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Resolved: The Therapist—Patient Relationship is the Crucial Factor to Change in Child Psychotherapy
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Assistant Editor: Lenore C. Terr. M.D.
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Resolved: The Therapist-Patient Relationship is the Crucial Factor to Change in Child Psychotherapy AFFIRMATIVE: ALVIN A ROSENFELD, M.D.
Human beings are social creatures, born with a fundamental need to relate well to the people around them. To survive, children need strong ties to adult caretakers. But some children are born into troubled circumstances that make forming relationships difficult. For instance, they may have disturbed or inconsistent parents who are hard to relate to, or they may be temperamentally mismatched to the parents. For constitutional or intrapsychic reasons, or because of disturbing experiences from which they generalize, some children misinterpret their environment or experiences. Whatever the etiology of the child's problems, difficulties relating to people and circumstances usually are what bring a child to psychotherapy. Often, a child's behavior has disturbed the parents, teachers, peers, or authorities, who then have recommended that the child go for professional help. But psychologically, the child's behavior does not simply aim to disturb: It often is a child's way to contend with-or an unsuccessful attempt to overcome-actual, or perceived, disappointments, humiliations, and nightmares. Psychotherapy uses a new relationship-the therapistpatient relationship-to help the child develop more constructive, effective solutions and to allow the child to live more comfortably with himself or herself and with others. This relationship is the cornerstone of psychotherapy, the factor that determines whether change occurs. The therapeutic relationship is a long conversation designed to deal symbolically with the child's repetitive, dysfunctional patterns of interacting. Working together within the relationship, patient and therapist develop a language to communicate about feelings, fantasies, and beliefs, be it in the medium of Barbie dolls or Ninja Turtles.
Accepted February 24, 1994. Dr. Rosenfeld is Director ofPsychiatric Services, Jewish Child Care Association, New York, NY. Dr. Onesti is Assistant ClinicalProfessor of Psychiatry, Harvard Medical School Boston, MA. Dr. Ornstein is Professor of Child Psychiatry, University ofCincinnati School ofMedicine, Cincinnati, OR Dr. Esman is Professor of ClinicalPsychiatry, Cornell University Medical College, New York, NY. 0890-8567/94/3307-1047$03.00/0©1994 by the American Academy of Child and Adolescent Psychiatry.
The relationship exerts its influence in a number of ways. For a child from a chaotic background, the therapeutic relationship-with its clear boundaries, comprehensible limits, and predictable times-serves a direct role: It gives the child an orderly interpersonal experience as a template on which the child can organize a personality. For the severely abused child, the daily interactions with a hospital or residential treatment center staff can lead to change simply by giving the youngster the kind of experience that shows it is possible to life safely and in relative comfort with others (Rosenfeld and Wasserman, 1990). The physically abused child may for the first time experience being valued and useful in a relationship as something other than an outlet for anger; the sexually abused child finds value in the self well beyond being an outlet for sexual exploitation. The therapeutic relationship gives the child another important experience: It uses intellect to solve problems and reason to diminish anxiety. The abused child begins to realize that not physical force but a skillfully employed mind is the most effective power. This, combined with a positive, warm relationship to the therapist, is a "corrective emotional experience" (Alexander and French, 1946) that can give the dejected child hope, a sense that "even for me there is the hope of something better. After all, I had that experience with my therapist." Children whose past relationships have wounded them may push away anyone who gets close. In these cases, the therapist must recognize that because past relationships were painful, the child is frightened of the desired closeness. The therapeutic relationship, in its slow, persistent way, can persuade the elusive, angry, or rejecting child that relationships are worth the risk. Children learn that uniquely valuable and satisfying interpersonal involvements are possible, ones that differ dramatically from the ones they have experienced until then. If treatment is effective, the interaction can restore, or even awaken, the child's capacity for intimacy. The therapeutic relationship enables a child to try out personality styles and behavioral changes that seemed to be too difficult or frightening to make in everyday life. Allied with the therapist, the child may feel safe and strong enough to experiment with roles the family objects to, or to explore
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fantasies and feelings that cannot be expressed in "polite" circles. In this freer atmosphere, the child works hard to get some peace between warring aspects of the inner self, or between the child and the family or school. For the child whose family is more interested in performance than in who the child is and what kind of person the child becomes, the relationship with the therapist can help the child discover that it is possible to have a relatively undemanding relationship. After all, the therapist accepts and respects the youngster not for any great scholastic achievements or outstanding athletic performance, a prevalent problem in activity-overburdened children in contemporary middle-class families (Bettelheim and Rosenfeld, 1993). The therapist is interested in, and accepts and respects the child simply for, who he or she is as a person. In some cases, the psychiatrist may act as a "silent partner," helping the child to change by standing back entirely. The safe, encouraging envelope the therapeutic relationship provides may be the child's only opportunity to take the time needed to play freely. This can permit the child to heal wounds that painful events have caused. In other situations , the child psychiatrist makes interpretations, indirectly decoding the messages that transference phenomena are giving. As the therapeutic relationship evolves, the child grows to trust the therapist and to value the therapist's opinion. In this context, the child comprehends the interpretation's thrust and realizes, often only subconsciously, that the therapist is saying something worth paying attention to. Like Barbie dolls and Ninja Turtles in play, the way the child behaves may inadvertently recreate hurtful experiences from the past. But the child may also realize that if he or she is the one creating the troubling situation now, he or she also has the potential to stop the repetition. Then the child can use the therapeutic relationship to try out behavioral changes. A child who feels secure in the therapeutic relationship is less anxious. The relationship encourages children to
generalize observations they make with their therapist, to think about changes they could make to achieve more rewarding relationships elsewhere, with peers and with adults other than their psychiatrist. But the child's relationship with the therapist cannot be "faked." Ifit is not genuine, mutuall y involving, and sturdy, the child may ignore therapeutic interpretations, reject insights and behavioral suggestions, and play, if at all, perseverarively. To devote valuable time to listen to the child carefully, the psychiatrist must have confidence in the child and the child's potential . If, in the context of the psychiatrist's close attention, this occurs, child psychiatry patients start listening to what they say more closely and to take their own words and feelings more seriously. For if the therapist pays such close attent ion to the child's words, the child has to be valuable and important as a person. Often this represents a critical positive change in a depressed or dejected child's self-view (Bettelheim and Rosenfeld, 1993). With time, child psychiatry patients may feel more empowered and less victimized. In light of the satisfying therapeutic relationship , the child may even reinterpret painful past experiences with less rage, guilt, and self-blame. Therapeutic relationships allow children to leave therapy with better capacities to make friends, sustain personal relationships, and create rewarding, enlivening involvements in everyday life. That is why the therapist-patient relationship is the crucial factor facilitating change in child psychotherapy.
REFERENCES Alexander F, FrenchTM (1946), Psychoanalytic Therapy. New York: Ronald Bettelheirn B, Rosenfeld AA (1993), The Art of the Obvious. New York: AlfredA Knopf Inc Rosenfeld A, Wasserman 5 (1990), Healing the Heart: A Therapeutic Approach to DisturbedChildren in Group Care. Washington . DC: Child Welfare League of America
NEGATIVE: SILVIO]. ONESTI, M.D. My interest in change in psychotherapy derives from my interest-which began in medical school and has continued throughout my professional experience in internal medicine, pediatrics, psychiatry, child psychiatry, psychoanalysis, and child psychoanalysis-in the question, "Wh at is therapeutic?" I am pleased to respond to the related question in our four-person Debate about therapist-child relationships. A therapist-patient relationship is undeniably necessary for the transaction of psychotherapy, in the same way that a doctor-patient relationship is necessary for the transaction
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of general medical care. But I believe that the relationship is an insufficient factor and not the crucial factor that causes change in our young patients. To support my view, I will consider what is therapeutic, what is to be changed, what takes place in the transactions between therapist and patient, what are the values that guide these transactions, and what are the limitations to our therapeutic expectations. When I try to assist people who have problems with their lives, I make inferences and assess them according to biological, psychological, and social standards derived from
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the study of human development and mental disorder. These standards structure my observations, questions, and interventions; they strongly influence my assumptions about my patient's welfare. From my patients' point of view, the purpose of treatment is to obtain relief from a disorder. From my own point of view, the purpose is to restore and protect my patients' health. What my patients see as desirable and what I see as necessary may not be identical. This is particularly so when health is defined, as Sigmund Freud defined it, as the human ability to love and to work (Erikson, 1950a; S. Freud, 1930). Because the ability to love and to work continually evolves, my patients and I will find common purpose when the goal that we pursue is the development of that ability. Development is most apparent in the child, there being many steps from the helplessness and involvement in self of the infant to the autonomy and involvement in others of the adult. Each step prepares the child for the next, and the process of development integrates increasingly complex tasks, abilities, and desires. As Anna Freud (1965) emphasized, the appropriate progression ofdevelopment denotes the mental health of the child. Human development continues throughout life (Erikson, 1950b). Its essentials are equilibrium , change, and adaptation, attained through the reciprocal interaction of internal forces of the individual with external forces of the environment. The psychotherapeutic relationship between patient and therapist possesses characteristics similar to those essential to development . Equilibrium in a child may result automatically and physically in response to pharmaceutical agents, but it may also occur through the protective environment of a hospital or through the sense of attachment to a therapist. The remembered image of the therapist and the emotions associated with that image may reduce the child's tensions in the therapist's absence. The relationship is an important factor. In the course of psychotherapy, the patient tries different patterns of behavior, departs from habits, considers suggestions, and uses the therapist as a model. Through rewarding interactions and thoughtful responses to the desires of others, the young patient in therapy eventually learns to make choices among conflicting wishes, and he or she accepts the limitations and responsibilities of relationships that are mutually interdependent. The psychotherapist does more, however, to help the patient change. As psychotherapists we function as teachers who observe and inform, as figures on whom patients place desires and expectations, and as individuals who feel and react. OUf psychotherapeutic instrument is our person. Our psychotherapeutic setting acquires the qualities of a laboratory in which data can be identified, a classroom in which concepts can be learned, a craft shop in which skills can be acquired, a stage or playground in which fantasies can be
elaborated, a haven in which desires can be expressed, and a place in which current and past life issues can be faced. In the psychotherapeutic situation patients feel, act, imagine and think; they use play as trial of interaction, fantasy as trial of desire, and thought as trial of action. Rules of procedure and professional protection mitigate consequences but not responsibilities for words and acts. A moratorium on impulsive action promotes choice and decision; a holding structure contains fear and desire. It is important to note that when therapist and patient do not adhere to protective boundaries and engage in reciprocal acts based on fear and desire, psychotherapy becomes drama transformed into tragic reality. Under these circumstances, the therapist breaks the physician's first rule, not to do harm. Therapist and patient must maintain the integrity of their work together that is dedicated to healing and development. The psychotherapeutic method is behavioral, affective, and cognitive. The therapist limits disruptive action, identifies emotions, and directs the patient's attention toward thoughtful exploration and clarification. The therapist shows the patient that the patient's behavior is based on beliefs that stem from past mistaken conclusions. The patient recognizes and learns that the behavior is habitual, predictable, and familiar and lacks promise. Therapist and patient consider alternatives and their consequences. The patient attempts new approaches toward new fulfillments of new desires, and, with successes, accepts new understanding. Psychotherapeutic work organizes experience and integrates facts into a life's history. Context itself becomes therapeutic. A sense of order fosters the patient's tolerance of uncertainty. The acceptability to the patient of the historical narrative leads to recognition of self and others, and, especially, to recognition of the self as an actor in and a critic of the history. The patient's life history shows the sequence of forces and reactions, and the persistent influence of convictions, attitudes, and values. It indicates the ability of the patient to love and to work, and to develop. We adapt our work to the developmental ability of our patient, but as we enter the realm of a person's mind we are involved with more than our patient's abilities. Our patients confront us with their choices and they demand our responses. We cannot and should not avoid this, but in order to respond without unduly influencing our patients, we must know our own values and beliefs. We must understand the amount of authority that we exert over our patients ' choices. We exercise power, but do so with the intention that our patients take control of the aberrant forces within them . We wish our patients to make their choices based on understanding and knowledge, after they have examined their past and present actions, emotions, and ideas. We want them to relinquish unpromising, inappropriate longings, and the behavior based on those longings. We value their facing
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disasters and decisions directly, with as much responsibility as possible, with as much courage as possible, with as much respect and consideration for others as possible, and facing them in the full context of their lives. Our psychotherapy has limitations. As psychotherapists, we cannot prevent injury and loss, nor can we eliminate resultant misery. We can only try to help our patients acquire the capacity to bear pain and suffering. We all need the courage to face what we fear, and in doing so with clarity and will, we accept the human condition with a sense of freedom, the freedom to love and to work, and to develop. I believe that the crucial factor to change in child psychotherapy is not the therapist-patient relationship. It is the employment by the therapist of a number of specific therapeutic skills in the multipurpose therapeutic setting, aimed
at valued therapeutic goals within the limits of human development.
REFERENCES Erikson E (1950a), Childhood and Society. New York: W W Norton, pp 264-265 Erikson E (1950b), Childhood and Society. New York: WW Norton, pp 269-274 Freud A (1965), Normality and Pathology in Childhood: Assessments of Development. New York: International Universities Press, pp 138-147 Freud 5 (1930), Civilization and Its Discontents. 21:55-145, especially pp 80-82 and 101, The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth, 1962
AFFIRMATIVE: ANNA ORNSTEIN, M.D. The conceptual framework for my therapeutic work with children has been derived from Winnicott's Therapeutic Consultations in Child Psychiatry (1971). The implication for child psychotherapy of this theoretical frame of reference is that the insight that therapists gain into the inner world of children in their diagnostic-therapeutic interviews has to be "translated" to the significant people in the child's emotional environment. More specifically, explanations or interpretations of the unconscious motivations of the child's symptoms have to be translated into simple language to the significant people in the child's environment, who, in turn, have to make use of these insights in their everyday behavior and responsiveness to the symptomatic child. This approach to the treatment of young and latency-age children comes from my conviction that only in the context of an accepting and empathic relationship and in the everyday interactions between caretakers and the symptomatic child (eating, going to sleep, school and family activities) can fundamental changes in the child's symptomatic behavior be achieved. In other words, it is the parent-child relationship mediated by the relationship with the therapist that carries the major responsibility for the treatment process. As a psychoanalyst, Winnicott's approach to the treatment of children was primarily determined by developmental considerations; he was mindful of the importance of assessing and therapeutically addressing the child's anxieties, mode of defense and adaptation, fantasies and dreams. However, at the same time, he was fully conscious of the impact that the child's environment had on these inner experiences and with that, on the child's progressive development. Combining his developmental considerations with his recognition that children's minds remained an "open system" (open
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to pathological as well as therapeutic influences), he had recommended that therapists ought to aim at "unblocking the child's progressive maturational processes ... so that the change he had so achieved can be made use of by the parents and those who are responsible in the immediate social setting" (Winnicott, 1971, p. 5). To accomplish this, Winnicott relied on the availability of an "average expectable environment" (Hartmann, 1958). Winnicott's emphasis on the child's emotional environment in development and pathogenesis is in keeping with Heinz Kohut's (1971) theory of the self within the emparhically responsive "selfobjecr" milieu. Selfobject functions (mirroring, validating, and merger with the caretaker's strength and power) are those relationship functions of caretakers that affect the child's self development in terms of cohesion, resiliency, and self-esteem regulation. Changes in the behavior of symptomatic children cannot be brought about without simultaneously effecting changes in the relationships with which these children live. But the families that our child patients come from are rarely "average" and "expectable." In addition, we are no longer satisfied with the overtly average appearing environment. We have learned to appreciate the subtle forms of emotional neglect and abuse that children may be exposed to, emotional abuse that the environment itself may not be aware of. The major and more difficult part of our therapeutic work may not be connected with the treatment of children but to our efforts to create an environment that can be therapeutic for them; hence the emphasis on the relationship between symptomatic children and their emotional environment. There has been a growing disappointment among psycho-
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therapists with the individual treatment of children even when this is combined with the collaborative treatment ofone or another of the child's primary caretakers. Interpretations directed at young children have been found to be of limited value (Carek, 1972). Because of this disappointment, in many instances, the individual treatment of children was replaced with family treatment. However, this rarely gave child therapists a chance to explore the unconscious motives of the children's behavior. What was needed was a theoretical frame of reference that facilitated the integration of the insight that child therapists gained in the individual treatment of children with that of the behavior and attitude of their emotional environment. I have found that the conflicts in which caretakers and symptomatic children are caught are more likely to become loosened in the earlier rather than in the later phases of treatment. However, such loosening of pathological interactions depends on therapists' being able to convey during the first (or certainly during the first few) interviews their understanding of the most urgent current difficulties that the caretakers have to face. As child therapists listen to the parents' complaints and as they listen and try to comprehend the child's subjective, intrapsychic experiences, they are engaged in an effort to locate that area of the parent-child relationship in which parental attitudes and dysfunctional responses continue to aggravate the child's symptomatic behavior. The most challenging aspect of this treatment process is the therapist's ability to maintain an empathic listening relationship to the caretakers, similar to the one he or she is maintaining with the child. What has to become the focus of the therapist's interventions is the area in which the child's psychopathology and dysfunctional parental responses intersect. No effort ought to be made to "rherapize" the environment in all respects; rather, attention has to be focused on the child's specific anxieties and the specific manner in which caretakers respond to the behavior caused by these anxieties. Relationships lie at the center of this therapy. "Child-centered family treatment" (Ornstein, 1976, 1981; Ornstein and Ornstein, 1985) has to be distinguished from family treatment conducted according to systems theory as well as from individual psychoanalytically oriented psychotherapy. In child-centered family treatment, children remain the focus of the therapist's diagnostic and therapeutic concerns while the aim of treatment is to familiarize the primary caretakers with the unconscious motives of the child's disturbed and disturbing behavior. It is my preference to have the whole family attend the first diagnostic-therapeutic hour. This permits a reasonably quick diagnostic overview of family interactions and it provides the symptomatic child and the caretakers with an opportunity to present their respective views in each other's
presence. In the next phase, the child is seen individually as many times as is necessary for a thorough diagnostic assessment, which may include psychological testing and/or a neurological examination. It is during these individual hours that children are being helped to identify and articulate the way they feel about themselves, their problems, and their interactions with others. While therapists' nonjudgmental attitude, acceptance, and understanding keep the door to the child's inner world open and permit an in-depth assessment of their difficulties, the therapists' interpretive responses alone cannot bring about therapeutic changes. Once children establish trusting relationships with their therapists and feel protected and understood by them, these children will be ready to share their feelings with their caretakers. It is in these "integrative sessions" that the therapist "translates" the child's manifest behavior into its latent meaning to the caretakers. Countertransference toward caretakers may greatly complicate the treatment process. While most therapists have little difficulty in being empathic with their child patients and respond to them with acceptance and understanding, this is not necessarily the case with caretakers who have little or no understanding of the child's internal state and respond punitively to the child's behavior. It is important to appreciate the caretakers' frustrations in having to be therapeutically responsive to a child, who, either directly or through his or her symptoms, continually undermines their ability to parent effectively. The therapist's appreciation of the caretakers' anxieties and sense of failure goes a long way toward securing their meaningful participation in treatment. Here relationships are central to therapy. In treating children who live in families where empathy toward the child's suffering cannot be generated, either it becomes necessary to remove the child from the home, or the child must be helped by the therapist to adapt to a difficult situation with the least amount of developmental sacrifice.Young children derive benefits from the relationship with their therapists by "using" them as empathically responsive selfobjects; in this manner, therapists actively participate in the development of the child's self-cohesion. Only a relatively well-consolidated self can manifest the kind of resiliency that is required to withstand caretaker indifference and humiliation.
REFERENCES Carek D (1972), Principles of ChildPsychotherapy. Springfield; IL: Charles C Thomas Hartmann H (1958), Ego Psychology and the Problem of Adaptation. New York: International Universities Press Kohut H (197 I), TheAnalysis oftheSelf.New York: International Universities Press
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DEBATE FORUM Ornstein A (1976), Making contact with the inner world of the child: towards a theory of psychoanalytic psychotherapy with children. Compr
Psychiatry 17:3-36 Ornstein A (1981), Self pathology in childhood: clinical and developmental considerations. Psychiatr Clin North Am 4:435-453
Ornstein A, Ornstein P (1985), Parenting as a Function of the Adult Self: A Psychoanalytic Developmental Perspective. In: Life. Adelphi, MD: US Department of Health and Human Services. 1:425-442 Winnicott OW (1971), Therapeutic Consultations in ChildPsychiatry. New York: Basic Books
NEGATIVE: AARON H. ESMAN, M.D.
Psychotherapy, whether with children, adolescents, or adults, is a complex, multivariant process, involving both cognitive and affective elements in varying combinations from case to case. Debate has raged for years about the relative contributions of what have been called "specific" (i.e., interpretive/ clarificarory) and "nonspecific" (i.e., relationship) factors in generating therapeutic success. It is probable that, until improved methods of assessingtherapeutic process are developed, such debates will continue. To the categorical position stated in this "resolution" I would have to say "no"; the evidence does not seem to me to bear it out. There is no question that the therapist-patient relationship is a crucial factor in promoting the treatment process in any kind ofpsychotherapy. It provides the baseline, the indispensable sine qua non for such work; whether called the "therapeutic alliance," the "basic transference," or whatever, some such relationship based on a level of basic trust and positive expectation must be present or potentially present for psychotherapy to take place at all. The question here, however, is not that, but whether such a relationship is the crucial factor in the therapeutic engagement. Were this to be the case, it would seem likely that a benevolent grandparent would be as effective a therapist as the best-trained child analyst or the most knowledgeable behaviorist. Experience indicates that this is, unfortunately, rarely true. Cognitive interventions-be they clarifications, confrontations, interpretations, suggestions, explanations, advice, exhortations, reassurances-all play crucial roles in psychotherapy of one persuasion or another. Since I am best acquainted with psychoanalytic/psychodynamic psychotherapy, I shall primarily address this approach. The literature of child analysis and child psychotherapy is replete with demonstrations of the therapeutic effects of interpretive interventions. Hoffman (1989), for example, describes the analysis of an 8-year-old boy who appeared clearly to have responded to consistent interpretation with greater awareness ofhis disturbing affectsand with increasing capaciry to control the aggressive and regressive behaviors his emotions generated. It is, of course, true that such interpretations, where accurate and accurately timed, increase the child's sense of being understood and cared for; indeed, it is doubtless this factor that enables the therapeutic effect of interpretations couched in different (e.g., Kleinian versus
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Freudian) theoretical languages. Nonetheless, it is the resonance of the verbal content of such interventions with the state of the child's unconscious mental life that fosters such deepening of the alliance. The child (certainly one capable of concrete operational thought) is able to process such interventions, and thus to be, in the language of Sandler et al. (1980), "in touch with feelings, motivations and behavior" (p. 67). It is certainly true that one does not expect of the child the kind ofintegrative insight one anticipates in the treatment of adults. The young child's immature cognitive functioning, undeveloped sense of time, and continuing dependence on and primary involvement with parenting figures, all make the understanding of the impact of past on present and the meaning of transference enactments difficult for the child to grasp and retain. But consistent identification and clarification of affects, the translation of action-dispositions into verbal terms, the interpretation of projected punitive superego elements, all can have substantial impact on at least the older child's self-awareness and expectations and perception of others. As Winnicott (1965) put it, "A girl of 10 said to me, 'it doesn't matter if some of the things you say are wrong, because I know which are wrong and which are right' " (p. 324). And in the case of adolescents, with their more advanced verbal, cognitive, and introspective capacities, the gamut of interpretive techniques, including judicious transference interpretations, is feasible and capable of assimilation. In the case of behaviorally oriented psychotherapies, of course, the situation is even more clear. For all that behavioral and cognitive therapists have come to recognize the importance of the child-therapist relationship, the primary levers of therapeutic change are the therapists' explicit verbal instructions, prohibitions, conditioning stimuli, homework exercises, and the like, often implemented by parents. To the extent that these succeed in modifying or eliminating symptoms, they would appear to have an effect that transcends the "nonspecific" contribution of the patienttherapist alliance. Altogether, then, I believe that the psychotherapy of at least the post-oedipal child or adolescent requires more than a "helping" or "empathic" relationship. Given reasonable intelligence and a reasonable level of psychic organization,
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such children are capable of learning (1) that their behaviors or symptoms have meaning; (2) that they tend to be connected with their feelings; (3) that these feelings can often be comprehensibly connected with current life experiences; and (4) that other ways of managing these feelings exist and can be tried out. The child's ability to hear and make use of such interventions depends on the state of the relationship with the therapist, but can and should be understood as distinct from that relationship itself. Together, they make up the complicated process under discussion. In his usual way, perhaps Winnicott said it best: "... the interpretations did not produce the result, but they helped toward the
child's own discovery of what was already there in herself. This is the essenceof therapy" (Winnicott, 1964/68, p. 316).
REFERENCES Hoffman L (1989), The psychoanalytic process and the development of insight in child analysis: a case study. Psychoanal Q 58:63-80 Sandler ], Kennedy H, Tyson P (1980), The Technique of Child Analysis: Discussions with Anna Freud. Cambridge, MA: Harvard University Press Winnicott D (1965), The valueofthe therapeutic consultation. In: Psychoanalytic Explorations, Winnicott C, Shepherd R, Davis M, eds. (1989) Cambridge, MA: Harvard University Press, pp 318-327 Winnicott D (1964/68) The Squiggle Game. In: Psychoanalytic Explorations, Winnicott C, Shepherd R, Davis M, eds. (1989) Cambridge, MA: Harvard University Press, pp 299-317
AFFIRMATIVE REBUTTAL: ROSENFELD
Much of this disagreement amounts to splitting hairs. For instance, Dr. Onesti eloquently tells us that "our psychotherapeutic instrument is our person." Then he attempts to argue that the individual therapist's specific tools, not the relationship, are crucial. I suppose that to be "precise" one could argue that when a surgeon operates, the scalpel and careful hand motions, not his or her person, are crucial. But when a person and his or her skills are so inextricably linked, what does this distinction mean? I think we all agree that our special, hard-earned skills are essential factors to being effective therapeutically. But the child therapist's most unique skill is being able to make and sustain relationships with children who have difficulty forming them, and then using these relationships for therapeutic ends. Children often come to therapists because they are unable to find-or because their constitution, experience, or psychological makeup leaves them unable to useameliorative, even healing, relationships that are available to most people in everyday life. Rather than being driven away by (or becoming moralistic because of) disturbed and disturbing behavior, we therapists understand it as a message we need to decode. Dr. Esman doubts that the relationship is the crucial factor, because if it were, a benevolent grandparent would provide effective therapy. I think that "accepting and empathic," (to use Dr. Ornstein's term) grandparents, relatives, and friends often are therapeutic. If they were not, all 50% of Americans who have psychiatric conditions during their lives (Kessler et al., 1994) would see therapists. It is likely that more could benefit from therapy. But a good number
of people overcome emotional difficulties because someone in the community is there for, and acts therapeutically toward, them. In fact, in exploring the life course of potentially delinquent children, Vailliant found that the presence of one good relationship with someone in the community made the difference between a good outcome and a poor one (Vailliant, 1993). I believe that the therapeutic relationship is the crucial context that lets our other tools and skills be effective. For instance, Dr. Onesti says that one skill is that the therapist "directs the patient's attention toward thoughtful exploration and clarification." I have not found my patients to be particularly malleable and open to direction, especiallywhen I first meet them. Teachers, parents, scoutmasters, etc., have usually failed in their attempts to "direct" the child. So without my special skill in forming a relationship different from others in the child's past, why would the patient give my "direction" any credence? Only within the safe security of this new relationship do our patients develop skills they may then use in other relationships, both while in treatment and after they leave us. Emotional sustenance from those relationships are what ultimately will help prevent their falling back into rage, discouragement, and pessimism.
REFERENCES KesslerRC, McGonagle KAet al. (1994), Lifetime and 12-month prevalence of DSM-IlI-R Psychiatric disorders. Arch Gen Psychiatry 51:8-18 Vailliant G (1993), Wisdom ofthe Ego. Cambridge, MA: Harvard University Press
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NEGATIVE REBUTTAL: ONESTI
The response of each partICIpant in this Debate on the Resolution that the therapist-patient relationship is the crucial factor to change in child psychotherapy, whether arguing an affirmative or negative position, has been to point out the importance ofthe therapist-patient relationship to the therapeutic work. So far there is full agreement. Our disagreement resides in our differing conceptualizations of what is essential for the therapist and patient even to engage in the therapy, namely, their relationship, and what is crucial for the therapist and patient to produce therapeutic work and consequent change, namely, the various skilled interventions on the part of the therapist. Dr. Ornstein stated, "only in the context of an accepting and empathic relationship ... can fundamental changes in the child's symptomatic behavior be achieved." She added, "it is the parent-child relationship mediated by the relationship with the therapist that carries the major responsibility for the treatment process." Relationships do provide context and responsibility for the treatment process, but in her example ofWinnicott's approach "assessing and therapeutically addressing the child's anxieties, mode of defense and adaptation, fantasies and dreams" and his "unblocking the child's progressive maturational processes," she alluded to the therapeutic work on the part of Winnicott, work that I believe is the crucial factor to change. Dr. Ornstein stated, "The most challenging aspect of this treatment process is the therapist's ability to maintain an emphathic listening relationship to the caretakers, similar to the one he or she is maintaining with the child." Again, she underscored the importance of the relationship, but when she added that "the aim of treatment is to familiarize the primary caretakers with the unconscious motives of the child's disturbed and disturbing behavior," she confirmed the need for therapeutic work, in this example clarification and interpretation, presumably for the treatment to produce change. Dr. Rosenfeld stated, "Psychotherapy uses a new relationship-the therapist-patient relationship-to help the child develop more constructive, effective solutions...." He defined the therapeutic relationship as "a long conversation
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designed to deal symbolically with the child's repetitive, dysfunctional patterns of interacting." He elaborated: "Working together within the relationship, patient and therapist develop a langauge to communicate about feelings, fantasies, and beliefs...." "The therapeutic relationship ... uses intellect to solve problems and reason to diminish anxiety." "The therapeutic relationship enables a child to try out personality stylesand behavioral changes...." "Allied with the therapist, the child may ... experiment with roles ... or ... explore fantasies and feelings...." Dr. Rosenfeld noted, "the child psychiatrist makes interpretations, indirectly decoding the messages that transference phenomena are giving." He emphasized that the child's relationship with the therapist must be "genuine, mutually involving, and sturdy" for the child not to "ignore therapeutic interpretations, reject insights and behavioral suggestions, and play, if at all, perseveratively." From Dr. Rosenfeld's statements I would conclude that the therapist-patient relationship is the vehicle that enables the therapeutic work-consisting of the use ofsymbolic conversation to communicate and explore feelings, fantasies and beliefs, the use of intellect and reason, the use of trying out styles, behaviors, and roles, and the use of interpretations, insights, behavioral suggestions, and free play-to take place. I would also conclude that the therapeutic work is the crucial factor to effect change. Dr. Esman pointed out that a "relationship based on a level of basic trust and positive expectation must be present or potentially present for psychotherapy to take place at all. The question here, however, is not that, but whether such a relationship is the crucial factor in the therapeutic engagement. Were this to be the case, it would seem likely that a benevolent grandparent would be as effective a therapist as the best-trained child analyst or the most knowledgeable behaviorist." I agree. I restate my own conclusion that the crucial factor to change in child psychotherapy "is the employment by the therapist of a number of specific therapeutic skills in the multipurpose therapeutic setting, aimed at valued therapeutic goals within the limits of human development. "
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AFFIRMATIVE REBUTTAL: ORNSTEIN
The contributions of these four child psychiatrists confirm my conviction that no categorical position can be taken relative to the therapist-patient relationship constituting the crucial factor in the treatment of children: we all included a variety of other factors which we consider "crucial" in the achievement of our therapeutic goals. The contributions to the debate make it also clear that what we consider to be the curative factor depends on the meaning we attribute to anyone of our interactions with our patients. For example, when Dr. Esman says that "... interpretations ... increase the child's sense of being understood and cared for" and that "it is the resonance of the verbal content ... with the state of the child's unconscious mental life that fosters the deepening of the therapeutic alliance," he considers interpretations to have primary significance in treatment insofar as it strengthens the therapistpatient relationship. In other words, he considers interpretations to have therapeutic effectiveness because "feeling understood" promotes the therapeutic relationship. This is a perspective on interpretations with which I am in full agreement. However, I would add to this that while feeling understood by their therapists is the crucial factor in the treatment of adults, young children also have to feel understood by the emotional environment in which they live. Similarly, many of Dr. Onesti's statements could be understood as belonging to the category of the therapistpatient relationship. This is how I would understand his inclusion of teaching, modeling, and learning skills into the functions of a child therapist. Relationship as the crucial aspect of treatment is particularly clear in Dr. Onesti's considering the therapist as a model with whom the child is expected to identify. My major disagreement with Dr. Onesti is that I find his categorical statements much too idealistic; his assumption that by providing a safe environment, children will be able to examine their past and present
actions and make conscious choices as to their behavior also lacks developmental considerations. On similar grounds, I also question how he can expect changes from his interpretive activities: can children recognize that their behavior is "based on beliefs that stem from past mistaken conclusions" and "consider alternatives and their consequences"? This requires cognitive capacities that most young children do not possess. Not surprisingly, on the side of the affirmative, I found myself in agreement with most of Dr. Rosenfeld's assertions. Dr. Rosenfeld argues successfully that a therapeutic relationship ought not be considered only as a nonspecific aspect of treatment as Dr. Esman maintains. The "clear boundaries, comprehensible limits, and predictable times" take on specificity in caseswhere children live with inconsistent parenting and chaotic households. Also, I am in full agreement with the importance that being listened to attentively and with interest may, for the first time, provide the child with an experience of being valued, an experience that has curative value. In this sense "the therapeutic relationship in a slow, persistent way can persuade the elusive, angry child that relationships are worth the risk." However, I disagree with Dr. Rosenfeld, as I do with my other two colleagues, that even when these properties of the relationship are taken into consideration, the therapistpatient relationship constitutes the crucial factor in the treatment of young children; young children who live in chaotic and abusive environments cannot gain enough strength from the relationship "to experiment with roles the family objects to." All four contributions point up the importance of differentiating between the treatment of young children and that of adolescents; in the treatment of young children, changes in caretaker attitudes are as crucial as is the therapist-patient relationship, while this is less so in the treatment of adolescents.
NEGATIVE REBUTTAL: ESMAN Dr. Ornstein's eloquent statement seems to me to conceive the child as the passive victim of abuse and/or neglect, and his or her psychopathology as merely reactive to such parental misfeasance. No reference is made to intrapsychic conflict, nor is there any consideration of the child's own contribution to the pathological interactions, symptoms, or action tendencies that may have brought him or her to treatment. Consistent with the tenets of "self-psychology," this point of view is, I believe, misguided at worse, and one-sided at best.
J.
Although I agree that the preschool child is often (perhaps always) best treated by way of the parents, I do not believe that this is the case for the latency child (let alone the adolescent). Such children, if reasonably bright, are capable of grasping interpretations, learning about their affects and, through focus on transference manifestations, confronting at least some of their misconceptions and moderating their punitive or inconsistent superegos. Of course, concurrent work with families is needed; we are far from the days of
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"pure-culture" child analysis when it was thought necessary to avoid "contaminating" contact with parents. But children can and do develop internalized structured pathologies that will not yield to environmental change alone, but can respond to judicious interpretation (in the largest sense) from an ernphathic, concerned therapist. Dr. Rosenfeld seems to me to be speaking primarily of the severely disturbed child and adolescent in residential treatment. Such children do, certainly, require a "corrective emotional experience" continuing over a long period of time in order to undo the adverse consequences of severe parental abuse and/or deprivation. But even these children are best served, I believe, by a comprehensive treatment that offers them an opportunity to master their past experiences and current feelings through language, and to understand the connections between their maladaptive behaviors and the painful events in their lives. There are, I maintain, cognitive as well as affective consequences to unfavorable life experiences, and it is in the end the meaning to the child of those
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experiences and the coping resources he or she brings to them that matter. I believethat for children who have suffered major losses and traumas, the shared verbal interactions of clarification, interpretation, and response can have major value in persuading them of the validity of their own perceptions, the mutuality of human interchange, and the healing power of verbal communication. Dr. Onesti and I are in essential agreement, so I shall not comment on his contribution except to note that, for me, the definition of health is not only the ability to love and to work, but also to play. It is this capacity that we often have to free up in our patients, not only through providing a "holding environment" but also through helping them to understand the reasons for their affective and behavioral constriction. This, I believe, can enable them, in some measure at least, to resolve the conflicts that have impaired their ability to enjoy the very essence of their childhood.
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Assistant Editor: Lenore C. Terr. M.D.
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Resolved: The Therapist-Patient Relationship is the Crucial Factor to Change in Child Psychotherapy AFFIRMATIVE: ALVIN A ROSENFELD, M.D.
Human beings are social creatures, born with a fundamental need to relate well to the people around them. To survive, children need strong ties to adult caretakers. But some children are born into troubled circumstances that make forming relationships difficult. For instance, they may have disturbed or inconsistent parents who are hard to relate to, or they may be temperamentally mismatched to the parents. For constitutional or intrapsychic reasons, or because of disturbing experiences from which they generalize, some children misinterpret their environment or experiences. Whatever the etiology of the child's problems, difficulties relating to people and circumstances usually are what bring a child to psychotherapy. Often, a child's behavior has disturbed the parents, teachers, peers, or authorities, who then have recommended that the child go for professional help. But psychologically, the child's behavior does not simply aim to disturb: It often is a child's way to contend with-or an unsuccessful attempt to overcome-actual, or perceived, disappointments, humiliations, and nightmares. Psychotherapy uses a new relationship-the therapistpatient relationship-to help the child develop more constructive, effective solutions and to allow the child to live more comfortably with himself or herself and with others. This relationship is the cornerstone of psychotherapy, the factor that determines whether change occurs. The therapeutic relationship is a long conversation designed to deal symbolically with the child's repetitive, dysfunctional patterns of interacting. Working together within the relationship, patient and therapist develop a language to communicate about feelings, fantasies, and beliefs, be it in the medium of Barbie dolls or Ninja Turtles.
Accepted February 24, 1994. Dr. Rosenfeld is Director ofPsychiatric Services, Jewish Child Care Association, New York, NY. Dr. Onesti is Assistant ClinicalProfessor of Psychiatry, Harvard Medical School Boston, MA. Dr. Ornstein is Professor of Child Psychiatry, University ofCincinnati School ofMedicine, Cincinnati, OR Dr. Esman is Professor of ClinicalPsychiatry, Cornell University Medical College, New York, NY. 0890-8567/94/3307-1047$03.00/0©1994 by the American Academy of Child and Adolescent Psychiatry.
The relationship exerts its influence in a number of ways. For a child from a chaotic background, the therapeutic relationship-with its clear boundaries, comprehensible limits, and predictable times-serves a direct role: It gives the child an orderly interpersonal experience as a template on which the child can organize a personality. For the severely abused child, the daily interactions with a hospital or residential treatment center staff can lead to change simply by giving the youngster the kind of experience that shows it is possible to life safely and in relative comfort with others (Rosenfeld and Wasserman, 1990). The physically abused child may for the first time experience being valued and useful in a relationship as something other than an outlet for anger; the sexually abused child finds value in the self well beyond being an outlet for sexual exploitation. The therapeutic relationship gives the child another important experience: It uses intellect to solve problems and reason to diminish anxiety. The abused child begins to realize that not physical force but a skillfully employed mind is the most effective power. This, combined with a positive, warm relationship to the therapist, is a "corrective emotional experience" (Alexander and French, 1946) that can give the dejected child hope, a sense that "even for me there is the hope of something better. After all, I had that experience with my therapist." Children whose past relationships have wounded them may push away anyone who gets close. In these cases, the therapist must recognize that because past relationships were painful, the child is frightened of the desired closeness. The therapeutic relationship, in its slow, persistent way, can persuade the elusive, angry, or rejecting child that relationships are worth the risk. Children learn that uniquely valuable and satisfying interpersonal involvements are possible, ones that differ dramatically from the ones they have experienced until then. If treatment is effective, the interaction can restore, or even awaken, the child's capacity for intimacy. The therapeutic relationship enables a child to try out personality styles and behavioral changes that seemed to be too difficult or frightening to make in everyday life. Allied with the therapist, the child may feel safe and strong enough to experiment with roles the family objects to, or to explore
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fantasies and feelings that cannot be expressed in "polite" circles. In this freer atmosphere, the child works hard to get some peace between warring aspects of the inner self, or between the child and the family or school. For the child whose family is more interested in performance than in who the child is and what kind of person the child becomes, the relationship with the therapist can help the child discover that it is possible to have a relatively undemanding relationship. After all, the therapist accepts and respects the youngster not for any great scholastic achievements or outstanding athletic performance, a prevalent problem in activity-overburdened children in contemporary middle-class families (Bettelheim and Rosenfeld, 1993). The therapist is interested in, and accepts and respects the child simply for, who he or she is as a person. In some cases, the psychiatrist may act as a "silent partner," helping the child to change by standing back entirely. The safe, encouraging envelope the therapeutic relationship provides may be the child's only opportunity to take the time needed to play freely. This can permit the child to heal wounds that painful events have caused. In other situations , the child psychiatrist makes interpretations, indirectly decoding the messages that transference phenomena are giving. As the therapeutic relationship evolves, the child grows to trust the therapist and to value the therapist's opinion. In this context, the child comprehends the interpretation's thrust and realizes, often only subconsciously, that the therapist is saying something worth paying attention to. Like Barbie dolls and Ninja Turtles in play, the way the child behaves may inadvertently recreate hurtful experiences from the past. But the child may also realize that if he or she is the one creating the troubling situation now, he or she also has the potential to stop the repetition. Then the child can use the therapeutic relationship to try out behavioral changes. A child who feels secure in the therapeutic relationship is less anxious. The relationship encourages children to
generalize observations they make with their therapist, to think about changes they could make to achieve more rewarding relationships elsewhere, with peers and with adults other than their psychiatrist. But the child's relationship with the therapist cannot be "faked." Ifit is not genuine, mutuall y involving, and sturdy, the child may ignore therapeutic interpretations, reject insights and behavioral suggestions, and play, if at all, perseverarively. To devote valuable time to listen to the child carefully, the psychiatrist must have confidence in the child and the child's potential . If, in the context of the psychiatrist's close attention, this occurs, child psychiatry patients start listening to what they say more closely and to take their own words and feelings more seriously. For if the therapist pays such close attent ion to the child's words, the child has to be valuable and important as a person. Often this represents a critical positive change in a depressed or dejected child's self-view (Bettelheim and Rosenfeld, 1993). With time, child psychiatry patients may feel more empowered and less victimized. In light of the satisfying therapeutic relationship , the child may even reinterpret painful past experiences with less rage, guilt, and self-blame. Therapeutic relationships allow children to leave therapy with better capacities to make friends, sustain personal relationships, and create rewarding, enlivening involvements in everyday life. That is why the therapist-patient relationship is the crucial factor facilitating change in child psychotherapy.
REFERENCES Alexander F, FrenchTM (1946), Psychoanalytic Therapy. New York: Ronald Bettelheirn B, Rosenfeld AA (1993), The Art of the Obvious. New York: AlfredA Knopf Inc Rosenfeld A, Wasserman 5 (1990), Healing the Heart: A Therapeutic Approach to DisturbedChildren in Group Care. Washington . DC: Child Welfare League of America
NEGATIVE: SILVIO]. ONESTI, M.D. My interest in change in psychotherapy derives from my interest-which began in medical school and has continued throughout my professional experience in internal medicine, pediatrics, psychiatry, child psychiatry, psychoanalysis, and child psychoanalysis-in the question, "Wh at is therapeutic?" I am pleased to respond to the related question in our four-person Debate about therapist-child relationships. A therapist-patient relationship is undeniably necessary for the transaction of psychotherapy, in the same way that a doctor-patient relationship is necessary for the transaction
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of general medical care. But I believe that the relationship is an insufficient factor and not the crucial factor that causes change in our young patients. To support my view, I will consider what is therapeutic, what is to be changed, what takes place in the transactions between therapist and patient, what are the values that guide these transactions, and what are the limitations to our therapeutic expectations. When I try to assist people who have problems with their lives, I make inferences and assess them according to biological, psychological, and social standards derived from
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the study of human development and mental disorder. These standards structure my observations, questions, and interventions; they strongly influence my assumptions about my patient's welfare. From my patients' point of view, the purpose of treatment is to obtain relief from a disorder. From my own point of view, the purpose is to restore and protect my patients' health. What my patients see as desirable and what I see as necessary may not be identical. This is particularly so when health is defined, as Sigmund Freud defined it, as the human ability to love and to work (Erikson, 1950a; S. Freud, 1930). Because the ability to love and to work continually evolves, my patients and I will find common purpose when the goal that we pursue is the development of that ability. Development is most apparent in the child, there being many steps from the helplessness and involvement in self of the infant to the autonomy and involvement in others of the adult. Each step prepares the child for the next, and the process of development integrates increasingly complex tasks, abilities, and desires. As Anna Freud (1965) emphasized, the appropriate progression ofdevelopment denotes the mental health of the child. Human development continues throughout life (Erikson, 1950b). Its essentials are equilibrium , change, and adaptation, attained through the reciprocal interaction of internal forces of the individual with external forces of the environment. The psychotherapeutic relationship between patient and therapist possesses characteristics similar to those essential to development . Equilibrium in a child may result automatically and physically in response to pharmaceutical agents, but it may also occur through the protective environment of a hospital or through the sense of attachment to a therapist. The remembered image of the therapist and the emotions associated with that image may reduce the child's tensions in the therapist's absence. The relationship is an important factor. In the course of psychotherapy, the patient tries different patterns of behavior, departs from habits, considers suggestions, and uses the therapist as a model. Through rewarding interactions and thoughtful responses to the desires of others, the young patient in therapy eventually learns to make choices among conflicting wishes, and he or she accepts the limitations and responsibilities of relationships that are mutually interdependent. The psychotherapist does more, however, to help the patient change. As psychotherapists we function as teachers who observe and inform, as figures on whom patients place desires and expectations, and as individuals who feel and react. OUf psychotherapeutic instrument is our person. Our psychotherapeutic setting acquires the qualities of a laboratory in which data can be identified, a classroom in which concepts can be learned, a craft shop in which skills can be acquired, a stage or playground in which fantasies can be
elaborated, a haven in which desires can be expressed, and a place in which current and past life issues can be faced. In the psychotherapeutic situation patients feel, act, imagine and think; they use play as trial of interaction, fantasy as trial of desire, and thought as trial of action. Rules of procedure and professional protection mitigate consequences but not responsibilities for words and acts. A moratorium on impulsive action promotes choice and decision; a holding structure contains fear and desire. It is important to note that when therapist and patient do not adhere to protective boundaries and engage in reciprocal acts based on fear and desire, psychotherapy becomes drama transformed into tragic reality. Under these circumstances, the therapist breaks the physician's first rule, not to do harm. Therapist and patient must maintain the integrity of their work together that is dedicated to healing and development. The psychotherapeutic method is behavioral, affective, and cognitive. The therapist limits disruptive action, identifies emotions, and directs the patient's attention toward thoughtful exploration and clarification. The therapist shows the patient that the patient's behavior is based on beliefs that stem from past mistaken conclusions. The patient recognizes and learns that the behavior is habitual, predictable, and familiar and lacks promise. Therapist and patient consider alternatives and their consequences. The patient attempts new approaches toward new fulfillments of new desires, and, with successes, accepts new understanding. Psychotherapeutic work organizes experience and integrates facts into a life's history. Context itself becomes therapeutic. A sense of order fosters the patient's tolerance of uncertainty. The acceptability to the patient of the historical narrative leads to recognition of self and others, and, especially, to recognition of the self as an actor in and a critic of the history. The patient's life history shows the sequence of forces and reactions, and the persistent influence of convictions, attitudes, and values. It indicates the ability of the patient to love and to work, and to develop. We adapt our work to the developmental ability of our patient, but as we enter the realm of a person's mind we are involved with more than our patient's abilities. Our patients confront us with their choices and they demand our responses. We cannot and should not avoid this, but in order to respond without unduly influencing our patients, we must know our own values and beliefs. We must understand the amount of authority that we exert over our patients ' choices. We exercise power, but do so with the intention that our patients take control of the aberrant forces within them . We wish our patients to make their choices based on understanding and knowledge, after they have examined their past and present actions, emotions, and ideas. We want them to relinquish unpromising, inappropriate longings, and the behavior based on those longings. We value their facing
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disasters and decisions directly, with as much responsibility as possible, with as much courage as possible, with as much respect and consideration for others as possible, and facing them in the full context of their lives. Our psychotherapy has limitations. As psychotherapists, we cannot prevent injury and loss, nor can we eliminate resultant misery. We can only try to help our patients acquire the capacity to bear pain and suffering. We all need the courage to face what we fear, and in doing so with clarity and will, we accept the human condition with a sense of freedom, the freedom to love and to work, and to develop. I believe that the crucial factor to change in child psychotherapy is not the therapist-patient relationship. It is the employment by the therapist of a number of specific therapeutic skills in the multipurpose therapeutic setting, aimed
at valued therapeutic goals within the limits of human development.
REFERENCES Erikson E (1950a), Childhood and Society. New York: W W Norton, pp 264-265 Erikson E (1950b), Childhood and Society. New York: WW Norton, pp 269-274 Freud A (1965), Normality and Pathology in Childhood: Assessments of Development. New York: International Universities Press, pp 138-147 Freud 5 (1930), Civilization and Its Discontents. 21:55-145, especially pp 80-82 and 101, The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth, 1962
AFFIRMATIVE: ANNA ORNSTEIN, M.D. The conceptual framework for my therapeutic work with children has been derived from Winnicott's Therapeutic Consultations in Child Psychiatry (1971). The implication for child psychotherapy of this theoretical frame of reference is that the insight that therapists gain into the inner world of children in their diagnostic-therapeutic interviews has to be "translated" to the significant people in the child's emotional environment. More specifically, explanations or interpretations of the unconscious motivations of the child's symptoms have to be translated into simple language to the significant people in the child's environment, who, in turn, have to make use of these insights in their everyday behavior and responsiveness to the symptomatic child. This approach to the treatment of young and latency-age children comes from my conviction that only in the context of an accepting and empathic relationship and in the everyday interactions between caretakers and the symptomatic child (eating, going to sleep, school and family activities) can fundamental changes in the child's symptomatic behavior be achieved. In other words, it is the parent-child relationship mediated by the relationship with the therapist that carries the major responsibility for the treatment process. As a psychoanalyst, Winnicott's approach to the treatment of children was primarily determined by developmental considerations; he was mindful of the importance of assessing and therapeutically addressing the child's anxieties, mode of defense and adaptation, fantasies and dreams. However, at the same time, he was fully conscious of the impact that the child's environment had on these inner experiences and with that, on the child's progressive development. Combining his developmental considerations with his recognition that children's minds remained an "open system" (open
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to pathological as well as therapeutic influences), he had recommended that therapists ought to aim at "unblocking the child's progressive maturational processes ... so that the change he had so achieved can be made use of by the parents and those who are responsible in the immediate social setting" (Winnicott, 1971, p. 5). To accomplish this, Winnicott relied on the availability of an "average expectable environment" (Hartmann, 1958). Winnicott's emphasis on the child's emotional environment in development and pathogenesis is in keeping with Heinz Kohut's (1971) theory of the self within the emparhically responsive "selfobjecr" milieu. Selfobject functions (mirroring, validating, and merger with the caretaker's strength and power) are those relationship functions of caretakers that affect the child's self development in terms of cohesion, resiliency, and self-esteem regulation. Changes in the behavior of symptomatic children cannot be brought about without simultaneously effecting changes in the relationships with which these children live. But the families that our child patients come from are rarely "average" and "expectable." In addition, we are no longer satisfied with the overtly average appearing environment. We have learned to appreciate the subtle forms of emotional neglect and abuse that children may be exposed to, emotional abuse that the environment itself may not be aware of. The major and more difficult part of our therapeutic work may not be connected with the treatment of children but to our efforts to create an environment that can be therapeutic for them; hence the emphasis on the relationship between symptomatic children and their emotional environment. There has been a growing disappointment among psycho-
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therapists with the individual treatment of children even when this is combined with the collaborative treatment ofone or another of the child's primary caretakers. Interpretations directed at young children have been found to be of limited value (Carek, 1972). Because of this disappointment, in many instances, the individual treatment of children was replaced with family treatment. However, this rarely gave child therapists a chance to explore the unconscious motives of the children's behavior. What was needed was a theoretical frame of reference that facilitated the integration of the insight that child therapists gained in the individual treatment of children with that of the behavior and attitude of their emotional environment. I have found that the conflicts in which caretakers and symptomatic children are caught are more likely to become loosened in the earlier rather than in the later phases of treatment. However, such loosening of pathological interactions depends on therapists' being able to convey during the first (or certainly during the first few) interviews their understanding of the most urgent current difficulties that the caretakers have to face. As child therapists listen to the parents' complaints and as they listen and try to comprehend the child's subjective, intrapsychic experiences, they are engaged in an effort to locate that area of the parent-child relationship in which parental attitudes and dysfunctional responses continue to aggravate the child's symptomatic behavior. The most challenging aspect of this treatment process is the therapist's ability to maintain an empathic listening relationship to the caretakers, similar to the one he or she is maintaining with the child. What has to become the focus of the therapist's interventions is the area in which the child's psychopathology and dysfunctional parental responses intersect. No effort ought to be made to "rherapize" the environment in all respects; rather, attention has to be focused on the child's specific anxieties and the specific manner in which caretakers respond to the behavior caused by these anxieties. Relationships lie at the center of this therapy. "Child-centered family treatment" (Ornstein, 1976, 1981; Ornstein and Ornstein, 1985) has to be distinguished from family treatment conducted according to systems theory as well as from individual psychoanalytically oriented psychotherapy. In child-centered family treatment, children remain the focus of the therapist's diagnostic and therapeutic concerns while the aim of treatment is to familiarize the primary caretakers with the unconscious motives of the child's disturbed and disturbing behavior. It is my preference to have the whole family attend the first diagnostic-therapeutic hour. This permits a reasonably quick diagnostic overview of family interactions and it provides the symptomatic child and the caretakers with an opportunity to present their respective views in each other's
presence. In the next phase, the child is seen individually as many times as is necessary for a thorough diagnostic assessment, which may include psychological testing and/or a neurological examination. It is during these individual hours that children are being helped to identify and articulate the way they feel about themselves, their problems, and their interactions with others. While therapists' nonjudgmental attitude, acceptance, and understanding keep the door to the child's inner world open and permit an in-depth assessment of their difficulties, the therapists' interpretive responses alone cannot bring about therapeutic changes. Once children establish trusting relationships with their therapists and feel protected and understood by them, these children will be ready to share their feelings with their caretakers. It is in these "integrative sessions" that the therapist "translates" the child's manifest behavior into its latent meaning to the caretakers. Countertransference toward caretakers may greatly complicate the treatment process. While most therapists have little difficulty in being empathic with their child patients and respond to them with acceptance and understanding, this is not necessarily the case with caretakers who have little or no understanding of the child's internal state and respond punitively to the child's behavior. It is important to appreciate the caretakers' frustrations in having to be therapeutically responsive to a child, who, either directly or through his or her symptoms, continually undermines their ability to parent effectively. The therapist's appreciation of the caretakers' anxieties and sense of failure goes a long way toward securing their meaningful participation in treatment. Here relationships are central to therapy. In treating children who live in families where empathy toward the child's suffering cannot be generated, either it becomes necessary to remove the child from the home, or the child must be helped by the therapist to adapt to a difficult situation with the least amount of developmental sacrifice.Young children derive benefits from the relationship with their therapists by "using" them as empathically responsive selfobjects; in this manner, therapists actively participate in the development of the child's self-cohesion. Only a relatively well-consolidated self can manifest the kind of resiliency that is required to withstand caretaker indifference and humiliation.
REFERENCES Carek D (1972), Principles of ChildPsychotherapy. Springfield; IL: Charles C Thomas Hartmann H (1958), Ego Psychology and the Problem of Adaptation. New York: International Universities Press Kohut H (197 I), TheAnalysis oftheSelf.New York: International Universities Press
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DEBATE FORUM Ornstein A (1976), Making contact with the inner world of the child: towards a theory of psychoanalytic psychotherapy with children. Compr
Psychiatry 17:3-36 Ornstein A (1981), Self pathology in childhood: clinical and developmental considerations. Psychiatr Clin North Am 4:435-453
Ornstein A, Ornstein P (1985), Parenting as a Function of the Adult Self: A Psychoanalytic Developmental Perspective. In: Life. Adelphi, MD: US Department of Health and Human Services. 1:425-442 Winnicott OW (1971), Therapeutic Consultations in ChildPsychiatry. New York: Basic Books
NEGATIVE: AARON H. ESMAN, M.D.
Psychotherapy, whether with children, adolescents, or adults, is a complex, multivariant process, involving both cognitive and affective elements in varying combinations from case to case. Debate has raged for years about the relative contributions of what have been called "specific" (i.e., interpretive/ clarificarory) and "nonspecific" (i.e., relationship) factors in generating therapeutic success. It is probable that, until improved methods of assessingtherapeutic process are developed, such debates will continue. To the categorical position stated in this "resolution" I would have to say "no"; the evidence does not seem to me to bear it out. There is no question that the therapist-patient relationship is a crucial factor in promoting the treatment process in any kind ofpsychotherapy. It provides the baseline, the indispensable sine qua non for such work; whether called the "therapeutic alliance," the "basic transference," or whatever, some such relationship based on a level of basic trust and positive expectation must be present or potentially present for psychotherapy to take place at all. The question here, however, is not that, but whether such a relationship is the crucial factor in the therapeutic engagement. Were this to be the case, it would seem likely that a benevolent grandparent would be as effective a therapist as the best-trained child analyst or the most knowledgeable behaviorist. Experience indicates that this is, unfortunately, rarely true. Cognitive interventions-be they clarifications, confrontations, interpretations, suggestions, explanations, advice, exhortations, reassurances-all play crucial roles in psychotherapy of one persuasion or another. Since I am best acquainted with psychoanalytic/psychodynamic psychotherapy, I shall primarily address this approach. The literature of child analysis and child psychotherapy is replete with demonstrations of the therapeutic effects of interpretive interventions. Hoffman (1989), for example, describes the analysis of an 8-year-old boy who appeared clearly to have responded to consistent interpretation with greater awareness ofhis disturbing affectsand with increasing capaciry to control the aggressive and regressive behaviors his emotions generated. It is, of course, true that such interpretations, where accurate and accurately timed, increase the child's sense of being understood and cared for; indeed, it is doubtless this factor that enables the therapeutic effect of interpretations couched in different (e.g., Kleinian versus
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Freudian) theoretical languages. Nonetheless, it is the resonance of the verbal content of such interventions with the state of the child's unconscious mental life that fosters such deepening of the alliance. The child (certainly one capable of concrete operational thought) is able to process such interventions, and thus to be, in the language of Sandler et al. (1980), "in touch with feelings, motivations and behavior" (p. 67). It is certainly true that one does not expect of the child the kind ofintegrative insight one anticipates in the treatment of adults. The young child's immature cognitive functioning, undeveloped sense of time, and continuing dependence on and primary involvement with parenting figures, all make the understanding of the impact of past on present and the meaning of transference enactments difficult for the child to grasp and retain. But consistent identification and clarification of affects, the translation of action-dispositions into verbal terms, the interpretation of projected punitive superego elements, all can have substantial impact on at least the older child's self-awareness and expectations and perception of others. As Winnicott (1965) put it, "A girl of 10 said to me, 'it doesn't matter if some of the things you say are wrong, because I know which are wrong and which are right' " (p. 324). And in the case of adolescents, with their more advanced verbal, cognitive, and introspective capacities, the gamut of interpretive techniques, including judicious transference interpretations, is feasible and capable of assimilation. In the case of behaviorally oriented psychotherapies, of course, the situation is even more clear. For all that behavioral and cognitive therapists have come to recognize the importance of the child-therapist relationship, the primary levers of therapeutic change are the therapists' explicit verbal instructions, prohibitions, conditioning stimuli, homework exercises, and the like, often implemented by parents. To the extent that these succeed in modifying or eliminating symptoms, they would appear to have an effect that transcends the "nonspecific" contribution of the patienttherapist alliance. Altogether, then, I believe that the psychotherapy of at least the post-oedipal child or adolescent requires more than a "helping" or "empathic" relationship. Given reasonable intelligence and a reasonable level of psychic organization,
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such children are capable of learning (1) that their behaviors or symptoms have meaning; (2) that they tend to be connected with their feelings; (3) that these feelings can often be comprehensibly connected with current life experiences; and (4) that other ways of managing these feelings exist and can be tried out. The child's ability to hear and make use of such interventions depends on the state of the relationship with the therapist, but can and should be understood as distinct from that relationship itself. Together, they make up the complicated process under discussion. In his usual way, perhaps Winnicott said it best: "... the interpretations did not produce the result, but they helped toward the
child's own discovery of what was already there in herself. This is the essenceof therapy" (Winnicott, 1964/68, p. 316).
REFERENCES Hoffman L (1989), The psychoanalytic process and the development of insight in child analysis: a case study. Psychoanal Q 58:63-80 Sandler ], Kennedy H, Tyson P (1980), The Technique of Child Analysis: Discussions with Anna Freud. Cambridge, MA: Harvard University Press Winnicott D (1965), The valueofthe therapeutic consultation. In: Psychoanalytic Explorations, Winnicott C, Shepherd R, Davis M, eds. (1989) Cambridge, MA: Harvard University Press, pp 318-327 Winnicott D (1964/68) The Squiggle Game. In: Psychoanalytic Explorations, Winnicott C, Shepherd R, Davis M, eds. (1989) Cambridge, MA: Harvard University Press, pp 299-317
AFFIRMATIVE REBUTTAL: ROSENFELD
Much of this disagreement amounts to splitting hairs. For instance, Dr. Onesti eloquently tells us that "our psychotherapeutic instrument is our person." Then he attempts to argue that the individual therapist's specific tools, not the relationship, are crucial. I suppose that to be "precise" one could argue that when a surgeon operates, the scalpel and careful hand motions, not his or her person, are crucial. But when a person and his or her skills are so inextricably linked, what does this distinction mean? I think we all agree that our special, hard-earned skills are essential factors to being effective therapeutically. But the child therapist's most unique skill is being able to make and sustain relationships with children who have difficulty forming them, and then using these relationships for therapeutic ends. Children often come to therapists because they are unable to find-or because their constitution, experience, or psychological makeup leaves them unable to useameliorative, even healing, relationships that are available to most people in everyday life. Rather than being driven away by (or becoming moralistic because of) disturbed and disturbing behavior, we therapists understand it as a message we need to decode. Dr. Esman doubts that the relationship is the crucial factor, because if it were, a benevolent grandparent would provide effective therapy. I think that "accepting and empathic," (to use Dr. Ornstein's term) grandparents, relatives, and friends often are therapeutic. If they were not, all 50% of Americans who have psychiatric conditions during their lives (Kessler et al., 1994) would see therapists. It is likely that more could benefit from therapy. But a good number
of people overcome emotional difficulties because someone in the community is there for, and acts therapeutically toward, them. In fact, in exploring the life course of potentially delinquent children, Vailliant found that the presence of one good relationship with someone in the community made the difference between a good outcome and a poor one (Vailliant, 1993). I believe that the therapeutic relationship is the crucial context that lets our other tools and skills be effective. For instance, Dr. Onesti says that one skill is that the therapist "directs the patient's attention toward thoughtful exploration and clarification." I have not found my patients to be particularly malleable and open to direction, especiallywhen I first meet them. Teachers, parents, scoutmasters, etc., have usually failed in their attempts to "direct" the child. So without my special skill in forming a relationship different from others in the child's past, why would the patient give my "direction" any credence? Only within the safe security of this new relationship do our patients develop skills they may then use in other relationships, both while in treatment and after they leave us. Emotional sustenance from those relationships are what ultimately will help prevent their falling back into rage, discouragement, and pessimism.
REFERENCES KesslerRC, McGonagle KAet al. (1994), Lifetime and 12-month prevalence of DSM-IlI-R Psychiatric disorders. Arch Gen Psychiatry 51:8-18 Vailliant G (1993), Wisdom ofthe Ego. Cambridge, MA: Harvard University Press
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NEGATIVE REBUTTAL: ONESTI
The response of each partICIpant in this Debate on the Resolution that the therapist-patient relationship is the crucial factor to change in child psychotherapy, whether arguing an affirmative or negative position, has been to point out the importance ofthe therapist-patient relationship to the therapeutic work. So far there is full agreement. Our disagreement resides in our differing conceptualizations of what is essential for the therapist and patient even to engage in the therapy, namely, their relationship, and what is crucial for the therapist and patient to produce therapeutic work and consequent change, namely, the various skilled interventions on the part of the therapist. Dr. Ornstein stated, "only in the context of an accepting and empathic relationship ... can fundamental changes in the child's symptomatic behavior be achieved." She added, "it is the parent-child relationship mediated by the relationship with the therapist that carries the major responsibility for the treatment process." Relationships do provide context and responsibility for the treatment process, but in her example ofWinnicott's approach "assessing and therapeutically addressing the child's anxieties, mode of defense and adaptation, fantasies and dreams" and his "unblocking the child's progressive maturational processes," she alluded to the therapeutic work on the part of Winnicott, work that I believe is the crucial factor to change. Dr. Ornstein stated, "The most challenging aspect of this treatment process is the therapist's ability to maintain an emphathic listening relationship to the caretakers, similar to the one he or she is maintaining with the child." Again, she underscored the importance of the relationship, but when she added that "the aim of treatment is to familiarize the primary caretakers with the unconscious motives of the child's disturbed and disturbing behavior," she confirmed the need for therapeutic work, in this example clarification and interpretation, presumably for the treatment to produce change. Dr. Rosenfeld stated, "Psychotherapy uses a new relationship-the therapist-patient relationship-to help the child develop more constructive, effective solutions...." He defined the therapeutic relationship as "a long conversation
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designed to deal symbolically with the child's repetitive, dysfunctional patterns of interacting." He elaborated: "Working together within the relationship, patient and therapist develop a langauge to communicate about feelings, fantasies, and beliefs...." "The therapeutic relationship ... uses intellect to solve problems and reason to diminish anxiety." "The therapeutic relationship enables a child to try out personality stylesand behavioral changes...." "Allied with the therapist, the child may ... experiment with roles ... or ... explore fantasies and feelings...." Dr. Rosenfeld noted, "the child psychiatrist makes interpretations, indirectly decoding the messages that transference phenomena are giving." He emphasized that the child's relationship with the therapist must be "genuine, mutually involving, and sturdy" for the child not to "ignore therapeutic interpretations, reject insights and behavioral suggestions, and play, if at all, perseveratively." From Dr. Rosenfeld's statements I would conclude that the therapist-patient relationship is the vehicle that enables the therapeutic work-consisting of the use ofsymbolic conversation to communicate and explore feelings, fantasies and beliefs, the use of intellect and reason, the use of trying out styles, behaviors, and roles, and the use of interpretations, insights, behavioral suggestions, and free play-to take place. I would also conclude that the therapeutic work is the crucial factor to effect change. Dr. Esman pointed out that a "relationship based on a level of basic trust and positive expectation must be present or potentially present for psychotherapy to take place at all. The question here, however, is not that, but whether such a relationship is the crucial factor in the therapeutic engagement. Were this to be the case, it would seem likely that a benevolent grandparent would be as effective a therapist as the best-trained child analyst or the most knowledgeable behaviorist." I agree. I restate my own conclusion that the crucial factor to change in child psychotherapy "is the employment by the therapist of a number of specific therapeutic skills in the multipurpose therapeutic setting, aimed at valued therapeutic goals within the limits of human development. "
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AFFIRMATIVE REBUTTAL: ORNSTEIN
The contributions of these four child psychiatrists confirm my conviction that no categorical position can be taken relative to the therapist-patient relationship constituting the crucial factor in the treatment of children: we all included a variety of other factors which we consider "crucial" in the achievement of our therapeutic goals. The contributions to the debate make it also clear that what we consider to be the curative factor depends on the meaning we attribute to anyone of our interactions with our patients. For example, when Dr. Esman says that "... interpretations ... increase the child's sense of being understood and cared for" and that "it is the resonance of the verbal content ... with the state of the child's unconscious mental life that fosters the deepening of the therapeutic alliance," he considers interpretations to have primary significance in treatment insofar as it strengthens the therapistpatient relationship. In other words, he considers interpretations to have therapeutic effectiveness because "feeling understood" promotes the therapeutic relationship. This is a perspective on interpretations with which I am in full agreement. However, I would add to this that while feeling understood by their therapists is the crucial factor in the treatment of adults, young children also have to feel understood by the emotional environment in which they live. Similarly, many of Dr. Onesti's statements could be understood as belonging to the category of the therapistpatient relationship. This is how I would understand his inclusion of teaching, modeling, and learning skills into the functions of a child therapist. Relationship as the crucial aspect of treatment is particularly clear in Dr. Onesti's considering the therapist as a model with whom the child is expected to identify. My major disagreement with Dr. Onesti is that I find his categorical statements much too idealistic; his assumption that by providing a safe environment, children will be able to examine their past and present
actions and make conscious choices as to their behavior also lacks developmental considerations. On similar grounds, I also question how he can expect changes from his interpretive activities: can children recognize that their behavior is "based on beliefs that stem from past mistaken conclusions" and "consider alternatives and their consequences"? This requires cognitive capacities that most young children do not possess. Not surprisingly, on the side of the affirmative, I found myself in agreement with most of Dr. Rosenfeld's assertions. Dr. Rosenfeld argues successfully that a therapeutic relationship ought not be considered only as a nonspecific aspect of treatment as Dr. Esman maintains. The "clear boundaries, comprehensible limits, and predictable times" take on specificity in caseswhere children live with inconsistent parenting and chaotic households. Also, I am in full agreement with the importance that being listened to attentively and with interest may, for the first time, provide the child with an experience of being valued, an experience that has curative value. In this sense "the therapeutic relationship in a slow, persistent way can persuade the elusive, angry child that relationships are worth the risk." However, I disagree with Dr. Rosenfeld, as I do with my other two colleagues, that even when these properties of the relationship are taken into consideration, the therapistpatient relationship constitutes the crucial factor in the treatment of young children; young children who live in chaotic and abusive environments cannot gain enough strength from the relationship "to experiment with roles the family objects to." All four contributions point up the importance of differentiating between the treatment of young children and that of adolescents; in the treatment of young children, changes in caretaker attitudes are as crucial as is the therapist-patient relationship, while this is less so in the treatment of adolescents.
NEGATIVE REBUTTAL: ESMAN Dr. Ornstein's eloquent statement seems to me to conceive the child as the passive victim of abuse and/or neglect, and his or her psychopathology as merely reactive to such parental misfeasance. No reference is made to intrapsychic conflict, nor is there any consideration of the child's own contribution to the pathological interactions, symptoms, or action tendencies that may have brought him or her to treatment. Consistent with the tenets of "self-psychology," this point of view is, I believe, misguided at worse, and one-sided at best.
J.
Although I agree that the preschool child is often (perhaps always) best treated by way of the parents, I do not believe that this is the case for the latency child (let alone the adolescent). Such children, if reasonably bright, are capable of grasping interpretations, learning about their affects and, through focus on transference manifestations, confronting at least some of their misconceptions and moderating their punitive or inconsistent superegos. Of course, concurrent work with families is needed; we are far from the days of
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"pure-culture" child analysis when it was thought necessary to avoid "contaminating" contact with parents. But children can and do develop internalized structured pathologies that will not yield to environmental change alone, but can respond to judicious interpretation (in the largest sense) from an ernphathic, concerned therapist. Dr. Rosenfeld seems to me to be speaking primarily of the severely disturbed child and adolescent in residential treatment. Such children do, certainly, require a "corrective emotional experience" continuing over a long period of time in order to undo the adverse consequences of severe parental abuse and/or deprivation. But even these children are best served, I believe, by a comprehensive treatment that offers them an opportunity to master their past experiences and current feelings through language, and to understand the connections between their maladaptive behaviors and the painful events in their lives. There are, I maintain, cognitive as well as affective consequences to unfavorable life experiences, and it is in the end the meaning to the child of those
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experiences and the coping resources he or she brings to them that matter. I believethat for children who have suffered major losses and traumas, the shared verbal interactions of clarification, interpretation, and response can have major value in persuading them of the validity of their own perceptions, the mutuality of human interchange, and the healing power of verbal communication. Dr. Onesti and I are in essential agreement, so I shall not comment on his contribution except to note that, for me, the definition of health is not only the ability to love and to work, but also to play. It is this capacity that we often have to free up in our patients, not only through providing a "holding environment" but also through helping them to understand the reasons for their affective and behavioral constriction. This, I believe, can enable them, in some measure at least, to resolve the conflicts that have impaired their ability to enjoy the very essence of their childhood.
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