relate those thoughts to others. Therapeutic relationships provide surrogate experiences of this genre. Lest this freedom to express becomes an invitation to wanton license, the therapist may provide the assurance that thinking does not necessarily lead to doing. Contrariwise, some thoughts and wishes may become realities in time if ego support is available to provide appropriate opportunity. The therapist in this setting becomes the needed peer who permits freedom of thought. On the other hand, he or she does not join in on the new freedom but maintains an appropriate and optimal therapeutic distance. Psychoanalytic work with adolescents has also heightened our awareness of their need to resolve the conflictual attachment to the same sex parent ("negative oedipal relationship"); to come to terms with the deidealization of early parent images, and to reformulate a realistic ego ideal (BIos, 1985). BIos (1967) has further illuminated the analogy of adolescence with the separation-individuation process, occurring at a time when biological maturity and sexual procreative powers are at their height, but when, paradoxically, modern industrial society imposes an unnatural prolongation of the process (Esman, 1990b). These ideas have trickled down into psychotherapeutic approaches with adolescents, leading to the possibility of less intense and more focused modes of treatment, and to support for ego growth during this formative period. Curiously enough, the sexual revoluJ.Am.Acad. Child Adolesc.Psychiatry,31:1, January1992
PSYCHOANALYSIS AND CHILD AND ADOLESCENT PSYCHIATRY
tion and other .so-called revolutions that are supposed to further emancipate adolescents have led to new problems that dynamic psychotherapies have addressed. The same problems of intimacy and relation to objects are found, despite the fact that children and adolescents are more sexually active than in earlier times (Esman, 1990b; Ginsberg et aI., 1972). Such knowledge and reemphasis has been integrated by the larger community of those who work with adolescents. For example, we know that it is not sufficient to provide condoms for safety in this period of fear of AIDS. Moreover, we fail our adolescents if we provide information on the mechanics of sexual behavior without addressing the environment of safety in which mature intimacy can be integrated with sexuality. Ever since Freud, psychoanalysis has been at the forefront emphasizing these integrations. Erikson was an inaugural spokesman for this developmental point of view from the side of the ego. Similarly, the hospital treatment of adolescents has been enriched by the psychodynamic notion that it is not sufficient to medicate adolescents without observing their response to the milieu, their resistant phase, their engagement, and the necessity to work through the aspects of damage, dependency, and loss that emerge in the course of hospitalization (Rinsley, 1971). The psychoanalytic emphasis on meaning has helped to make child and adolescent psychiatrists increasingly aware of the importance of the meaning of medication to the patient and the family and of the interaction between medication and the doctor-patient relationship in the pharmacological treatment of child and adolescent disorders (Schowalter, 1989; Shapiro, 1985b). Diagnosis and Dynamic Formulation
Ever since the publication of DSM-III and now with the impending appearance of DSM-IV, the new descriptive diagnostic scheme has preoccupied clinicians. However, dynamic psychiatrists have alerted us to the importance of an Axis in which dynamic factors can be coded. Unfortunately, this has not yet been achieved. In lieu of such a dimension, others have proffered a dynamic formulation, both for adult and child work (Perry et aI., 1987; Shapiro, 1989). Such formulations enrich our views of children and adolescents and enlarge our understanding of treatment aims. Since the adolescent is at a radical change point in biology and caught in an interpersonal and family flux at a time when his own personality may be at a crossroad, such a formulation seems paramount. As Cantwell (1980) stated, DSM-III is a book of disorders, it is not a book that describes children. The dynamic formulation can tell us something about how each child shapes his or her environment and how this environment, in tum, shapes the child even as he or she is responding to bodily changes. Recent work by Hauser (1991) has advanced our understanding of how adolescent development proceeds in line with ego integration and the surgent and regressive forces that determine the next step into young adulthood. This work is consistent with Offer's demonstration (Offer and Sabshin, 1984; Offer and Offer, 1975) that the classical analytic concept of " normal adolescent turmoil" requires extensive revision (Oldham, 1978). J.Am.Acad. Child Adolesc.Psychiatry,31:1, January1992
Hauser and others interested in childhood adaptation take us back to our repetitive tendencies to have our lives unfold in what seem to be patterns even if some patterns are discontinuous and nonlinear. It is the patterned behavior that the psychotherapist must capture in concepts and ultimately in words. As Freud (1910) noted in his paper on "Wild Psychoanalysis," if we discover universals that underlie disorder, merely tell ing the patient about them does not promote change. It is the careful dynamic work with the patient that creates the climate of trust, the transference enactments, and potential experiences that lead to conviction. This conviction and the will to change are the aims of dynamic therapies now as then-but we have broadened the scope of techniques to that end, using new data from normal development, adult dynamic therapy and analysis, and from experimental therapeutic ventures. Conclusion The past 25 years have produced new models that enhance our view of and the armamentarium for dynamic therapy. Infant-parent observation, theory of attachment and object relations theory, and self-psychological ideas about selfesteem have been absorbed into ego psychological views of human interaction as it influences psychic structure. These models have had significant effect on therapeutic work, with increasing interest in biological determination of temperament in interaction with caretaking. Most recently, the role of affects as behavioral motivators and modulators of interaction must be considered in the transferencecountertransference dyad and triad in the therapy of children. Adolescence is well established as a developmental epoch in our postindustrial world. The unique problems of this stage have required changes in our understanding of how adolescents act and interact. We add to our treatments new ideas about individuation, sexual freedom, struggles for independence and normalization of experience as dynamic factors in behavioral organization, sexuality and expression of intimacy. Dynamic psychotherapy has been enriched by these new advances in knowledge from psychoanalytic experience, just as psychoanalytic ideas have influenced direct observation. The new dynamic therapists are freer to be themselves with children and adolescents. They are likely to be more flexible in their integration of work with parents and other family members in the therapeutic process. They will be cognizant of the levels of cognitive and language development of their child patients and their impact on communicative processes in the treatment work. They will be alert to the nuances of transference and their varied meanings. They will probably be less ambitious in their goals and more likely (especially with adolescents) to accept limited results and to appreciate the growth enhancing value of symptomatic improvements. Still, they will be always cautious that they are engaged in endeavoring to learn about how the child or adolescent mind is organized and how the meaning of enactments can be interpreted for therapeutic aims and gains. The diagnostic formulation uniformly applied, regardless of a psychiatrist 's orientation, is a tool that will aid clinicians in the appropriate choice of therapy and disposition. It will
11
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also provide a sense of stepwise solutions as interventions are staged and, finally, provide an overview that encompasses many points of view.
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