A Retrospective Study of the Outcome of Psychoanalysis and Psychotherapy for Children with and without Chronic Medical Conditions Maureen Avis Parr Thesis submitted for the Degree of Doctor of Philosophy of the University of London 1994 University College London ProQuest Number: 10016733 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest. ProQuest 10016733 Published by ProQuest LLC(2016). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. Microform Edition © ProQuest LLC. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 Acknowledgements I am glad to record my warm appreciation of those who have furthered my interest in, and curiosity about, psychoanalytic concepts. Among those who have inspired and encouraged me to think critically and creatively about such matters or who have enabled me to find the intellectual and emotional space to do so, are Parveen Adams, Liam Hudson, and Gillian Russell. My special thanks to them. My interest in the effects of physical handicap on children's development was first aroused by watching the skilled and intelligent interactions between a blind friend and his sighted family. I am grateful to Norman Octon, to Valerie Octon, and to their children for teaching me so much. This thesis was written under the supervision of Professor Peter Fonagy whose expertise and help I am happy to acknowledge. It is part of a large and ambitious psychotherapy process and outcome project based at the Anna Freud Centre. I am indebted to the entire research team, under the direction of Mary Target, for their hard work and patient attention to detail. This thesis is dedicated to the memory of Dr George Moran, Director of the Anna Freud Centre from 1987 until his tragically early death in 1992. The Project reported on in this thesis is a large-scale piece of research which has benefited from the input of a number of different researchers. The author of this report played a full part in collecting data, making research decisions about the data and discussing the findings and implications of the analysis. Her unique contribution was the analysis and interpretation of findings relating to children with chronic medical conditions. The present author alone was responsible for operationalising the parameters which identified these children, deciding the best way to control for extraneous variables, selecting their matched pairs, and subjecting their outcome scores and other data to statistical analysis. The interpretation of the results of such analyses are hers alone. In addition, the groundwork research reported on in the last chapter, demonstrating how children's psychoanalytic outcome may be reliably predicted from a simple procedure which takes an overall 'therapeutic benefit' score from a number of variables, some expeditious, others inhibitory, but all available to clinicians at the assessment period, is the sole work of the author of this thesis. ABSTRACT There is a good deal of evidence that medical and psychiatric conditions co-exist in patients considerably more frequently than would be expected by chance. Although the direction of causality is difficult to determine, there seems little doubt that childhood chronic physical illness or disability may precipitate emotional and behavioural pathology. Little is known about response to psychological treatment of children with severe long-term physical problems and few studies to date have compared the clinical response and outcome of such children with physically healthy control groups. In particular, children's reaction to psychoanalytic intervention has received almost no empirical attention at all. An extensive outcome study set up at the Anna Freud Centre, London, and reported on in this thesis is, as far as is known, the first large-scale study of child psychoanalysis ever attempted. The Centre is engaged in long-term, intensive psychoanalytic treatment of children and adolescents. Retrospective study of the process and outcome of child analysis, using material from cases spanning 40 years, has uncovered a large quantity of demographic, clinical and therapeutic information. This thesis presents a brief overview of the psychoanalytic or psychotherapeutic treatment of 769 children and young people between the ages of two and 19 years, looking at a wide range of variables associated with diagnostic profiles, demographic characteristics and parental and family factors and relating these, where possible, to treatment and outcome. More detailed attention has been paid to a subgroup of 81 children with long-term physical disabilities, including chronic handicaps such as visual, motor or auditory impairment, chronic organic illnesses like diabetes and epilepsy, and the chronic psychosomatic syndromes of asthma and eczema. They have been matched with appropriate control subjects to try to ascertain the extent to which the presence of a defined medical condition influences the effectiveness of psychotherapy. We found that medical conditions alone did not affect response to treatment. The target groups of chronically disordered children showed few differences from related control groups. However, a variety of other factors influencing outcome have been identified. Table of Contents Part One Background and Introduction CHAPTER ONE Psychoanalysis and its Epistemological Background 1.1 What is Psychoanalysis? 15 1.2 Further considerations of psychoanalytic theory 17 1.3 The relationship between psychoanalytic theory and therapy 18 1.4 Can case studies be used as scientific evidence? 23 1.4i Free association 26 1.4Ü Transference 28 1.4iii Implications 29 1,4iv Some disadvantages of the case study 30 1.4v Case studies concluded 34 1.5 Scientific criteria 35 1.6 Experimental evidence 37 1.7 The deterministic substrate of psychoanalytic theory and method 39 1.8 Psychoanalytic therapy 42 1.9 Therapies compared 45 1.10 Two universes 49 1.11 Conclusion 49 CHAPTER TWO The Psychoanalysis of Children 2.1 Children in psychiatry and psychoanalysis 53 2.2 The first child patient 56 2.3 Ego psychology 57 2.3i Ego origin 59 2.4 Conclusion 62 CHAPTER THREE Outcome Research 3.1 Outcome versus process 64 3.2 The self-evaluation of psychoanalysis 65 3.3 Child psychotherapy outcome research 69 3.4 Specific issues in outcome research 71 3.4i Ecological validity 71 3.4Ü Treatment length 72 3.4iii Treatment defectors 73 3.4iv Follow-up 74 3.4v Diagnostic profiles 77 3.4vi Maturational effects 79 3.4vii Long-term retrospective studies 80 CHAPTER FOUR Child Psychiatric Epidemiology 4.1 Introduction 83 4.2 Epidemiology 84 4.2i Clinic referrals 87 4.3 Major child psychiatric diagnoses 88 4.3i Learning disorders 88 4.3Ü Specific reading retardation 89 4.3iii Under-achievement 89 4.3iv Problems in speech and communication 89 4.3v School refusal 90 4.3vi Fears and anxieties 91 4.3vii Enuresis 91 4.3viii Sleep disturbance 91 4.3ix Conduct disorders 93 4.4 Children at risk 93 4.4i Age 94 4.4Ü Sex 94 4.4iii Social class 94 4.4iv Family size 95 4.4v Ordinal position 95 4.4vi Migration 96 4.4vii Family type 96 4.4viii Marital distress 97 4.4ix Parental loss 98 4.4x Separations 99 4.4xi Hospitalisation 100 4.4xii Parental mental illness 101 4.5 Factors associated with improvement or failure to improve 103 CHAPTER FIVE Medical Conditions in Children 5.1 Introduction 106 5.2 Epidemiology 106 5.3 The interaction between physical and psychological states 108 5.3i From the psychological to the physical 109 5.3Ü From the physical to the psychological 111 5.4 The reaction of others to illness or disability 111 5.4i The reactions of the family 112 5.4Ü The general public 113 5.4iii The children themselves 114 5.5 Coming to terms with chronic disability 115 5.6 Unconscious reactions 116 5.7 Self-esteem and the development of the ego 117 5.8 Common problems 121 5.Si Separations 121 5.8ii Hospitalisations 121 5.8iii Operations 125 5.8iv Restraint 125 5.9 Disabled group 126 5.9i Deaf 126 5.9Ü Blind 127 5.10 III group 129 5.10i Epilepsy 130 5.1 Oil Diabetes 132 5.10iii Haemophilia 133 5.11 Psychosomatic group 133 5.11i Asthma 136 CHAPTER SIX Linking the Conceptuai to the Empiricai 140 Part Two The Anna Freud Centre Project CHAPTER SEVEN Methodology 7.1 Selecting subjects 147 7.2 Information extracted 148 7.2i Assessment procedure 148 7.2Ü Treatment and termination material 156 7.3 Data elicited 157 7.3i The Child Behaviour Checklist 158 7.3.ia Our use of the Achenbach checklist 159 7.3Ü The Diagnostic and Statistical Manual 162 7.3iia Our use of the DSM 163 7.3iii International Classification of Diseases 166 7.3iv Children's Global Assessment Scale 169 7.3v Global Assessment of Functioning Scale 171 7.3va Our use of the CGAS and the GAF 171 7.3vi Parental Symptom Checklist 171 7.4 Summary of instruments used 172 7.5 Selection of target groups 174 7.5i Subset of chronically ill and handicapped children 175 7.5ia Accidents 177 7.5ib Operations 177 7.5ic Chronic conditions 178 7.5id Acute illness 179 7.5Ü Severely disabled target group 180 7.5iii Severely ill target group 183 7.5iv Limitations to the validity of psychosomatic as an aetiological category 183 7.5iva Organic illnesses 183 7.5ivb Psychosomatic