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PSYCHODYNAMIC CHILD AND ADOLESCENT PSYCHIATRY
SPECIAL SECTION SPECIAL SECTIONS EDITOR: JOHN E. SCHOWALTER , M.D.
PSYCHODYNAMIC CHILD AND ADOLESCENT PSYCHIATRY GUEST EDITOR: G. PIROOZ SHOlEYAR, M.D.
Introduction There are many interpretations of the word psychodynamics, but the contributors in this section adhere to Moore and Fine's ( 1968) widely accepted definition
similar to investigation of other treatment modalities. Child analytic research focuses particularly on the set of factors occurring between the analyst and the child in the therapeutic situation and explores the link between the changes in the child's inner life and symptomatic behavior. Reviewing psychodynamic psychotherapy research with children in the past decades, Marans (1989) highlights the shift of emphasis from research questions examining treatment outcome only to those addressing treatment process. He describes the development of increasingly rigorous methods for collecting and evaluating clinical data in the field of psychoanalytic child psychotherapy. The new research question focuses on which set of procedures is effective when applied to what kind of patients and practiced by which sort oftherapists. An important finding in some of the studies is the enhancement of therapeutic gains in the period following termination of psychoanalytic treatment in comparison to other psychotherapeutic approaches. This finding may underline the importance of new intra-psychic structure formation and its contribution to improved functioning. Psychoanalytic psychotherapy views symptomatic behavior as having psychological meaning. The search for the meaning of such behavior in the context of the child's family life, present and past experiences, and fantasies are a major focus of clinical investigation and intervention. The success or relative failure of the child in completing his developmental tasks in the prior stages of development are other major foci of treatment. In contrast to short-term intervention with children , psychoanalytic treatment has the goals of helping young patients resolve long-standing neurotic and personality conflicts that interfere with their overall adaptation and functioning, gain mastery over their conflicts and impulses, and enhance their autonomy and adaptation to the environment. The psychodynamic formulation , as an addition to diagnosis, encompasses the clinician's inferences about the child and provides a tool for succinct conceptualization of the case to guide the treatment plan. Such concise and coherent understanding of the child's maladaptive behavior and developmental failure can provide a coherent plan of intervention with emotionally disturbed children and their parents. This tool assists the clinician with inquiry about the form and
[Psychodynamics is] a body of knowledge and theory of human behavior which attempts to explain the mental phenomena in normal and pathological conditions as a result of interacting and opposing goal-directed or motivational forces, illuminating processes, developments , progressions and regressions. (p. 78) While the contributions of other psychodynamic theories, such as separation-individuation theory, object relation theory, and self-psychology are recognized by the authors, the viewpoints expressed in this special section adhere to the traditional, structural, and ego psychological model of psychodynamic psychotherapy . The authors have chosen the psychoanalytic model of psychodynamic psychotherapy because it has a long-standing historical tradition, because it is the most widely investigated discipline, and because there is clarity in the training requirements and standards established for its practice. Rapid advances in infant development research have resulted in new and refined findings regarding children's development and motivational systems. The research has defined more clearly the infant's capacities and assigned an increasing importance to context in the development of children as well as continuities and discontinuities in the developmental process. Such research findings have significant implications for psychodynamic theory and practice and have complemented clinical investigations with neurotic children. Equipped with developmental findings from a controlled research setting, the clinician can apply his increased knowledge in intervention with clinical disorders. The implications of infant research have been described comprehensively by Zeanah et al. (1989) in this section. The investigation of treatment outcome and process in psychoanalytic psychotherapy has been an active endeavor Dr. Sholevar, guest editor ofthis section, is on the/acuity 0/Jefferson Medical College, Philadelphia, PA. 0890-8567/89/2805-0655$02.00/00 1989 by the American Academy of Child and Adolescent Psychiatry.
655
656
SHOLEVAR
origin of a child's symptoms and enhances the comprehensiveness of the therapeutic and intervention approaches. In addition to treatment setting, the psychodynamic formulation can be used in other parts of the child's milieu such as the educational situation. The synergistic use of psychotherapy and psychopharmacological agents can help the physician transcend the mindbrain barrier and effectively treat a complex range of disorders, such as attention deficit hyperactivity disorder and depression. The combined application of psychotherapy and pharmacotherapy requires special attention to the meaning of the medication to the child, the vicissitudes of the doctorpatient relationship, and the need for methodological sophistication. The persistent controversy about the concurrent use of psychotherapy and pharmacotherapy, in spite of significant advances in the scientific base of both approaches, seems to be primarily rooted in irrational belief systems of some therapists based on historical, political, interpersonal, and intrapersonal factors. In the past four decades, psychodynamic psychotherapy has gone beyond the individual and been applied in the interpersonal sphere. The application of psychodynamic concepts to families expands the therapeutic reach of the psychotherapist
to the disturbed relationships. It enables him to address developmental failures from earlier stages offamily life that may exert a strong regressive pull on the family and interfere with family adaptation in certain areas. In addition to attention to contemporary family structure as the final common pathway for the unfolding of family dynamics, the therapist can use the psychodynamic concepts to recognize shared family defenses, shared family conflicts, and shared unconscious family fantasy systems. The object-relation school of psychodynamic family therapy pays special attention to the concept of holding environment and that its failure can playa crucial role in the genesis of a range of psychopathological disorders in children. A major advantage of psychodynamic family therapy over other modes of family therapy is its logical continuity with individual psychotherapy in which the psychodynamic factors can be addressed concomitantly or serially within individual or conjoint family sessions. Reference Moore, B. & Fine, B. (1968), The Glossary of Psychoanalytic Terms and Concepts. New York: The American Psychoanalytic Association.
PSYCHODYNAMIC CHILD AND ADOLESCENT PSYCHIATRY GUEST EDITOR: G. PIROOZ SHOlEYAR, M.D.
Introduction There are many interpretations of the word psychodynamics, but the contributors in this section adhere to Moore and Fine's ( 1968) widely accepted definition
similar to investigation of other treatment modalities. Child analytic research focuses particularly on the set of factors occurring between the analyst and the child in the therapeutic situation and explores the link between the changes in the child's inner life and symptomatic behavior. Reviewing psychodynamic psychotherapy research with children in the past decades, Marans (1989) highlights the shift of emphasis from research questions examining treatment outcome only to those addressing treatment process. He describes the development of increasingly rigorous methods for collecting and evaluating clinical data in the field of psychoanalytic child psychotherapy. The new research question focuses on which set of procedures is effective when applied to what kind of patients and practiced by which sort oftherapists. An important finding in some of the studies is the enhancement of therapeutic gains in the period following termination of psychoanalytic treatment in comparison to other psychotherapeutic approaches. This finding may underline the importance of new intra-psychic structure formation and its contribution to improved functioning. Psychoanalytic psychotherapy views symptomatic behavior as having psychological meaning. The search for the meaning of such behavior in the context of the child's family life, present and past experiences, and fantasies are a major focus of clinical investigation and intervention. The success or relative failure of the child in completing his developmental tasks in the prior stages of development are other major foci of treatment. In contrast to short-term intervention with children , psychoanalytic treatment has the goals of helping young patients resolve long-standing neurotic and personality conflicts that interfere with their overall adaptation and functioning, gain mastery over their conflicts and impulses, and enhance their autonomy and adaptation to the environment. The psychodynamic formulation , as an addition to diagnosis, encompasses the clinician's inferences about the child and provides a tool for succinct conceptualization of the case to guide the treatment plan. Such concise and coherent understanding of the child's maladaptive behavior and developmental failure can provide a coherent plan of intervention with emotionally disturbed children and their parents. This tool assists the clinician with inquiry about the form and
[Psychodynamics is] a body of knowledge and theory of human behavior which attempts to explain the mental phenomena in normal and pathological conditions as a result of interacting and opposing goal-directed or motivational forces, illuminating processes, developments , progressions and regressions. (p. 78) While the contributions of other psychodynamic theories, such as separation-individuation theory, object relation theory, and self-psychology are recognized by the authors, the viewpoints expressed in this special section adhere to the traditional, structural, and ego psychological model of psychodynamic psychotherapy . The authors have chosen the psychoanalytic model of psychodynamic psychotherapy because it has a long-standing historical tradition, because it is the most widely investigated discipline, and because there is clarity in the training requirements and standards established for its practice. Rapid advances in infant development research have resulted in new and refined findings regarding children's development and motivational systems. The research has defined more clearly the infant's capacities and assigned an increasing importance to context in the development of children as well as continuities and discontinuities in the developmental process. Such research findings have significant implications for psychodynamic theory and practice and have complemented clinical investigations with neurotic children. Equipped with developmental findings from a controlled research setting, the clinician can apply his increased knowledge in intervention with clinical disorders. The implications of infant research have been described comprehensively by Zeanah et al. (1989) in this section. The investigation of treatment outcome and process in psychoanalytic psychotherapy has been an active endeavor Dr. Sholevar, guest editor ofthis section, is on the/acuity 0/Jefferson Medical College, Philadelphia, PA. 0890-8567/89/2805-0655$02.00/00 1989 by the American Academy of Child and Adolescent Psychiatry.
655
656
SHOLEVAR
origin of a child's symptoms and enhances the comprehensiveness of the therapeutic and intervention approaches. In addition to treatment setting, the psychodynamic formulation can be used in other parts of the child's milieu such as the educational situation. The synergistic use of psychotherapy and psychopharmacological agents can help the physician transcend the mindbrain barrier and effectively treat a complex range of disorders, such as attention deficit hyperactivity disorder and depression. The combined application of psychotherapy and pharmacotherapy requires special attention to the meaning of the medication to the child, the vicissitudes of the doctorpatient relationship, and the need for methodological sophistication. The persistent controversy about the concurrent use of psychotherapy and pharmacotherapy, in spite of significant advances in the scientific base of both approaches, seems to be primarily rooted in irrational belief systems of some therapists based on historical, political, interpersonal, and intrapersonal factors. In the past four decades, psychodynamic psychotherapy has gone beyond the individual and been applied in the interpersonal sphere. The application of psychodynamic concepts to families expands the therapeutic reach of the psychotherapist
to the disturbed relationships. It enables him to address developmental failures from earlier stages offamily life that may exert a strong regressive pull on the family and interfere with family adaptation in certain areas. In addition to attention to contemporary family structure as the final common pathway for the unfolding of family dynamics, the therapist can use the psychodynamic concepts to recognize shared family defenses, shared family conflicts, and shared unconscious family fantasy systems. The object-relation school of psychodynamic family therapy pays special attention to the concept of holding environment and that its failure can playa crucial role in the genesis of a range of psychopathological disorders in children. A major advantage of psychodynamic family therapy over other modes of family therapy is its logical continuity with individual psychotherapy in which the psychodynamic factors can be addressed concomitantly or serially within individual or conjoint family sessions. Reference Moore, B. & Fine, B. (1968), The Glossary of Psychoanalytic Terms and Concepts. New York: The American Psychoanalytic Association.