Michael Fitzgerald


The goal of psychoanalytic psychotherapy with a distressed child is to alter the child’s 
psychic structure and function. The technique is based on the same theory as adult psychoanalytic psychotherapy. The unconscious is central, as is the interpretation of
 defence, resistance, transference, working through and the reconstruction of earlier life.
 It differs from adult psychotherapy in that the child’s age and level of development are 
at all times central to the work. In young children, the focus of interpretation is on free 
play, while with adults it is free association of ideas. In the treatment of adolescents a 
combination of techniques, both adult and pre-adolescent, are used, while for late adolescents the technique is basically adult technique with attention to issues relevant to that 
stage of the life cycle.

First Session

It is not unusual for a child, coming the their first session, to have fears of fantasies about 
the treatment. They may feel that they are ‘naughty’ and may see it as a punishment. If 
they have been mistreated for most of their life, they will have much mistrust and very 
little hope of help. Siblings may have mentioned the word ‘mad’ in relation to coming 
for therapy, and this can cause the child great anxiety. Sometimes they will have been 
given other explanations of the visit and are completely confused. These prior fantasies 
or explanations need to be explored by the therapist with the child. The major part of 
treatment is opening up clear lines of communication and openness, and dealing with fantasies so that the world makes sense to the child.

General Approach

If the therapist asks themselves the following questions, he/she is far more likely to 
remain focused on what is important:

(a) What is the link between the end of the previous session and the beginning of this 
session?


(b) What is the affect or anxiety in this session?


(c) What is the relationship of this anxiety to: (i) current preoccupations; (ii) therapist;
 (iii) childhood experiences?


d) What is the theme of this session?


(e) What is the overall theme of the sessions?


(f) What are this person’s core conflicts?


(g) What are the contradictions in the person’s material today?


(h) What is the transference and counter-transference?

(i) What is the link between a dream and the transference (if relevant)?


(j) What is the resistance?

Conditions Where Psychotherapy Has a Role


Abuse

One of the first tasks of healthy development is the acquisition of basic trust which will
 grow in the child in a good enough family. Children who are physically abused, sexual
ly abused or suffer serious neglect grow up very mistrustful and fearful of people. Child
 psychotherapy takes a very long time to reverse this mistrust of people, and an element
 of it probably always persists.

Aggression


Uncontrolled aggression in the classroom is a common reason for referral for child psychotherapy. Such children tend to have a history of being in a family where there was considerable violence, or have experienced violent attacks in or outside the family. There is often marital disharmony or alcoholism in the family. The child may be part of
 a very large family where the parents are overwhelmed by the excessive care-taking needs and not able to meet them. These experiences can leave children feeling very angry and resentful. They take these feelings out on other pupils or on the teacher in the classroom. In child psychotherapy, the child is helped to understand why they are so angry and aggressive and are helped to see the origins of their symptoms. The therapist helps the child to express feelings about experiences in earlier childhood and to under
stand them, and therefore to work through them and resolve them by talking about them so that they are not acted out.

Anxiety


A child may present with feelings of anxiety, nightmares, or fear of going out onto the street alone. This could be because he or she lives with extremely anxious, over-protective parents who are constantly worried about their welfare, telling them that the world
 is full of dangers and that all kind of catastrophes could happen. The child has nightmares of catastrophes, clings to his or her parents and is terrified of any separation from them. The child psychotherapist tries to help the child to see the world as a relatively safe place, and that there is not ‘a catastrophe round every corner,’ which is an example of reality testing.

Parasuicide


Children from the age of about 12 years can commit or attempt suicide. For children who attempt suicide, child psychotherapy is required in addition to some other treatment like family therapy. It may be because the child is being abused in some way, or they may feel that they are not being treated well in the family and that some other sibling is being favoured. They may express their anger at someone close to them for not caring enough for them. The attempted suicide is then a way of punishing this person. The child psychotherapist helps the child to see that this is not an appropriate way of communicating with this other person and helps them to communicate in a more direct verbal fashion.

Depression


Childhood depression is not an uncommon presenting symptom. The father of a child
 (who was very small in stature) was tall, athletic and had a very successful athletic
 career. The father was totally unaccepting of his son who was not athletic like himself. 
The father favoured another son who was athletic and fulfilled the father’s ideal for a son.
 Clearly, in this case, work is required with both father and child. The child in psychotherapy had to be helped to come to terms with his small stature and not to be so 
angry about it, and to express anger directly to his father about his inappropriate attitude 
towards him. The father had to be helped to accept his son as he was.

In depressed children anger is usually turned inwards, and helping the child to express
 this anger outwards can be beneficial. The child has to be helped to value the assets that 
they have, as these can often get overlooked by the child when there is excessive focus
 on some negative issue, like short stature. The therapist must try to help the child to
 build up a positive self-image and increase their self-esteem.

Some children in families where there is marital violence blame themselves and feel 
inappropriately that it is caused by something in them that is ‘bad’. The child psychotherapist helps the child to differentiate between that which they are responsible for
 and that which they are not.

Abdominal Pain


A child complaining of tummy pain at 8 o’clock each morning may do so because they 
inappropriately fear criticism from a teacher, or cannot face their own perfectionist academic standards. They may see it as a total disaster if they are not top of the class. The
 child experiences conflict which is then expressed as abdominal pain. The child psychotherapist helps the child to understand this pain and to modify their standards and to 
see the teacher as he or she is in reality.

Effectiveness of Child and Adolescent Psychotherapy


This is of critical importance to psychotherapists, referrers and policy-makers. It is important because of the large numbers of children with emotional and conduct problems: one study of 2,000 ten-year-olds found a rate of 16% (Fitzgerald & Berman, 1996).
 Clearly not all these would be candidates for psychodynamic psychotherapy. Psychodynamic child psychotherapy is one of the three most commonly used therapies, the other two being child behaviour modification and child cognitive therapy. Some of 
the positive effects of psychotherapy are not seen immediately. Some of the improvements continue to arise between 18 months and three years after a child finishes psychotherapy treatment. For children, the overall improvement with psychotherapy has
 been put at between 67% and 78%. The spontaneous improvement rate without treatment has been put at about 25% (Kolvin et al, 1981). It is likely that child psychotherapy considerably speeds the rate of improvement. The majority of scientific outcome studies are behavioural and only about 20% are non-
behavioural. 9% of the studies used dynamic psychotherapy. A number of meta-analyses of controlled studies have been carried out. Weisz and Weiss (1993) found a greater 
effect for behavioural than non-behavioural treatments. Nevertheless, Shirk & Russel 
(1992) have shown convincingly that it is erroneous for the wider scientific community 
to be under the impression that psychodynamic therapy has been shown to be less effective for children than the newer treatments. 8% of the studies showed a negative effect
 of treatment. Effect sizes are similar in meta-analyses of child and adult psychotherapy.
 However, there are a number of limitations to meta-analytic studies, including problems
 with confounding variables and unrepresentativeness of many studies. An important clin
ical finding in relation to adolescents was that they showed a high attrition rate and benefited as much from less intensive treatment. Indeed, Anna Freud favoured less intensive treatment for adolescents because it is important for adolescents to become independent from their parents and psychotherapy is dependence-inducing.

Fitzgerald (1996) has shown that an eclectic mixture of psychotherapy showed a significant improvement in an out-patient child psychiatric clinic at three-months follow-up 
but that the positive effects had disappeared at one year follow-up. In the years after 
treatment further ‘booster’ periods of psychotherapy may be needed as there is evidence
 that many forms of treatment may not have lasting effects.

Conclusion


While child psychotherapy has a considerable amount to offer to many disturbed children, there is little doubt that some children will require multi-modal treatments. It is
 important for the psychotherapist to keep in mind that about 30% of the variance in relation to the aetiology of psychopathological problems will probably be explained by biological factors. A holistic approach is the only way that makes sense, with the therapist 
taking internal and external factors into account and keeping in mind a biopsychosocial 
model.

References:

Fitzgerald, M. (1996); Irish Families Under Stress, Vol 5, Dublin: EHB

Fitzgerald M. & Berman D. (1996); ‘Obsessive-Compulsive Disorder in the 1990’s, Irish Journal of Child & Adolescent Psychotherapy, 1,65,74.

Shirk S.R. & Russel R.C. (1992); ‘A Re-evaluation of Estimates of Child Therapy 
Effectiveness’, Journal of American Academy of Child & Adolescent Psychiatry‘, 31, 703,
709.

Weisz J.R. & Weiss B. (1993); Effects of Psychotherapy with Children & Adolescents, 
London, Sage

Michael Fitzgerald is Director of the Child & Family Centre, Ballyfermot and is an
Associate Member of the British Psychoanalytical Society.

[This article is slightly abbreviated from the original article by Michael Fitzgerald pub
lished in Advances in Psychiatric Treatment (1998) Vol 4.1]