Bernstein, I. (1975). On the Technique of Child and Adolescent Analysis. J. Amer. Psychoanal. Assn., 23:190-232.

(1975). Journal of the American Psychoanalytic Association, 23:190-232

On the Technique of Child and Adolescent Analysis

Isidor Bernstein, M.D.
DURING THE COURSE OF ITS GROWTH to its present status, child analysis began, as children often do, to follow in the footsteps of its parents. Like the analysis of adults, analysis of children originated as a form of therapy, became a method of research, and contributed toward a general theory of personality. Particularly with regard to research, child analysis has furnished its progenitor with important additions to analytic knowledge concerning object relations and ego development in infancy and early childhood. Child analysis also became a means of clarifying, enriching, refining, and validating or disproving formulations and hypotheses of analysis that had been based on reconstructions from the treatment of adults. The special focus of child analysis has been on development of the personality. One example of

Anna Freud: THE WRITINGS OF ANNA FREUD, VOLUME VII, 1966-1970. PROBLEMS OF PSYCHOANALYTIC TRAINING, DIAGNOSIS, AND THE TECHNIQUE OF THERAPY.New York: International Universities Press, 1971. Elisabeth R. Geleerd, ed.: THE CHILD ANALYST AT WORK. New York: International Universities Press, 1967. Gerald H.J. Pearson, ed.: A HANDBOOK OF CHILD PSYCHOANALYSIS. New York: Basic Books, 1968. Victor Smirnoff: THE SCOPE OF CHILD ANALYSIS. New York: International Universities Press, 1971. Benjamin B. Wolman, ed.: HANDBOOD OF CHILD PSYCHOANALYSIS. New York: Van Nostrand Reinhold, 1972. I wish to thank Peter Blos, Ph.D. and Jules Glenn, M.D. for their helpful comments and suggestions. Submitted July 12, 1974
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contributions of more general and clinical significance made by child analysis is the division of latency into two phases (Bornstein, 1951). This has been useful to analysts of adults dealing with persistent defects due to faulty or atypical latency development. Then too, Mahler's (1968) studies of separation-individuation have enabled recognition of those adults who have not completed psychological differentiation and who continue to struggle with anxieties and conflicts from this unfinished early phase of development. In addition, psychoanalytic understanding of infancy and childhood has became important in the field of prevention of emotional and mental disorders, with more and more emphasis on recognizing the earliest signs of disturbance in development and prompt intervention to alleviate and correct the pathogenic influences. We have to include, in child analysis, the knowledge gained by the researches of child analysts, not only from the treatment of children by psychoanalysis, but also from observational and longitudinal studies conducted by analysts, as well. Reconstruction from the analysis of adults enabled Freud to make his momentous discoveries and formulations about childhood experiences and psychosexual development. In complementary fashion, observational and treatment data furnished by child analysis have contributed to a better understanding by analysts of thechildhood of their adult patients. Hartmann (1950), Kris (1950) and Anna Freud (1951) have examined in detail the ways in which child observation

and analysiscontribute to a theory of personality development of the normal as well as the neurotic child and adult. In the first volume of The Psychoanalytic Study of the Child, Bornstein (1945) referred to an effort in the twenties to implement a suggestion to have the training of every analyst include child analysis. The attempt failed, probably because of inadequate instruction in the different technique and the inability of the analysts to comprehend the child's communications. More recently, the American Psychoanalytic Association and some of its institutes have encouraged
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the inclusion of analyses of children in the training of analysts who do not necessarily intend to go on to full training in child analysis by accepting such analyses as equivalent fulfillment of case requirements for graduation or eligibility for membership. Included in Volume VII of Anna Freud's Writings, is a 1970 paper on "Child Analysis as a Subspecialty of Psychoanalysis." She decribes the history of child analysis and relates the disappointment in the expectation that all analysts of adults would be interested in the realistic confirmation provided by analytic work with children of reconstructions of childhood made during the course of analyses of adults. As the number of child analysts increased, efforts were begun and continue to be made to set standards for their training in the established psychoanalytic institutes both here and abroad. The American Psychoanalytic Association in May, 1973 published the training standards in child psychoanalysis that had been approved and adopted by the Board on Professional Standards in December, 1966. Along with these signs of growth has been the emergence of a feeling of independence but not estrangement of child analysis from the field of adult analysis. One could characterize this (with a bow to Mahler) as the development of individuation of child analysis, a progression from the earlier phase of symbiosis with lack of differentiation from adult analysis. This advance is represented in institutional terms by the severalchilddevelopment research centers and the Association for Child Analysis, and in scientific and academic terms by the volumes of The Psychoanalytic Study of the Child, the programs of the Association for Child Psychoanalysis , and the publications of Anna Freud, Mahler, Spitz, M. Klein, and Winnicott, among others. Along this developmental line have appeared The Writings of Anna Freud, two Handbooks of Child Psychoanalysis , a casebook titled The Child Analyst at Work,and one, ostensibly for the general public, by Smirnoff, The Scope of Child Analysis. The time-honored approach to the learning of analytic technique has been by case presentation, by supervised
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analysis, and by continuous case seminars. These were methods of illustrating the correct technical handling of analytic material with dreams, transference, acting out, and the like. A fine example of the first form is Geleerd's book, The Child Analyst at Work, while Pearson's Handbook of Child Psychoanalysis can be recognized as an edited version of the traditional institute course in the technique of treatment of children and adolescents. The curriculum for child analytic training in most institutes includes observation of "normal" children with discussion by a child analysis supervisor or instructor. This is gradually being extended to the curriculum for all analytic candidates. The reciprocal relation between child analysis and the analysis of adults resembles, in some respects, that of pediatrics and general medicine. (One could argue with those who advocate the establishment of a separate track for child analysis, on the basis of this analogy, about how valid it would be for a doctor to be a pediatrician without having the background of preparation and experience of treating adults. Recognition of the point is evident in a change in the Hampstead child analysis program; it now includes analysis of adults.) The child analyst needs to understand the parents he works with as adults with their particular characterology and problems. The ideal base for this is the establishedtraining for analysis of adults. In complementary fashion, the analyst of adult patients needs to understand the childhood of his analysands. A highly effective means of achieving a truly empathic familiarity with children is by observation and analysis of children. Through such experience, the analyst becomes better able to distinguish screen memories, adultomorphized recollections of childhood, childhood romances, "personal myths" (Kris, E., 1956), and significant actual childhood events. It is not unusual, in the analysis of adults, to hear allegedly important early experiences described in patently age-inappropriate terms. Recognition of this has, at times, enabled analysand and analyst to penetrate defensive structures and to reach important and genuine affect-laden memories.

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Any effort to systematize the knowledge of child analytic technique requires the assumption that the reader is familiar with analytic literature on child development or the presentation of a digest of the present status of such knowledge. The latter is a truly herculean task, admirably performed by Smirnoff, despite his disclaimer that his book is "not intended as a textbook for psychotherapeutic or psychoanalytic practice." As an example of his effort to clarify present approaches, the book begins with a section on definitions. Certainly, some of the apparent confusion that exists in the minds of analysts as well as the lay public is the blurring of distinction between child analysis and analytically-oriented child therapy.1 If it is generally agreed that child analysis refers to the analytic treatment of the child, then some of the problems regarding treatment of the parents, management of the familyincluding family therapy and educational measuresare seen to be outside the area to be focused upon in discussions of technique of child analysis. Use of the term "parameter" to include extra-analytic behavior or technique on the part of the analyst serves to obscure the fact that one is no longer referring specifically to child analysis, valuable as these other measures may be. From this standpoint, the handbook by Wolman could remain truer to its title if it eliminated the section on group therapy and material on other nonanalytic treatment approaches. One contributor (R. Dreikurs) states, "Not only do I consider my approach as not being 'psychoanalytic'; what is even more serious, I have reservations about the term child psychoanalysis , or even childpsychiatry." One wonders about the rationale for including such a nihilistic view on the grounds of a desire to be complete or comprehensive. A more useful approach is apparent in Smirnoff's limiting himself to a consideration of Kleinian theory and technique as a variant of child psychoanalysis . Smirnoff

1 It is important to maintain the distinction between work with children and parents involving guidance, instruction of parents, use of surrogate parents and other helpful measures, from the

psychoanalysis of the child.

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gives a lucid summary of Melanie Klein's theories regarding the development of fantasies in the first weeks of life and the central position of unconscious fantasies in subsequent mental life. He also presents her formulations of the development of normal object relations in terms of what she postulates as paranoid-schizoid and depressive positions. He follows this with a review of the criticisms of Klein's views by Glover, Lebovici, and Diatkine. In his comprehensive condensation of research inchild analysis, Smirnoff includes work by French and German analysts who are generally less well known than their English and American counterparts.

Indications for Treatment

A logical starting point for a consideration of the present status of the technique of child analysis would be the indications for and goals of psychoanalytic treatment of children and adolescents. Anna Freud's book, The Psychoanalytical Treatment of Children(1959), served to demarcate the special field of child analysis and announced her particular interest in the diagnosis of childhood disturbances. She has continued to study and broaden her earlier ideas with the result that her more recentNormality and Pathology in Childhood(1965) contains a deceptively simple yet comprehensive discussion not only of diagnosis, which utilizes her concept of developmental lines, but also of the relation between child and adult analysis, principles of technique, and choice of treatment modality. The richness of her approach is in striking contrast to efforts to deal with diagnosis along traditional (standard) psychiatric nomenclature. J. S. Silverman and N. Ross in the Wolman Handbook make a valiant attempt to supply a Coordinated Diagnostic Profile along five basic themes leading to a therapeutic statement: 1. Traditional clinical descriptive phenomenological formulation. 2. Psychodynamic and metapsychological statement of personality and psychopathology (including chronological

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age and developmental stages, predisposing, precipitating, and perpetuating factors). 3. Assessment of degree of consonance of lines of development. 4. Assessment of family, marital integration, and interpersonal relations. 5. Psychosocial, sociocultural assessment. 6. Therapeutic recommendation and prognostication. They offer as a case illustration a five-and-a-half-year-old preschool boy with what they term a tension-discharge disorder, neurotic personality type. They present a discussion which includes descriptive statements, dynamic formulations, and genetic propositions. Despite a claim that a "study along developmental lines of an autonomous functionmotor activityled us to comprehensive diagnostic clarity" (p. 174), they conclude their chapter with what seems to me a more appropriate estimate: "Our case illustration demonstrates the difficulties, some perhaps impossible to overcome at this time, in establishing nomenclature, classification, and diagnostic formulation, without a specific etiological basis" (p. 178). The Pearson Handbook, in the section on Indications, points out that cases of classical neurosis are rare at the present time and then refers the reader to Anna Freud. The trend has been away from alleviation of symptoms to recognition of more fundamental underlying disturbances. With adults, this has resulted in a shift fromsymptom analysis to character analysis. A parallel to this, with children, is the more recent stress, particularly by Anna Freud, on interferencese.g. arrests, indevelopment. This has been expanded for both clinicali.e., diagnostic purposesand research interests into a comprehensive developmental profile. For most childanalysts, such a detailed profile becomes too laborious to be employed in everyday practice. Most clinicians probably have such a profile in mind when they are making their diagnostic study to determine the type and degree of pathology. Nevertheless,
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the assessment through use of the concept of developmental lines has considerably sharpened thinking about the earliest indications of aberrations in the child's psychicdevelopment. Smirnoff discusses the confusion that has resulted from the two different usages of the term "infantile neurosis"the first referring to a childhood disturbance with the structure of a neurosis, the second to a particular point in the child's psychological development that may or may not have a pathological outcome. This second meaning was the one Freud (1909) originally used and that Smirnoff follows. Freud declared that in every analysis of an adult he found the neurosis to originate in theinfantile neurosis. This has been and can continue to be misinterpreted to mean that there had been a full blown symptomatic childhood neurosis. In the Wolman Handbook, M. Goldblatt does uses the term "infantile neurosis" to designate a childhood neurosis. At a recent Panel (1973) on Indications and Contraindications for Child Analysis, considerable attention was paid to the specific type of pathology in development of ego functioning or of object relations. For a particular group of children with poor integrative capacity and ego defects, Weil (1973) suggested preparatory educational therapeutic help. It is my impression that there is a preoccupation with attempts to be more precise about these matters, important as they are, to the relative neglect or underemphasis of the characteristics of the parents and the motivating factors in the child that would favor the choice of analysis. Some years ago (Bernstein, 1958), I drew attention to these factors, stressing the need for a "parent or set of parents to be sufficiently well to provide the following: (1) recognition of conflict, suffering, andinhibition present in the child; (2) ability to tolerate frustration, narcissistic injury caused by admitting that the child is ill, other object relations of the child, and privacy of the child's treatment; (3) a desire for the child to be well and independent which exceeds the neurotic gratification to be derived from the child's neurosis;
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(4) sufficient ability to detach themselves from the child to attain a somewhat objective attitude so that they can report daily activities, cooperate with the analyst

regarding practical arrangements, and refrain from acting out or permitting the child to act out; (5) a scale of values which places mental and emotional health above the expense, inconvenience and deprivation required by the analysis" (p. 73). To meet the objectives that we would be expecting too much of the parents and that the requirements could be met only by some "ideal" parents, I pointed out that, although these were all desirable characteristics, we could not realistically expect a parent to possess them all to a maximum degree. However, analysis of a child would require a parent to have a working or workable combination of these characteristics to enable him to establish the needed relationship with the analyst for analysis to be sustained. Most but not all children are referred for analysis because of the concern of the parents or the school without the child's acknowledging that he is having any difficulties. For these children, some time will be spent following the precedent of Bornstein and Anna Freud in making them aware of their need for help, i.e., by defenseanalysis. There are some children who are in distress, are aware of their suffering and look for help. To necessitate analysis, the child's intraphysic conflicts should be of sufficient severity and duration to make it seem probable that he will be unable to resolve his difficulties by himself during the course of his development, or, to put it another way, that there will be no "spontaneous cure." This eliminates transitory disturbances such as may be caused by unusual external stress or those due to maturational progression. What would be desired of the child to function as an analysand would be (1) that he have the ability to tolerate separation from the parent (although there are exceptional situations where a child is treated with a parent present, as described by McDevitt in The Child Analyst at Work), (2) that he can comprehend that help is being offered in the form of interpretations,
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(3) that he can communicate in nonverbal and verbal manner in a fashion that can be understood by the analyst, (4) that he have some capacity for libidinal investment in the person of the analyst as well as the emergence of some regressive representation, meaning that some degree of transference is possible. It is an important task of the early assessment to determine to what degree the child will be able to ally himself with the analyst in the effort to free him of his difficulties, to diminish his defensiveness, and to perceive his illness as a result of something within himself. Anna Freud (1965) classifies intrapsychic childhood conflicts as follows: 1. Developmentally determined inner disharmonies, 2. Uneven progression rate in drive and ego development, 3. The infantile neuroses. She suggests that it is not clear whether the first two categories require analytic treatment, but that the indication for analysis is clear for the infantile neuroses. Also, the lesser disturbances may eventuate in neurosis. Also, the lesser disturbances may eventuate in neurosis, and this should be considered in decisions regarding treatment. As mentioned earlier, Pearson and others have noted a relative absence of classical neuroses in children and present-day practice tends to include a larger number of ego disturbances.

Free Association
Nearly all analysts would agree with Anna Freud (1965) that children do not engage in free association in their analyses. Weiss et al. (1968) share Melanie Klein's(1932) view that the child's behavior, play, and fantasies should all be treated as free associations. Anna Freud, Glover, Bornstein, and Geleerd have all taken exception to the Kleinian viewpoint since it would minimize the importance in children of such defensive ego functions as secondary elaboration, displacement, symbol formation, and the like. It also mistakes manifest content for latent content. This does not contradict the obvious premise that whatever the child says
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and does has importance for the analysis and needs to be understood. In the Wolman Handbook, Hanna Segal gives examples from her clinical work with children of theplay technique and the type of direct interpretation made to her young patients. One two-and-a-half-year-old responded by saying, "You talk very funny, but go on

talking." One gets the impression, based, admittedly, on fragmentary data, that the children react to the reassuring tone and manner of the analyst as much as or more than to the content of the interpretation. In contrast to this illustration, Segal's example of an interpretation made to a young adolescent differs very little from the type ofinterpretation made by non-Kleinians. Berta Bornstein (1945), (1949) demonstrated the technique of selecting from various possible methods of dealing with a child's communications the analytic choice of interpreting the defense against warded-off affects before undertaking interpreting the conflict. Although the dramatic play helped the analyst to understand the child's conflicts and defenses, the interpretations were made in relation to the behavior of the child in current actual daily life. The child was then shown the connection with his earlier experiences. Where appropriate, the interpretations were made in relation to the child's fantasies and/or transference reactions. Bornstein was particularly emphatic about the danger of direct interpretation of play, drawings, and stories. She observed how such interpretations interfered with the process of sublimation by causing sexualization. Dramatization as a form of communication needs to be distinguished from acting out. In Volume VII of her Writings, Anna Freud includes her paper on Acting Out; in this, she traces the history of the concept from its origin in Freud's 1914 essay, "Remembering, Repeating and Working Through." The term "acting out" was there used to denote repetition within the analysis by reliving instead of remembering events of the past. Acting out does, of course, occur in child and adolescent analyses. Dramatization may be in the form of play with dolls or puppets, or by the child's action or
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role playing, something which may involve the analyst in direct action and require prompt interpretation. The materials provided to the young child for the purpose of eliciting communications include play materials, drawing, clay, etc. Such materials can vary according to the age being treated and the predilections of the analyst. A practical discussion of this is contained in Pearson's Handbook; others, including Anna Maenchen (1970), have contributed suggestions based on their own experience. The objective is to permit the child the freest and fullest possible expression of his thoughts, feelings, and wishes. Although there is the essential difference that the child is not so restricted in motility as the adult patient lying on the couch, realistic limits are set. These again depend on the age of the child, the nature of his difficulties, and the temperament of the analyst. Seriously disturbed children and the out-of-control child will require special help as, for example, described by Furman in The Child Analyst at Work. With the improvement of technique and with an expectant attitude on the part of the analyst, many children can be brought to express themselves in predominantly verbal fashion with no loss of the affective quality of such communications. Particularly inadolescence, and sometimes in preadolescence, the couch may be employed after its use has been explained. It is surprising that not much has been written about the use of the couch in the analysis of children and adolescents, although child analysts discuss this among themselves from time to time. For example, it may be of help in an extremely self-conscious adolescent who would find it difficult to face the analyst while discussing erotically tinged transference fantasies. Ultimately, such defensive use of the couch would need to be analyzed (Rosner, 1972). In the Wolman Handbook of Child Psychoanalysis , Friend devotes several paragraphs to what he calls "couch requirements" (p. 347). He advocates the use of the couch for adolescents and believes that, without it, analysis cannot accomplish its goals. He does, however, caution against the use of the couch where there is the danger of regression in borderline patients
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or where it may be used for the gratification of magical wishes and narcissistic needs.

Transference and Transference Neurosis

Just as the discussion of transference and transference neurosis in adult analysis became involved in questions of definition and differentiation of such varieties as basic trust, transference reactions, transference neurosis, and reaction to the analyst as a real person, so there has been some confusion and shifting about among childanalysts concerning transference and transference neurosis in child analysis. Early in her writings, Anna Freud expressed the belief that, since the child was still realistically dependent and hence involved with his real parents, transference would not develop in a child. Her views have undergone modification and she has

recently(1965) stated, "Taught by experience, by the elimination of the introductory phase (except in selected cases), and by the deliberate use of defense analysis (Bornstein, 1949) as an introduction, I have modified my former opinion that transference in childhood is restricted to single 'transference reactions' and does not develop to the complete status of a 'transference neurosis.' Nevertheless, I am still unconvinced that what is called transference neurosis with children equals the adult variety in every respect" (p. 36). In a highly illuminating discussion, she examines the total relationship of the child to the analyst, separating it into the use by the child of the analyst as a new object, as an object of libidinal and aggressive transference, and an object for externalization. She describes the manifestations of these various forms and the implications for technique. Geleerd, in her introduction to The Child Analyst at Work, distinguishes the different relationships of the child to the analyst. Harley (1971)believes that a true transference neurosis can occur in children, but feels that the designation should be limited to those relatively rare cases where "a neurotic symptom formation arising from regressed conflicts is activated by the analytic situation and centered around
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the analyst" (p. 39). This is a controversial definition of transference neurosis for child and adult analysis (cf. Blum 1971). A much broader category of transferencereactions includes more fragmented affective, cognitive, and behavioral manifestations directed toward the analyst which express repressed infantile relationships without developing a more cohesive structure and expression in the form of a symptom neurosis centering around the analyst. This view is in direct contrast to Melanie Klein's(1932) view that everything occuring in the analysis is transferencean example of how far the concept of transference may be extended. She contends that "with children, the transference takes place immediately, and the analyst will often be given evidence straight away of its positive nature" (p. 46). Her reading of shyness,anxiety, or distrust on the part of a child as negative transference can more appropriately be recognized and handled as resistance to analysis, and constitutes an important part of the analytic work in the opening phase. The Pearson Handbook of Child Psychoanalysis devotes a chapter to the subject of Transference and Countertransference. They acknowledge their indebtedness to Anna Freud's observations. Examples are given to show how transference manifests itself in analytic treatment of children, and they make distinctions between "transference manifestations, transference neurosis, displacement, rapport, direct object relations with behavioral attitudes of a type characteristic of the child, and identification" (p. 337). The authors themselves, however, slip into blurring the use of the term "transference" when they say, "Transference is not unique to the analytic situation. It is a phenomenon present in any relationship" (p. 342). Such a broadening of the use of the term to include displacements of relationships outside the analytic setting violates the originally intended limitation of the term to its appearance during the course of analysis. In Volume VII of her writings, Anna Freud traces the viscissitudes of the concept of acting out. She cites the misuse of the term "transference" as an example of what can happen when, "starting out as precise, welldefined
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descriptions of psychic events, they [analytic concepts] proceeded from there to indiscriminate application until they ceased to be meaningful" (p. 95). Overall, however, the Pearson presentation is instructive and useful, especially the consideration of transference at different stages of development. There is no separate consideration of this important aspect of child analysis in the Wolman Handbook; the reader would have to use the index to find references to this topica cumbersome procedure.

The Role of the Parents

Beginning with Freud's use of Little Han's father as a surrogate analyst, parents have functioned in different ways in the analytic treatment of their children. This has depended on the assessment by the analyst of the part the parent(s) has played in the cause and continuation of the child's neurosis. Thus, it may be found that thechild's difficulties are either secondary to the parent's neurosis or that the child cannot be treated unless the parent is treated first or concomitantly. It is a well-established principle in child analysis that the analyst refrain from making interpretations to the parents of their own problems, because unrecognized and unmanageable transferenceresponses may occur. To avoid complicated transference reactions, child and parent are nearly always treated by different analysts. As with

the analysis of adults, when one member of the family changes as a result of analysis, the neurotic equilibrium may be upset and another member of the family may begin to display or recognize his own emotional difficulties and require treatment. In practice, it is not uncommon to find parents becoming disturbed as the child progresses in his analysis. To prevent interference or even interruption of the child's analysis, help may have to be provided for the parent. Such help can range from supportive psychotherapy by someoneother than the child's analyst to a separate analysis for the parent. Many parents will accommodate quite well to the
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changes in the child and will require nothing more than maintaining their periodic visits to the analyst to continue to function as adequate parents. With them, the analyst is primarily concerned with obtaining data about the child's daily life and additional information about the child's past. The rationale for the conventional method of obtaining history from the parents rests upon the fact that children cannot give such an accounting of their past. The repression that produces infantile amnesia has an anterograde as well as a retrograde effect on childhood memory, with the result that children usually remember very little of their past at the outset of the analysis. It is still a moot point whether the knowledge obtained from the parents may cause the analyst to make interpretations prematurely, i.e., before the material has been fully developed in the child's communications to the analyst. In some instances, the problems of the parent may hamper the analysis of the child so that it becomes necessary to minimize the participation of the parent. An example of this is reported by Abbate in The Child Analyst at Work. In her case, the mother became so distressed in the course of the analyst's interviews with her, that it was decided to eliminate her appointments. The mother did cooperate by bringing the child regularly and by keeping the analyst informed, via telephone, about the daily happenings at home. The analysis proceeded with benefit to the child so that a sleep problem disappeared, the child's tantrums diminished in frequency, and the relationwith the mother improved. As the therapeutic alliance with the child becomes stronger, the communications of the parent become less important. Technically, this is reflected in less frequent appointments for the parents. Melanie Klein excludes the parents entirely after the initial contact, a procedure which is open to question insofar as the productions of thechild need to be understood in the context of his daily life. Reduction of such contacts with the parents may be considered after a child has grasped the nature of analysissufficiently to
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recognize the need to report significant events in his current life as well as his past. With adolescents, parents are usually not seen after initial interviews; the aim is to reduce the identification of the analyst with the parental generation and to make more concrete the assurance that the relationship with the analyst will remain private, i.e., that the adolescent's sexual and aggressive feelings, fantasies, and wishes toward the parents will not be revealed to them. It also underlines one of the objectives of theanalysis, viz. to enable the adolescent to achieve his maturational goal of functioning independently of his parents.

The Technique of Analysis at Different Developmental Levels

An interesting and productive approach to the goal of formulating theory and principles of technique has been provided by a series of panels of the American Psychoanalytic Association and meetings and workshops of the Association of Child Psychoanalysis . These have discussed child analysis according to (1) levels of development (Panel, 1964a); (Panel, 1970) divided into preoedipal, oedipal, latency, and adolescent, and (2) phases of analysis. From such discussions, the technical procedures that are followed by experienced child analysts can be examined and deductions made regarding the theoretical basis for those techniques. Weiss et al., (1968) attempted to evolve a theory of technique of the treatment of the prelatency child. They focused on what they felt to be a major problem for the beginning of the analysis of these childreni.e., the separation from the mother. That is, of course, one of the developmental tasks the child must complete. The problem is more prominent among children with impairment of ego development. This points up the need to bear in mind that any discussion of technique for particulardevelopmental stages must differentiate techniques according to the severity of ego pathology. Given enough pathology and the introduction of modifications or

parameters, it becomes questionable

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whether one is dealing with analysis or a form of analytically based psychotherapy. Particularly where the emphasis is on guidance, advice, alteration of parental attitudes and behavior, the treatment loses the character of analysis. Such looseness in designating these treatments as analysis has caused some unsophisticated analysts to question whether it was possible for any child to be really analyzed. These doubts could be resolved if the term were reserved for those cases where the aim is to uncoverthe unconscious source of the child's difficulties through systematic analysis of his defenses, fantasies, dreams, and behavior, with interpretations of his communications, verbal and nonverbal, to give the child insight and the ability to resolve his conflicts, and to remove the barriers to normal development. Kestenberg (1969) has stressed the goal of helping the preoedipal child to "build an independent ego" by removing the obstacles. In the case she cited, she confronted the boy with his need to excite his mother and how this created confusion for himself and his environment. She felt that this clarified her role as analyst, to help him "put things together the right way, understanding their inside mechanism and preserving their function and integrity" (p. 362), i.e., to enlist the child's cooperation in dealing with the disrupting effects of excessive stimulation and consequent libidinization of ego functions. At that point, she declared, she had established a working alliance. The analyst's task is to understand the child's mode of thinking, symbolization, and expression and to convey to the child the analyst's ability to recognize, conceptualize, and verbalize the child's conflicts. For the preoedipal child, the analyst needs to be able to sample the primary-process type of thinking, comprehend thechild's fantasies, and be able to gauge correctly the mixture of primary- and secondary-process thinking and symbolization that the child uses and understands. Ultimately, this will enable the child to utilize verbal interpretations to expand his ego's capacity to deal with his tensions and affects with greater tolerance for delay and substitute gratification. In
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a workshop following Kestenberg's (1969) presentation, Mahler stated that the analyst finds the language to help the child put his primary-process verbalizations into secondary processes. At first, this would require the use of the mother's key words and concepts. In the Wolman Handbook, Neubauer has contributed a most informative chapter on the psychoanalysis of the preschool child. His presentation covers indications for analytic treatment. This includes a discussion of assessment of both child and parents as well as discussions of the child's language and of the therapeutic alliance. In a consideration of technique, he differentiates several types of relationships that the child can establish with the analyst. He distinguishes between the analyst as a primaryobject and as a transference object. The case of a six-and-a-half-year-old girl is used to illustrate developmental assessment through a longitudinal history or series of "profiles." The approach makes it difficult to get a clear picture of the whole child. Excerpts from the analysis of a boy (presumably a prelatency child, although the age is not given) are used to illustrate some aspects of technique. There are vivid descriptions of the analytic sessions, which are then discussed. Neubauer declares that "the technical approach in prelatency is to find the main theme." His reasons for making this statement are not given; the technical approach in any analysis would include this. This child's mother was ill during the time covered by the reported sessions, and the wish for a substitute mother was clear throughout the material, especially expressed in the transference. In the Wolman Handbook of Child Psychoanalysis , Kay has written a valuable summary of the literature on the psychoanalytic theory of development inchildhood and preadolescence. In order to achieve latency, the child must repress the Oedipus complex, establish internal controls, and identify with his peer group. In accordance with observations of Bornstein (1951), latency has been divided into two periods, the earlier being characterized by rather rigid controls necessitated by a less secure superego. In the later period,
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the superego is more tolerant and more stable (see also Williams, 1972). There is a consensus among child analysts that both latency and preadolescence (a term preferred to prepuberty, for reasons to be discussed later) begin earlier chronologically than was previously assumed. It is not clear whether biological or cultural factors are primarily responsible for this. Ideally, the expansion of ego functionsreality and self-observation, particularlyin latency should make the latency child a

cooperative and capable analysand. However, the retardation of these functions due to interference in development caused by neurotic conflict may necessitate a preparatory or introductory phase (cf. A. Freud, 1926), (1945, and her book under review here); (Weil, 1973). The educational, management, and supportive measures employed could be subsumed under this heading, while the opening phase proper would begin with the direct analytic work with the child. With the adult patient, the analyst begins here with some efforts to determine analyzability, including, perhaps, a trial analysis. The child analyst similarly assesses the analyzability of the child. Among the many factors to be evaluated are level of ego development, including resistance to regression, ability to tolerate anxiety, and capacity to form a therapeutic alliance and a transferencelike relationship. A "testing" of the analyst by the child and of the child by the analyst may be observed in the first sessions. In some respects, what occurs parallels the "customs inspection" of the practicing subphase (Brody & Axelrad, 1966). The child inspects the analyst's face, his tone, manner, clothes, and surroundings, while the analyst inspects the child's facial expression, bearing, tenseness, and movements, and makes a judgment as to what would be the best way to introduce himself to the child. The opening phase can be considered to have ended when a therapeutic alliance is established and, possibly, a transference neurosis has developed. However, as noted in the preceding discussion of transference and transference neurosis, not all children will develop a full transference neurosis and what is often seen is better termed a transference reaction. The
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duration of the opening phase is extremely variable, as may be seen by a comparison of different cases reported in the literature. It is affected by such factors as the kind oftrauma that has been suffered by the child, the type and degree of anxiety (including separation anxiety) present, and the quality and intensity of his defensiveness. A special problem for neurotic latency children is the need to cling to primary objects. Such a problem will be intensified by the mother's difficulty in seeing herself as separate, and both mother and child will need help during the preparatory period and opening phase. The latency child has established an equilibrium between his drives and defenses, anxieties and gratifications; he has made a more or less adequate adaptation to both inner and outer worlds and will resist attempts to disturb his precariously balanced situation. The analyst, by his analytic stance, attempts to convey a benevolentneutrality and wish to be of help. His main goal is to diminish resistance or defensiveness against the production of verbal and nonverbal communication of material fromthe unconscious. The lack of criticism and the permissive atmosphere, which nevertheless has some clearly defined limits, are intended to promote the development of trust. Such trust rests on a matrix of basic trust related genetically to the degree of adequate mothering that has been experienced by the child. It also depends on thechild's perception of the object-related interest of the analyst, sometimes in contrast with the narcissistic or symbiotic needs of the mother. The trust is affected by thechild's confidence in his ability to control his urges and to depend on the analyst to help him do this without fear of either seduction or rejection. Furthermore, the child's estimate of his ability to tolerate the regression invited by the analytic situation will influence the degree of trust he can achieve. The analyst, by his interpretations, provides reassurance and encouragement for the child's effort to separate, develop autonomous functioning, and promote his capabilities. Through his interpretations of the child's anxieties, guilts, and fears of punishment, the analyst will help the child to diminish the severity of the child'ssuperego. This is reinforced by the analyst's noncritical and nonpunitive attitude. The analyst acquaints the child with the analytic process by providing associations and connections to the material the child presents, and, by appropriately timed and dosed interpretations, the analyst will convey to the child how analysis works to help himmaster and reintegrate memories of traumatic or conflict-producing experiences through verbalizations. To motivate the child, i.e., to promote the therapeutic alliance, the analyst makes the child aware of the suffering and limitations imposed on the child by his neurosis, e.g., interference in learning, establishing and maintaining friendships, etc. In treating a latency child, then, the analyst places special technical emphasis on the enlistment of greater participation by the child with less reliance on the parents, the use of ego interests as a bridge to revealing conflicts and inhibitions, the appeal to the child's desire to develop maximum autonomy, and the greater reliance on verbalization by both child and analysat. Once the therapeutic alliance and transference relationship have been established, the analysis proceeds through interpretations of behavior, play, dreams, drawings, and the related associations via systematic analysis of defenses. Reports of fragments of the analysis of latency children are numerous. A detailed, rather lengthy report of an eight-year-old transvestite boy with conscious feminine strivings is reported in the Pearson Handbook of ChildPsychoanalysis . The presentation is similar to that found in a continuous case seminar. Silliness as a particular

regressive defense against aggression, and excitement in general were noted early, and consistent analysis of this defense whenever it appeared led the way to expressions of sibling and oedipal rivalry. The manner in which doll play reveals important genetic material was illustrated by the boy when he indicated, in this way, the overstimulating and anxiety-producing effects of
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family nudity. Additional significant material was provided by the analysis of the boy's conscious concern over his need to cheat. The eighth to fourteenth month of the boy's analysis are then presented in consecutive monthly fashion, with some sessions reported in detail to provide greater opportunities for illustrations of technique. The sense of movement and change and the dynamic interplay are vividly conveyed. An essential feature of the analysis of children is the analysis of the conflicts regarding masturbation and masturbation fantasies. There are many allusions to such conflicts in the material from the analysis of this transvestite boy which were not dealt with during the eight months reported. The analyst apparently had felt that the boy's defensiveness was too great and the anxiety too overwhelming, although others might disagree. In the Pearson Handbook, the authors give advice on how to deal with a number of typical situations, such as those involving time considerations, birthdays, gifts, parties, borrowing, answering the child's questions directly. It must be noted, however, that there are variations in strictness regarding responsibility for missed appointments, just as there are some differences among analysts of adult patients. Weiss (1964) regards the use of candy, birthday presents, playing games with the child, etc. as "deviations from a more classical technique such as exists in adult analysis" and gives illustrations of "parameters" to show how they complicate the therapeutic process. Some of these differences may have a theoretical basis. Others may reflect the personality of the analyst or countertransference reactions, and the child analyst will need to recognize what determines his choices and decisions regarding these and other practical arrangements. Some of these unresolved questions about techniquemay be dealt with in the future by appropriate workshops where experiences could be pooled and the theoretical basis for the analyst's choices could be conceptualized. Among the commonest errors of technique are those due to identification
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of the analyst with either child or parent, intolerance of the analyst for the child's anxiety, with need to reassure rather than to interpret, and scotomatization of the oedipal conflicts. Each stage in development has its share of anxieties and conflicts, which present themselves as resistances to analysis; this had led to such statements that a child in that particular stage is not analyzable, that something else should be done or, if analytic treatment was undertaken, the resultant improvement was not due to the analysisbut to development and maturation. In particular, this opinion has been expressed regarding preadolescence. Preadolescence has been defined as the interval betweenlatency and early adolescence; it is characterized by marked physical and physiologic changes accompanied by an upsurge of drive manifestations. According to Anna Freud, even with some children who began analysis in latency, preadolescent transference reactions of revolt may lead to interruption of the analysis. The term "preadolescence" is preferable to "prepuberty" in discussing the phase of psychic development between latency and adolescence because physical and physiological changes in prepuberty are not always synchronous with the mental and emotional shifts of preadolescence. Anna Freud (1936) describes the opposition by the ego of the preadolescent to changes in the structure established in latency. Blos (1962) emphasizes the difference between the route taken by the boy and that taken by the girl: the former goes through an increase of pregenitality whereas the girl more forcefully asserts her heterosexuality. A particular phase-specific resistance encountered inpreadolescence is the resistance to the development of transference (Brody, 1961). There is a turn toward and an emphasis on external reality that reinforces the avoidance and repression of fantasy and rejects introspection. The preadolescent, in his efforts to stem the rising tide of feelings, struggles against his own perception of those feelings and related urges and fantasies, especially those with passive aims, and tries to conceal
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them from the outside world, including the analyst. The technical difficulty involved in weakening these defenses through interpretation is that the preadolescent fears

thebreakdown of his controls and his illusion of narcissistic self-sufficiency. Feelings of helplessness and shame would overwhelm him should that occur. Consequently, for him the analytic situation requires some reassurance of his autonomy and activity with accompanying tension discharge. These are achieved, in part, through allowing some freedom of physical activity and repeated expressions by the analyst of his interest in helping the preadolescent to be rid of his symptoms and the limitations they impose upon him. In a panel devoted to indications and contraindications for the psychoanalysis of the adolescent (Panel, 1972), considerable attention was paid to the assessment of the analyzability of the adolescent. What emerges is the apprehension of analysts concerning, first, the possibility of severe regression with possible psychotic breakthrough or breakdowns and, second, the incapacity of the adolescent for form a workable therapeutic alliance and transference relation because of his narcissisticposition. The fact is that many analysts without special knowledge or training treat adolescents in a fashion ranging from surrogate parental roles to analysis identical with their treatment of adults. This has led to confusion regarding selection of appropriate techniques for the individual adolescent and a considerable difficulty in evaluating results of treatment modalities, including psychoanalysis. To correct the situation, more institutes are offering special courses devoted to adolescent development and the theory and technique of analytic treatment for them. What has also been recognized is that some analysts are interested in and capable of analyzing adolescents, but either do not wish to be involved in treating younger children or are not suited to do so because of resistances or incapacity for empathy and understanding of younger children(Bornstein, 1948). The result is that some institutes have a separate program to qualify analysts especially
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for the treatment of adolescents, in addition to regular training for the analysis of adults. This program differs from the full child analytic program principally in not requiring supervised analyses of latency and prelatency children. In keeping with the general trend to subdivide each developmental stage to permit more precise formulations and technique, adolescence has been divided into early, middle, and late periods, each characterized by particular developmental conflicts (Deutsch, 1944); (Blos, 1962); (Harley, 1970). Blos further subdivides the first period into preadolescence and early adolescence; he also follows late adolescence with a postadolescent phase devoted to character consolidation. Lest there be unwarranted criticism that subdividing leads to overschematization with artificially sharp boundaries, all of the authors indicate their awareness of overlapping of subphases and phases. The early adolescent period is marked by the intensification of the drives, a need to promote separateness from the parents and from homosexual attachments. The middle stage revolves around resolution of renewed oedipal strivings and establishment of genital primacy, while the last stage leading to adulthood concerns itself with the finding of a nonincestuous heterosexual object and the firm establishment of sexual identity. These are not the only problems for each stage. In analyzing the early adolescent, Harley (1970) emphasizes the maintenance, from the outset, of the analyst's neutrality and his respect and aim to further the adolescent's autonomy. In addition, an alertness to their narcissistic vulnerability must be tempered by an awareness of any tendency to cooperate with the adolescent's effort to avoid the powerfulaffects of shame, guilt, and anxiety. In those adolescents who had been subjected to intense stimulation during the preoedipal period, fear of libidinal strivings in thetransference requires early recognition and repeated verbalization. Another technical suggestion regarded the handling of perverse masturbatory practices by explaining
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that the decision whether or not to give them up would rest with the adolescent. Discussions by some authors give the impression that they focus mainly on the boy'spassive wishes. Harley found that it is easier to interpret the boy's passive wishes if he is given the assurance that the analyst recognizes his active strivings. It is equally important, in her view, to reduce the threat of fantasies of destroying the mother in order to diminish sadomasochistic trends. Blos (1962) declares that the overall task ofadolescence in general, and midadolescence especially, is the loosening of the ties to or decathexis of the incestuous objects and the finding of new libidinous ones. In his consideration of adolescence, Blos emphasizes the separate courses taken by the girl from that taken by the boy in their development. He stresses the necessity for the girlto diminish her bisexuality in favor of her femininity; the boy must also resolve the struggle in favor of his masculinity.

Blos has stated that a woman analyst is preferable for analysis during preadolescence and early adolescence of the girl. Against this must be weighed the consideration that, if the task of the preadolescent girl is to free herself from dependence on the mother, then the transference to a woman analyst could precipitate a revolt and cause an interruption of the analysis. In the Wolman Handbook, Friend discusses the question of the choice of the analyst according to sex and age. The problem iscomplex; woman analysts have reported successful analyses of preadolescent and early adolescent boys, and male analysts, including Blos, have analyzed preadolescent girls. Personality characteristics are at least as important as the gender of the analyst, and how comfortable the analyst is in working with the preadolescent and early adolescent will affect the degree to which he can assist the analysand to be comfortable in dealing with transference reactions. In the section of the Wolman Handbook devoted to the psychoanalysis of adolescents, Friend briefly traces the history of analytic treatment in general and that of adolescents
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in particular. Most of the chapter deals with "therapeutic and theoretical considerations." From his long and wide experience, Friend concludes that, "The psychoanalytic situation is maintained and supported in most instances by the parents. At the same time, the psychoanalyst of the adolescent must, in my opinion, modify his techniqueto enable parents to participate from time to time in the psychoanalysis of their child, with his consent" (p. 308). This is at variance with what most analysts of adolescents believe and practice. Friend illustrates with case examples the requirements for suitability for analysis. Some of the case illustrations are so brief that it becomes difficult to determine whether the decision not to analyze was justified. In particular, a lengthy case illustration deals mostly with the analyst functioning as a consultant to the family, preparing them for a referral to a child analyst. Subsequently, the analyst is used by the parents to arrive at a decision to send the boy to a boarding school. There is a degree of obscurity and idiosyncratic phrasing in his language that makes it difficult at times to follow Friend's reasoning and conclusions. However, there are many useful discussions, such as the assessment of the adolescent's "ego capacity" in determining analyzability, the technique of initial interviews with the adolescent and the parents and the possibility of a trial period. He also outlines what he considers the requirements for establishing the analytic situation, including frequency of appointments, setting of fees, form of verbal and nonverbal communication, and the use of the couch. A clearer and better organized presentation of such issues is contained in the Pearson Handbook. Mark, a twelve-and-a-half-year-old adolescent is the analysand chosen to demonstrate the essentials of analytic treatment of this age group. This passive and inhibited overweight adolescent suffered from hypochondriacal concerns and overwhelming fears of medical procedures. In addition, he had difficulty in learning mathematics. At the outset of the analysis, whining was understood by the analyst to be a regressive
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defense against castration anxiety linked to the boy's competitive feelings for his father. Fluctuations in school grades were useful as an index of his fear of these competitive feelings and his need to remain dependent upon his parents. Early allusions to masturbation were noted but ignored by the analyst until parental visits to the analyst had been discontinued (cf. Friend's views regarding the continuation of parental visits). Analysis of the sexual fantasies diminished Mark's fear of girls, whom he identified with his aggressive mother, and enabled him to date girls comfortably. There is a great deal to be derived from such a case illustration. It is much easier to evaluate a particular technical approach or suggestion when the author provides a frame of reference with a detailed description of the analysis. Efforts to condense theory and technique into the format of a Handbook or textbook inevitably lead to broad generalizations and oversimplifications. The books by Blos (1962), (1970), by Lorand and Schneer (1961) and the forthcoming The Adolescent and Analyst at Work, edited by Harley (1974), provide a richer and more useful source of information, with clinical examples that may be used to examine the theoretical validity of the authors' technical approach. Midadolescence or adolescence proper concerns itself with the establishment of the supremacy of genitality (A. Freud, 1936). The adolescent is attempting to integrate childhood elements, pregenital and oedipal, into his emerging adult personality. To achieve the necessary synthesis and psychic restructuring, some loosening or fluidity of the relationship between the various psychic structures is required via limited regression. This necessitates the capacity to regress without beingoverwhelmed

by either fears of going back too far ("becoming a baby") or by the intensity of the drives. The representation of the latter is the fear of loss of control or ofconsciousness. Symptomatically, this is presented as a fear of masturbation or of orgasm (Glenn, 1974); (Harley, 1961). Physiological concomitants of sexual excitement may complicate the clinical picture in the relatively abstinent adolescent whose drives have increased. These become expressed in bodily tensions or sensitivities and may also result in hypochondriacal concerns. The task of the analyst, then, is to facilitate the work of the ego by analyzing those conflicts that would foster repression, fixation, or inhibition of drives rather than to detach them from the original objects and aims and redirect them toward new ones. In the analysis, resistances against the revival of oedipal wishes in the transference may lead to acting out sexually, worsening of symptomatology leading to doubts by analysand, parents, and analyst about the advisability of continuing, and "realistic" needs to become independent by transferring to a school in a different geographical location or by dropping out of school to take a job or "find himself"the "psychosocial moratorium" (Erikson, 1956), (1968). In her excellent theoretical and clinical discussion of adolescence, Anna Freud(1958) describes " specific difficulties of the analyses of adolescents, namely, the urgency of their needs, their intolerance for frustration and their tendency to treat whatever relationship evolves as a vehicle for wish fulfillment and not as a source of insight and enlightenment" (p. 148). This preceded her more recent additional concerns about the present generation of adolescents vis-a-vis analysis. Nevertheless, the reports of analyses by Addato, Blos, Harley, Fraiberg, Laufer, Root, and others attest to the possibility and efficacy of adolescent analysis. Late adolescence involves the establishment of identitya stable concept of the self as an individual with particular characteristic ways of dealing with drives, defenses, affects, and relationships. Here, the function of the analysis is to enable the individual to recognize and accept those qualities determined by his innate constitution and developmental experiences and to adapt them in realistic fashion so that he may achieve gratifying experiences and relationships
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in the world of adults. Blos (1967) considers this phase of adolescence to consist of an integrative process of consolidation of psychic structure and character formation. Ritvo (1971) discusses the origin and consequences of the need of the late adolescent to find a suitable external heterosexual object. Technically, the analysis of a late adolescent most resembles that of the adult, with full use of the couch and free association and development of the transference neurosis. Special resistances include frequent and extended college vacations, transfer to other colleges, or parental interferences. Ritvo suggests that recognition of the conflict between the need for continuity of the analysis and the reality situation of the college student if he remains at college during vacations with no work or outside interests can help to overcome the resistance springing from the fears of infantile object ties. Another specific resistance of this phase has been described by Addatto (1958), (1966) and Blos (1972): After a period of analytic work, a comfortable equilibrium is established during which little or no analysis can be done and transference interpretations are rejected. The parallel with the situation in the second half of latency (Bornstein, 1951) is alluded to by Addato, who credits Wittels with this observation. With his patients, Addato interrupted the analyses at the stage where the involvement with the external heterosexual object dominated the scene and caused a waning of the transference so that it became useless for analytic progress. The patients were aware that the analysis had not been completed, and three of them returned after varying periods of time. Blos, however, views this period as one in which the adult neurosis is developing, concomitant with the consolidation of the personality. Blos states, "It has been my experience that the developmental forces, which are at this point working against analytic involvement can be kept within reasonable bounds if the analyst offers insighteven if such insights are limited to, or more or less remain on, the experiential level of comprehending the realities of psychic determinism" (p. 129). This rather obscure
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description of his approach does not do justice to the fine clinical examples he provides. These illustrate the sensitivity to his patient's anxieties which he allows to develop in the analysis, so that they become sufficiently focused and apparent in the transference to enable the analysis to proceed.

Countertransference
The special problems, for the analyst, of working with children were first examined in some detail by Bornstein (1948). She discussed the intricate problems

involved in the irrational reaction of adults to children. One of the responses she selected for emphasis was the adult's fear of the child due to his unpredictability, highly charged emotions, narcissism, and his closeness to the unconscious. The danger of rebellion against cultural standards that the adult senses is unconsciously linked to the threat of the oedipal crime. Other problems of the analyst include his narcissistic vulnerability vis-a-vis the child, the danger of regression, and the acting out of the child. The last mentioned, she pointed out, naturally affects the analyst's countertransference and blocks his intuition. Particular aspects of the child analytic situation that may make it difficult for the analyst to maintain a neutral and objective attitude include the use of action by thechild to communicate, sometimes involving the analyst's active participation; the face-to-face relationship which enables the child to see the analyst's facial and bodily responses; and, finally, the frequently insistent need or demand that the analyst respond quickly, leaving him little time for reflection. The Pearson Handbook contains a very brief consideration of countertransference in child and adolescent analysis. It consists mostly of broad statements, such as, "Generally, though, the problems involved in countertransference are problems which the person who is doing child analysis has to work through in his own analysis" (p. 354). Reference is made to the stress caused by acting out of the child and the
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complications created by the analyst's involvement with the parents as well as the child. In the Wolman Handbood, Friend discusses, in a section entitled Psychological Prerequisites of Analysts, what he considers these to be and refers tocountertransference problems. The most frequent problem, in his personal experience in supervising analysts of adolescents, was with analysts who have had parental losses in their own adolescence. According to Friend, this resulted in countertransference identifications. He also believes the age of the analyst is a factor to be considered in creating countertransference problems. Other than this, the book contains only a few scattered comments about countertransference. Kohrman et al. (1971) have remarked upon the general paucity of articles on this subject and relate it to the difficulty in first recognizing transference and transference neurosis in the analysis of children. After a review of the relatively sparse literature that exists on the subject of countertransference in child analysis, they propose a series of definitions. They suggest the term "counterreaction" as a generic term for all counterbehavior of the analyst. This follows Glover's (1955) and Kernberg's (1965)similar usage for adult analysis. What they call "universal countertransference" corresponds to Kernberg's "totalistic" and refers to the "total response of the child analyst to the patient, the parents, and the therapeutic situation. Second, is the spontaneously occurring unconscious reaction of the analyst to the patient's transference, which is quite specific and originates in the unresolved conflicts which complement those of the patient." This is designated as countertransference proper. A third category is designated as transference, "a spontaneous, unconscious, conflictual and immaturely determined reaction to the patient as he really is" (p. 38). It is difficult to see the value of the term "universal countertransference," inasmuch as it is so all-inclusive as to become practically meaningless. In fact, it seems to encompass the authors' own
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second and third categories. It would, perhaps, be preferable to limit the use of the term "countertransference" to the second category, countertransference proper, which could be defined as a neurotic response of the analyst that develops in the course of the analysis as a result of the analyst's own reawakened unconscious conflicts.Countertransference is the expression of resistance by the analyst against that participation in the analytic process which would lead to understanding and interpretation. This would exclude other reactions such as the initial responses to the child or the analyst's response to parental attitudes and behavior. Kohrman et al.'s article has a helpful section on the use of counterreactions in analyzing children. They suggest that the analyst, without necessarily analyzing his own reaction, can confront the patient with a particular piece of behavior. As an example, the analyst can point out to a provocative or seductive child the child's need to excite the analyst. Where the analyst's response is "not in tune with the behavior of the patient (e.g., sexual countertransference to oral transference)," they suggest that the analyst needs to examine himself or to consult with a colleague. The same caveat re terminology and classification applies to considerations of the attitude of the child analyst to the parents. Reactions of the analyst range from

responses to the parent as a real person with particular characteristics to countertransference reactions. Among the latter, the analyst may not infrequently identify with the parents or he may unconsciously identify the child's parents with his own parents or his analyst. The analyst may also be tempted to be what he thinks is a better parent and engage in rescue fantasies or a competitive relationship with the parent of his analysand. This may sometimes be abetted by the parent of the sex opposite to that of the analyst. This can lead to overgratification of the patient or to a censuring attitude toward parents the analyst considers too depriving or seductive.
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Reconstruction
Surprisingly, none of the books here reviewed give separate treatment to this important aspect of child analysis. One of the initial aims in the development of child analysis was to test the validity of reconstructions made from analyses of adults. Just as with adults, an essential part of the analysis of children consists ofreconstruction. In early reports of analyses of children, these concerned specific traumatic events, particularly observation of the primal scene or other sexual exposure, operations, hospitalizations, and separations. As the technique of both adult and child analysis advanced beyond the objective of recalling and abreacting specific traumata, the process of reconstruction became more complex, extending to transference, tracing the vicissitudes of particular defenses, and of object relations and correlating these with current patterns (Kanzer, 1953). The reliability of the history given by parents is open to question because of defensive repression, scotomatization, and the use of screen memories. Reconstructions clarify the patient's history (Kanzer & Blum, 1967). Continued contact with the parents, as the analyses of young children proceeds, often enables the parents to recall additional significant historical material. This is facilitated by the dimunition of anxiety and guilt as a result of the absence of criticism from the analyst and the reassuring effect of the child's improvement. A distinctive advantage of child analysis is the opportunity to have reconstructions made entirely from analytic material corroborated by the parents. Among the many examples of such reconstructive work in the analysis of a child is one provided by Furman in his report, in The Child Analyst at Work, of a child who had difficulty in controlling his behavior during analytic sessions. Furman describes how the analyst became aware, during the progress of the analysis, of unreported significant additional separations from the mother that the child had endured. Sprince, in the same book, provides an illustration of the derivation of a developmental history almost entirely from analytic reconstruction. Through
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this, the destructive and seductive behavior by the father could be seen to have played an important part in the development of the child's symptom of pseudostupidity.

Termination
As noted previously, there are differences in opinions and techniques regarding termination of child and adolescent analysis. Such divergences exist regarding criteria for termination of adult analysis, too (Reich, A., 1950). Smirnoff compares Anna Freud's views on termination with those of Melanie Klein. Anna Freud takes into account structural changes that favor developmental progress whereas Melanie Klein emphasizes the liberation of the child's fantasy life from conflict. The Pearson Handbook discusses some aspects of termination, relying principally on Anna Freud's contributions to the subject. Neubauer, in the Wolman Handbook, emphasizes the resolution of the internalized conflict. Friend, also in the Wolman Handbook, speaks of the psychoanalyst of the adolescent as undertaking a "piece of analysis" (p. 308; author's quotation marks), and declares that his analytic work is frequently interrupted rather than terminated. Friend sees this as an inevitable outcome of the adolescent's need for independence from family and analyst. This view is in agreement with Addato's technical approach to the analysis of adolescents, but differs from that of Blos, as described above. Where a true transference neurosis has developed in the child or adolescent, termination takes place when the transference neurosis has been analyzed, as with adults. The determination of when the analysis should end is more difficult where no full transference neurosis has developed. Assessment is made through evaluation of symptomatic, structural, developmental (maturational) change and progress. The goal of analysis is to free the child of the relatively fixed neurotic conflicts and patterns that interfere with both functioning and development. The division of the child's and adolescent's development into phases and subphases

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has enabled analysts to define more precisely what tasks are set for each stage. One way of judging the appropriateness of termination would be to decide whether thechild has, with analysis, been able to complete those tasks. Clinically, this has led to what might be termed trial terminations, which, in some cases, turn out to be interruptions to be followed by further analysis. It should, perhaps, be emphasized that the goal of analysis is not to continue to relieve the child or adolescent of the necessity of dealing with the usual developmental conflicts or anxieties by serving as a parent substitute or auxiliary ego. Rather, it is to diminish the burden on the ego imposed by continued internal conflicts, inhibitions, and anxieties so that it is more capable of dealing with the greater range of internal and external problems that present themselves with maturational progress. In a panel devoted to the issues involved in termination in a child analysis (Panel, 1969), Neubauer, Francis, Kohrman, and Salus presented material derived from interviews and case reports of Berta Bornstein, Marianne Kris, Jenny Waelder-Hall, Lucie Jessner, and Helen Ross. The practical side of ending an analysis due to external circumstances, including parental resistances, was distinguished from the analytically desired termination based on resolution of internal conflicts and evidence of resumption of developmental progress and a better adaptation to the real world. The differences from adult analysis, emphasized by Bornstein, included the relative absence of working through and of reconstruction, even though some early memories of traumata may be recovered in the analyses of children. As one surveys the present technique of the psychoanalysis of children and adolescents, the changes that have occurred over the past several decades become apparent. Analytic treatment has been extended to a greater variety of childhood disturbances. In particular, children with failures in ego- and drive development and atypical or borderline children are brought to analysis. Treatment of these children has required modifications in technique such as the reintroduction
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of a preparatory phase, educational measures on the part of the analyst, and the use of auxiliary personnel such as special teachers. The changes in technique in child analysis were the subject of the first international meeting of the Association for Child Psychoanalysis (Panel, 1971). Contributions by Neubauer, R. Edgecumbe, D. de Levita, and Lampl-deGroot were discussed by Anna Freud, Erikson, Jacobson, and others. Miss Freud acknowledged the necessity for flexibility in approach to the treatment of children and adolescents with severe ego restrictions and failures in development. However, it is important to distinguish this type of analytic aid fromanalysis proper as it is usually conducted with neurotic children. The analysis of children with phobias, compulsions, and less severe characterological disorders does not require extreme modifications of analytic interpretative technique. For clinical and teaching purposes, indications for the use of supportive and educational measures needs to be substantiated on theoretical grounds made specific for each problem in drive and ego development. More precision has developed regarding the assessment of the nature and degree of childhood psychopathology, with indications for or against analytic intervention. Greater knowledge of the etiology of childhood disturbances may ultimately lead to a clinically useful classification of the emotional disorders of childhood. As happened with analysis of adults, analytic treatment of children has shifted from dealing with what was considered to be a specific traumatic event or situation to systematic analysis of defenses, fuller development and analysis of transferences, and efforts at reconstruction. One effect of these changes has been to lengthen considerably the duration of the analysis of a child or adolescent. Anna Freud has recently stated that the conflicts, values and identities of adolescents are very different from what they were when she wrote her early papers onadolescence. According to her, today's adolescents show contrasts of feelings simultaneously instead of alternately, which may lead
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to a condition Erikson has suggested calling "identity confusion." This is usually a continuation or recrudescence of earlier separation-individuation problems. Erikson's contributions have enabled analysts to explore with their adolescent patients the problems involved in their search for identity. The task of the analysis of the adolescent includes the achieving of a cohesive self. The relevance to Kohut's (1968), (1971) and Kernberg's (1970), (1974) contributions to the analysis of narcissistic personalities is evident.

A number of questions regarding technique remain unanswered. Still to be clarified is the role of the parents in furnishing historical material, reporting daily events, and otherwise participating in the neurosis and in the analysis of the child. The amount of gratification or frustration the analysis requires is also a continuing area of differing opinions. The effect of the sex of the analyst upon the analysis is another moot point, as is the activity or passivity of the analyst. The child's ego developmentand developmental phase will influence problems of technique. The relative importance of verbal and nonverbal communication in the analysis of children remains a provocative field for further study. Additional investigation of the usefulness of the couch in later childhood and adolescence would be helpful. Beginnings have been made in appraising the personality of the child analyst, and research here will aid in selecting and training child analysts. Unsettled technical points regarding not only the issues of the opening phase and termination, but many of the other topics covered by the books and papers reviewed here still remain. It is to be hoped that future clinical reports, panels and workshops will continue to clarify and systematize the technique of child analysiswithout impairing the flexibility and sensitivity of approach needed to help both the child and the child analyst to achieve a successful analysis. There is really no satisfactory substitute for the actual personal experience of analyzing children and adolescents. The vicarious participation through attending a continuous
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case seminar is next best. A reading and rereading of Anna Freud's contributions in the volume under review, as well as of her other books, will, however, enrich all those interested in analysis. The Scope of Child Analysis provides a brief, condensed, yet surprisingly comprehensive survey of the origins and development of child analytic technique and theory. The excellent case material in The Child Analyst at Work illustrates the fascinating range of clinical problems dealt with by experienced child analysts, and will certainly heighten interest in child analysis. Additional clinical and technical information may be gleaned from the Pearson Handbook. Together, these four books constitute a well-balanced introduction to the field. The Wolman Handbook, although it contains several excellent chapters, will confuse more than enlighten all except those already familiar with the subject. That a solid body of clinical data, technical knowledge, and well-constructed theory already exists in child and adolescent analysisis unquestionable.

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Article Citation [Who Cited This?]

Bernstein, I. (1975). On the Technique of Child and Adolescent Analysis. J. Amer. Psychoanal. Assn., 23:190-232
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