Change variables in the psychoanalytic treatment of children and adolescents: A research report
This empirical study was designed to investigate the effectiveness and the variables of change in psychoanalytic treatment of children and adolescents. The survey was conducted collecting information from therapists with regard to a defined number of cases on the development of treatment, and the changes observed. The basic hypothesis was that the change, to be effective, must address the aspects of functioning, the relational (Fonagy, 2002), and the organization of the inner world, as follows from the thought of Sandler (1994). Consequently, were used for the survey questionnaires aimed to collect information about the phenomenal aspects, the relational, the expressions of the inner world, then crossing them. We expected significant results from research as to the therapeutic process and associated variables.
The research described is the first stage of a larger project aimed to investigate also the point of view of young patients. The project, funded by the RAB of IPA, was launched in 2006, after discussion in London at 2005 RTP of IPA. Partial presentation of the results, concerning a comparison between cases concluded and discontinued (drop-outs), took place in Rome, 2008, at ISAPP Conference "New Frontiers of the clinical Research in Adolescence", organized by M. Ammaniti, under the title Variables of change in the therapeutic process of children and adolescents, published in the Conference Proceedings. Additional articles are under completion.
The research was carried out by asking each of the therapists to answer extensively about a given number of cases, some ongoing, some who had completed therapy, some who had discontinued. Questionnaires were administrated to 125 experienced child psychoanalysts and psychodynamic psychotherapists belonging to Italian Psychoanalytic Society and to accredited Schools in different parts of the country. 24 valid questionnaires were returned, with an average of 19,2%. Overall responses covered 165 treated cases (average 6.79 cases for each psychoanalyst), 87 males and 78 females, distributed in three age groups (0-6, 7-12, 13-18). Of the 165 cases on which we have been answered, 63 cases were completed, 52 still in progress, 50 discontinued; 33 cases had started treatment in early childhood, 60 latency, 67 adolescence, 5 missing.
Treatments where therapists were asked to express were conducted with the psychoanalytic method, based on a proper setting and timing, performed by playing, drawings, dreams, in addition to the verbal expression. The duration of the cases discontinued had to be at least six months. No specific forms of pathology were selected for the survey, all forms of distress were included. During the processing of the data, we grouped the pathological forms into six groups relying on the severity and the quality of functioning of the subject.
Questionnnaires were aimed at highlighting the methodology, the process and the outcomes. We started from the assumption that the quality of development and consequently therapeutic transformation are involving the following areas: the modes of functioning, the quality of the inner world and the characteristics of the relationship or relationality; accordingly, we have formulated questionnaires and asked therapists to express themselves on these areas at different stages of treatment, through multiple choice questions, Likert scales on 4-point and open-ended questions, the latter related to dreams, fantasies and typical ways of behavior (considered an expression of the inner world, Sandler 1994, and of the internal working models, Jones 1997, 2000). When analyzing the unconscious material, the focus was on the relational factor and its level of development. Several findings have emerged; the results of some Likert scales relating to cases concluded and discontinued, where the conclusion was considered one of the indices of therapeutic success, in addition to the quality of the transformations and the functioning characteristics, were cross-validated through comparison with the content of responses to open-ended questions, coded by three independent judges, (Cohen's K> .7).
By the comments provided by the clinicians:
- a significant finding concerns the fact that the identified variables have a parallel development, concordant in cases concluded, erratic in drop-outs;
- as to the variables, have an influence on the outcome all the processes of acquisition of self-awareness, development of thought and mentalizing, the acquisition of a sense of trust and safety, knowledge and ability to express their own needs, acceptance of the other, the processing of traumatic factors; all the differences between cases concluded and discontinued are statistically significant at the Chi square test with p <0.003;
- a cross-comparison with the content of responses to open-ended questions about dreams, fantasies and functioning characteristics (aimed at assessing the acquisition of ‚internal‘ relatedness) confirmed the results obtained;
- the quality of the relationship is crucial to the development of the therapeutic process, particularly at risk when prevailing feelings of constriction and challenge in the therapeutic relationship;
- the severity of the disorder does not appear to have significant relevance to the outcome;
- work with families appears as a common and positive resource, even if the methodology is not defined; it can be considered as a common evolution in effective technique and probably constitutes an important tool to stop the process of transgenerational transmission of problems and maladaptive patterns of functioning.
Within the limits resulting from a retrospective study, conducted with non-standardized instruments, which involved a sample of therapists, the study provides a survey on the state of things with regard to the psychoanalytic treatment in children and adolescents; the results appear to provide useful information as for the assessment of factors related to therapeutic change, with intersection of phenomenal findings and data from the internal world. The results provided useful basis for switch to the collection of data from young patients.
The comparison between concluded and discontinued cases provides many elements for the evaluation of the cure and the efficacy variables, by showing that the balance of the various factors correlates with good outcome, while the unbalanced development correlates with more pronounced risk elements; major risk factors also correlate with insufficient processing of traumatic elements, insufficient quality of the therapeutic relationship and of the therapeutic alliance (feeling of constriction and challenge). These data were confirmed by the representational modalities of the inner world. The cross-examination of intra-psychic and phenomenal aspects appear ineresting both to the clinic and diagnostic, by indicating ways for measuring the psychic change. The fairly large number of cases described appears to provide greater reliability to the results, to be confirmed by further research on the side of patients.
Licia Reatto*, Giuseppe Benincasa*, Stefano Castelli**
* Italian Psychoanalytic Society; IPA
** Associate Professor, Bicocca State University, Milan, Italy
Licia Reatto firstname.lastname@example.org