Editorial

Two of our book reviews found at the end of this issue discuss works which raise questions, concerns, and thoughts about the essential value and current practice of psychoanalytic work in the contemporary workplace. Marcus Evans’ Making Room for Madness in Mental Health looks at the role of psychoanalytic thinking in responding to the needs of psychotic patients and argues that psychoanalysis enables services to identify the institutional defences which can be unconsciously activated by ‘psychotic communications’. Psychoanalysis, the NHS and Mental Health Work Today, edited by Alison Vaspe, is even more explicit in its identification of the need for psychoanalytic thinking to alleviate some of the pressures felt by those working within the present-day UK National Health Service.

These book reviews allude to a fundamental hypothesis that in order to better understand the external results of internal processes, be it in a single psychotic patient, or a mental health service department, the causative processes, which may well be unconscious and unclear to those directly involved, need to be identified and explored. The tendency and, as both books make clear, prevailing institutional culture, may actually be the opposite of this; to focus on the surface, the external and the conscious. These two books may well be informed primarily by reference to UK workplaces, yet it is surely not a UK-only matter, this ongoing battle to justify the place of psychoanalysis and child psychotherapy within mental health services and mental health culture. But how to do it? How to explain, inform and demonstrate the importance of psychoanalytic thinking and clinical practice? The five diverse articles in this issue, serve as an exemplar of the range of responses that child psychotherapy can contribute to the debate.

We lead with the updated critical review of the evidence base for psychodynamic psychotherapy for children and adolescents compiled by Nick Midgley, Sally O’Keeffe, Lorna French and Eilis Kennedy. Referring back to the earlier Midgley and Kennedy review of 2011 (Midgley and Kennedy, 2011), the authors bring us up to date by including research published in the intervening years and speak of ‘considerable developments’ in how our work with young people is being evaluated. The study reminds us of the findings of the previous report and shows how the evidence base has grown in the past five years not only in size, but also in the scope and variety of psychodynamic clinical work that is undertaken with children and young people. This research includes children with specific diagnoses, mixed diagnosis and results from Randomised Control Trials, as well as other research designs.

The reader could almost dip in at any place of this paper and find information and evidence that speaks of the importance and vitality of child psychotherapy as a discipline. Two studies, for example, focused on youth anxiety disorders. The first of these was comparatively small in scale and short-term, yet its outcomes are compelling, with all but one of the young people involved no longer meeting the diagnostic criteria at the end of treatment. The authors note that neither study contained a control group and therefore firm conclusions about effectiveness cannot be drawn; however even these smaller scale studies add to the overall picture presented, which is one of an increased volume of research providing increasingly convincing evidence for psychodynamic child psychotherapy.

The review alludes to the debate that continues within child psychotherapy as to ‘the science and politics’ of evidence-based practice and to the barriers that our discipline faces in terms of (under)funding. Despite these difficulties, the authors assert that when psychodynamic psychotherapy has been allowed the adequate resources – such as in the five RCT’s which investigate psychodynamic treatment across the time period – it is found to be as clinically efficacious and cost effective as other treatments. Here is powerful evidence with which to make the case both for more parity in the funding of child psychotherapy research and for child psychotherapy to be considered by those commissioning services as a suitable modality to resource and promote.

Whilst this important meta-study allows us to see an overview of the work with which child psychotherapists are currently involved, Sheila Levi sets herself a micro-version of this as her goal: to objectively measure the effects of individual psychotherapy with a child diagnosed with ASD through the use of psychological testing. Aware of NHS demands that clinical case notes should display evidence of clinical effectiveness and should refer to relevant research alongside the processes of therapy, to this end Levi utilises four psychological tests at pre-therapy, intermediate, and post-therapy stages of treatment. Interestingly, initially Eric sees this testing itself as a series of intrusive attacks which he needs to ward off, thus rendering their effectiveness, in a traditional sense, limited. Readers well may find echoes from their own work experiences when hearing details of Eric’s treatment and how children with similarly complex developmental difficulties can sometimes fall outside not only diagnostic criteria and assessment, but also treatment pathways. The strength and meaning of Levi’s work with Eric, based on fundamental child psychotherapeutic clinical practice, becomes clear as she formulates her argument that, within her psychoanalytic holding of the case, her ongoing evaluation and testing augments and facilitates the work. Whilst the detailed and, at times, moving clinical vignettes presented by Levi could perhaps have appeared in any issue of the journal from 1963 onwards, the novel methodology attempts to systematically measure the complex improvements made by a child engaged in psychotherapy using accepted psychological testing methods within a psychotherapy treatment.

Marianne Haugvik and Svein Mossige present a paper which demonstrates not only the breadth and diversity of psychotherapeutic treatment modalities available to those who work with children but also the ways in which this work can be captured as meaningful research. A 12 session model with explicit structure, focus and goals would have been unlikely to make an appearance in a 1963 issue of the JCP, yet the structured nature of the therapy is replicated by the structured presentation of the research which enables us to see clearly how such time-limited work has enabled the three children participating in the study to have the opportunity to develop their abilities to express their thoughts and feelings. The paper focuses on the therapeutic processes involved in delivering this therapy and concludes that the success of the intervention can be seen in the extent to which the therapist can help to contain and regulate the resulting emotional material.

Readers may be interested in the ways in which the traditional technical skills that psychoanalytic training instils – the creation of and adherence to a tight framing for the therapy, the therapist’s ability to reflect on their countertransference, the therapist’s identification of unconscious communication – can be seen to be present even within such short-term work. The clarity of the conclusions attest to the importance of child psychotherapists continuing to develop our ability to design, collect and make sense of research which gets to the heart of the relationship between the therapist and the child, and thus to the heart of the power of the psychotherapeutic work.

The following paper, co-authored by Lida Anagnostaki, Alexandra Zaharia and Mata Matsouka addresses that fundamental aspect of all psychoanalytic work, the setting, and explores the particular challenges of the setting when the patient is a child or adolescent. The authors draw out the distinctive reality of working with child patients for whom some, but not all, aspects of the ‘psychoanalytic contract’ must be established and re-negotiated with others who are not the patient – the parents or carers. The balance between the function of the setting boundaries which helpfully contain the child and the work and the potentially helpful function of a shift in these boundaries as a bespoke ‘interpretation in action’ is explored. A central contention of this piece, that as child psychotherapists we may, on occasion, need to be prepared to modify the rules of the setting and to validate the expressed needs of our patient rather than speak directly to their fears, has much in common with that proposed by Lanyado in her recent paper in this journal (Lanyado, 2017) and with Alvarez’ thinking on ‘wishes or needs’ (Alvarez, 2012). These kinds of clinical dilemmas are helpfully illustrated with vignettes from ruptures to the setting in work with three adolescent patients all drawn from the workshop in Greece which prompted the paper; the fragility of the setting and the need to remain alive to the possibility of adaptations are both in evidence. The authors conclude that the primacy of the unconscious symbolic meaning running underneath the dynamics at play must remain the guiding principle. This paper may be of especial interest to readers who are themselves working independently in private practice for whom the conflicts of interest exemplified seem likely to be all too familiar.

Our final paper explores the connections that a child psychotherapy perspective can facilitate between parents and clinicians, between behaviour and emotions, and between referral and treatment by the carrying out of a state of mind assessment. This is an area of clinical practice that is, perhaps, often overlooked and possibly even viewed as just an adjunct to our main clinical work. Peta Mees offers us a fresh look at the task and details ways in which such assessments may highlight the distinctive value that child psychotherapists can bring to multi-disciplinary teams, and to families, in terms of offering a nonjudgmental understanding which widens and enriches rather than attempting to narrow down and diagnose. The focus in her paper is of how state of mind assessments are needed to add meaning to a clinical picture and how this meaning may at times run counter to what clinical teams and parents may be expecting or be comfortable with. Here the role of the child psychotherapist may be subtly different to that of other clinicians in the team: Mees argues that as psychoanalytic child psychotherapists we are uniquely trained to be alive to the nuances of projection and transference even within such a short intervention as an assessment. These unconscious processes may provide us with information about the child’s needs and conflicts which others may not wish to hear about or feel able to deal with. As Mees makes clear through the case of Tommy, this privileged position may stir up powerful emotions within the family, such as envy, of which we need to be aware. She advocates that far from adopting a position of the ‘expert’ purveyor of wisdom, we should take an approach more akin to ‘puzzling it out together’ in which we are mindful of achieving a balance between the child, the parents, and other colleagues around us. Mees makes clear that our expertise here, in investigating and communicating about the child’s internal landscape (as opposed to a more behavioural assessment) derives from child psychotherapists’ ability to operate within a psychoanalytic model, and to simultaneously balance the feedback from this psychoanalytic understanding with an understanding of the wider perspectives of the family, the team and the referring colleague too.

In her introduction to this issue’s Research Digest, Cathy Troupp describes how the research papers attempt to find relationships between goals and treatment outcomes and to make sense of the complexity of collating outcome data for treatments such as child psychotherapy. More specifically outcomes in the relatively under-researched parent-infant psychotherapy modality are examined, an area of research and treatment that is growing in importance for child psychotherapists.

In addition we are pleased to include a third book review, in which Louise Allnutt assesses the merits and possible short-comings of Robert Bertolini’s What to do if the mind does not develop. This book explores an area of psychoanalytic clinical work whose relevance has been strengthened by recent neuro-developmental research.

It is surely from the breadth of work undertaken, and the unique positioning of child psychotherapists work as Mees and others describe that we can arrive at one possible starting point as an answer to the question we first posed. In their own ways each paper here shows the breadth, diversity and power of psychoanalytic work with young people, and offer arguments for how such work can be gathered, discussed and presented. The mental health working environment described by Evans, Vaspe et al., can at times seem like a world in which the need for psychoanalytic mental health provision is diametrically opposed by the inability of mental health services to tolerate such help. We hope that readers will be encouraged by this issue to consider how child psychotherapy can further marshal its arguments to facilitate such needed interventions.

Nigel Carter with Jo Russell