The monumental work of Sigmund Freud looms so large in the field of dynamic psychiatry that students in the twenty-first century easily equate Freudian psychoanalysis with dynamic psychiatry. However, it is useful to place psychodynamic psychiatry in a broader context both historically and epistemologically. Gabbard (1) describes the several uses of the term dynamic in the late nineteenth century by Leibniz, Herbart, Fechner, and the renowned neurologist Hughlings Jackson. In their usage, dynamic was contrasted with static. It referred to changing states of consciousness and physiologic processes, as opposed to anatomic structures. Dynamic included a concept of mental energy. It implied functional rather than fixed organic impairment. In the twentieth century dynamic psychiatry— with its emphasis on the patient’s subjective experience, the workings of unconscious psychological processes, and the patient’s unique inner life— was contrasted with descriptive psychiatry, which strove to categorize patients according to observable behavior.

Psychodynamic psychotherapy of children began with Freud’s publication (2) of the case of “Little Hans.” Freud’s interest was not the treatment of children but the centrality of childhood experience in shaping the adult psyche. Although he sought to “reconstruct” childhood experience from the analysis of adults, he encouraged his students to observe children for “a more direct and less round about proof” of the existence of infantile sexuality. It was in this context that Freud came to supervise the analysis of Little Hans by Hans’ father.

Hermine Von Hug-Hellmuth was the first to undertake psychoanalytic therapy of children and adolescents. Her paper “On the Technique of Child-Analysis” (3) surveyed technical aspects of the psychodynamic treatment of children recognized as core issues to this day. She noted that the child does not come of his own accord. She advises against a judgmental stance or the giving of direct commissions and prohibitions. Hug-Hellmuth demonstrated her engagement of the child in “talking over things together.” She introduced the role of an educational method founded on psychoanalytic knowledge. She examined the multiple ways in which work with children and adolescents
differs from that with adults, including the complexities of the relationship between the analyst and the child’s parents. Her observation that the child’s spontaneous play could stand in the place of the verbal communications of the adult to reveal unconscious conflict was most significant for the development of psychodynamic therapy with children. Further, she observed that fully conscious avowal of analytic understanding was not a prerequisite for therapeutic effect in children.

Melanie Klein (4) and Anna Freud (5) emerged as the founders of child psychoanalysis. Klein coined the term play analysis, emphasizing the child’s play as equivalent to free association in adult analysis. Her methods encouraged early, deep interpretations and minimized the analyst’s contact with parents and teachers. Anna Freud’s long career, from the 1920s to her death in 1982, allowed for significant evolution in her ideas regarding psychodynamic treatment of children and adolescents. Trained as a teacher, she was interested in the “educative” functions of the analyst in addition to the interpretive functions. Her work on ego mechanisms of defense (6) led to the development of defense analysis of children and adolescents. Her attention to observing the developmental process in children led her to conceptualize interweaving lines of development (7). Emigrant analysts in the wake of World War II brought both Kleinian and Freudian ideas to America. Child analytic training took root in the United States, allowing child psychoanalysts to play a major role in the training of child and adolescent psychiatrists throughout the mid- and late twentieth century.

Two distinctly American therapeutic traditions, admittedly influenced and stimulated by the frisson of psychoanalytic thought, have contributed their own unique emphases to the field of dynamic psychotherapy with children, particularly play therapy. The contributions of the child guidance movement (8) and client-centered therapy (9) to the development of dynamic play therapy reminds one not to equate “psychoanalytic” with “psychodynamic.” Homegrown American psychodynamic therapists such as Frederick Allen and Carl Rogers sought to counteract the impact of the American behaviorist tradition. Allen wrote:

Allen regarded the child:

The child’s exercise of free expression, a here-and-now focus, and the rapport in the relationship between patient and therapist were emphasized as “nondirective” therapy developed through the work of Axline (10) and Dorfman (11).

John Bowlby (12,13,14) was a psychoanalyst who broke with the mainstreams of mid-twentieth century child psychoanalysis in Britain and America by taking a strong empirical approach to studying psychoanalytic developmental constructs. His focus was on the direct observation of the behavior of infants and their caregivers through prospective studies of the effects of early attachment on relationships and on personality development. Attachment theory has bridged the gap between clinical psychodynamic theory and general psychology, particularly developmental psychology. In the past decade a rapprochement has occurred between attachment researchers and clinical psychodynamic researchers, with a new interest in empirical validation of psychoanalytic concepts and empirical tools to test the efficacy of therapeutic approaches. Of particular interest has been the elucidation of the impact of attachment history on patients’ capacity for mentalization, also referred to as reflective function and defined as “the ability to take account of one’s own and others’ mental states in understanding why people behave in specific ways (p. 470) (15).” An example of treatments developed by drawing on this research is Bleiberg’s relational approach to the treatment of personality disorder in children and adolescents (16).

Psychotherapy has been defined as a treatment that ameliorates psychopathologic conditions, functional impairments, and developmental disturbances by means of psychological processes and a therapeutic relationship with a trained therapist (17,18). In the treatment of children and adolescents these three elements— psychopathology, psychological processes, and the therapeutic relationship— should be considered in the context of the patient’s social environment and ongoing development (19). Psychodynamic psychotherapy aims at bringing about change in psychological processes that are largely unconscious but can be inferred from observable phenomena, such as actions or speech. The processes determining the inner world of subjective experience are of particular interest. The plethora of unconscious processes of which the human brain is capable allows for great diversity of focus for dynamic psychotherapy.

Psychodynamic therapy capitalizes on the observation that human beings are psychologically changed by relationships with other human beings. Psychodynamic technique utilizes two aspects of human relationships to achieve this mutative effect. Particular attention is paid to transference, the unconscious displacement onto the therapist of patterns of feelings, thoughts, and behavior originally experienced in relation to significant figures during childhood. Additionally, the manifest or “real” relationship between the therapist and patient is used to further the aims of the treatment.

The psychodynamic therapist conceptualizes psychopathologic conditions, functional impairments, and developmental disturbances in terms of unconscious psychological processes inferred from the observed symptoms and the patient’s history. Similarly, social context and developmental and maturational factors are evaluated for both their role in the etiology of the condition and potential interventions in the social environment that would affect the patient’s unconscious, internal psychological functions, e.g., defenses, self-concept, ego ideal, conscience, and reflective function.

Psychodynamic therapy requires as a foundation a theory of the functioning of the unconscious mind and the internal experience of the individual as well as a theory of the psychological impact of human relationships. Psychoanalysis provides a rich tradition of observation and theory on which dynamic therapists can draw. Sigmund Freud was a research neuroscientist at the cutting edge of his era before he turned to the clinical practice of neurology and eventually psychiatry. Although he recognized that the research methods of his time did not allow for a full explication of the neuronal base of psychic events, he endeavored to keep his psychological theories consistent with biology. For instance,
Freud conceptualized the mind as the interplay of excitatory (drive) and inhibitory (defense) phenomena. Greatly influenced by the Darwinian theories of the German zoologist Carl Claus, with whom he trained (20), Freud sought to construct a developmental framework for his psychology, an approach that put the psychic phenomena of childhood in the spotlight and paved the way for child psychotherapy. Psychoanalytic psychology as a theory of adaptation of the organism to its environment derived from these Darwinian roots, as did the “libidinal drive” as an aspect of the innate striving for survival and reproduction and the concept of conflicting forces within the mind. Modern neuroscience offers an opportunity to refine psychoanalytic theory. The growing field of neuropsychoanalysis seeks to integrate the latest findings from cognitive neuroscience with psychoanalytic observations to improve our understanding of the brain substrates of psychoanalytic constructs (21).

Freud (22) used the Darwinian concept of a complemental series to position himself as a centrist in the nature–nurture controversy over the origins of psychopathology with severe constitutional deficits at one end of the spectrum of pathogenic etiology and severely traumatic experiences at the other. The psychodynamic therapist utilizes these complementary series to evaluate the interaction and impact of nature and nurture on the patient’s pathology.

In dynamic theory the mind is not seen as a blank slate at birth but rather as endowed with the biological potential to develop psychic structure given an adequate environment. Internalization denotes the process by which experiences with the external world, usually in the realm of relationships, form stable intrapsychic structures or capacities. Once a process is internalized it no longer requires an external stimulus for its function to be executed. Identification, the psychological process by which one individual becomes like another, is a familiar mechanism of internalization.

Unconscious psychological processes may be considered as primary determinants of the inner world of subjective experience. The individual’s total subjective experiential world, including thoughts, feelings, and fantasies as well as perceptions of the external world, regardless of whether they accurately reflect the external world as viewed by another observer, has been designated psychic reality. The dynamic therapist attempts to grasp the patient’s psychic reality and convey to the patient an interest in understanding his experience of himself.

A primary tenet of psychoanalysis is psychic determinism (23), the principle that nothing in the mind happens by chance or in a random way. All psychic acts and events have meanings and causes and can be understood in terms of earlier psychic events. The mind retains experiences and is shaped by them. Conscious thoughts and overt behaviors provide observable clues to their underlying unconscious psychic determinants. A corollary hypothesis, overdeterminism or multideterminism, states that a psychic event (e.g., a symptom), is typically caused by more than one factor and may serve more than one purpose in the psychic framework. The multidetermined nature of symptoms provides the psychodynamic therapist with more than one way to approach a symptom. This clinical flexibility is very appealing to the practitioner but frustrating to researchers who seek standardization of method.

The concept of multideterminism is further refined in dynamic theory by the observation that the multiple determinants of a particular observable psychic phenomenon are frequently in opposition or conflict with one another. Psychodynamic theorists have identified several types of psychic conflict. External conflict denotes the conflicts that arise between the child and the environment, the consequent frustration demanding management by the child’s psyche. External conflicts are most evident in early childhood when the infant or toddler has little internal restraint and struggles with the caretaker over such matters as bedtime or playing with an electrical plug. As prohibitions become internalized, the conflicts become internal. Not all conflicts are caused by prohibitions. Conflicts may arise between competing urges, thereby creating ambivalence. For example, conflicts arise between urges toward passive-dependence and active-mastery. An external conflict may or may not become a fully internalized conflict. An internalized conflict is conceptualized as continuing in the individual’s psyche when environmental forces that triggered the initial internal conflict no longer exist.

Freud realized that a conceptual tool was needed to provide an orienting and systematizing framework for clinical data and hypotheses about unconscious phenomena and subjective experience. He termed such a tool “metapsychology” and offered several different models as he strove to find a conceptual frame that accommodated all his data. The most lasting of Freud’s metapsychological frameworks was a structural theory, the tripartite model, which divides mental functions into id, ego, and superego. Id is a concept that encompasses the mental representations of the instinctual drives (24). Drive is a term applied to a stimulus arising within the individual that arouses the mind and incites mental activity. The term ego encompasses all the capacities of the mind to manage and channel the arousal and activity incited by the drives. Freud, with an apt metaphor, says of ego:

Superego functions conceptualize the inner voice of conscience, which maintains ideals and values, observing and criticizing any shortfall of the self.

For many students id is difficult to conceptualize and to recognize in the clinical situation. “Id” did not make its way into the vernacular to the extent that “ego” did, nor is “drive” or “internal stimulus” as close to a common usage as “conscience,” which makes “superego” more accessible to the untutored ear. The internal stimuli that are most familiar to the average person are feelings. Because emotions arise from genetically endowed, physiologic response patterns, they are an early, although in psychoanalytic theory not primary, step in the pathway to arousal and mental activity. In psychoanalytic parlance affects serve a signal function triggering ego efforts to manage drives. The drives themselves may be thought of as genetically endowed motivational states. Commonly we think of these as urges, needs, wishes, and desires.

Advances in neuroscience have identified at least four basic mammalian instinctual mechanisms that might be correlated with the id of psychoanalytic theory: a seeking/reward curiosity system, an anger-rage system, a fear-anxiety system, and a panic system (26). The classical Freudian nomenclature works with a dualistic system of an aggressive and sexual drive. The sexual or libidinal drive includes affiliative and pleasure-seeking urges. A child who enjoys being bathed by the parent and having his or her naked body admired is displaying a derivative of the libidinal drive. The pleasure the child takes from the sensuous experience of the water would also be a libidinal drive derivative. The aggressive drive in its broad connotation includes impulses toward self-assertion and the desire to prevail in one’s wishes. This urge to prevail brings forth the more colloquially recognized aspect of the aggressive drive when in the face of frustration the urge to prevail becomes an urge to subjugate or destroy the perceived source of frustration. Pleasure in motoric or mental activity is an aggressive drive derivative at a basic level. Because pleasures sought in response to libidinal drive inevitably run into some requirement
for delay or other frustration in the external world, aggressive and libidinal drives are intimately related; ego mechanisms must develop to regulate aggressive drives if libidinal drives are to be satisfied. In this metapsychological model, a clinical formulation that failed to assess the role of aggressive drive in symptom formation would not be complete.

Many theorists and clinicians have been dissatisfied with Freud’s dual drive approach. When using conceptual models other than the tripartite model they postulate other motivating forces within the individual. For example, Miller (27), applying Kohut’s self-psychology to children, proposes three primary drives: the drive toward internal integration, the will to do, and the need for others. Whichever conceptual framework is utilized, dynamic psychotherapy sees the individual’s motivations, impulses, and desires as important determinants of subjective experience, mental functioning, and behavior.

In the tripartite model of the mind, ego includes all the mental capacities available to the individual for regulation of the internal milieu and adaptation to external reality. Ego’s task is to optimize pleasure and gratification of wishes and needs while maintaining internal equilibrium, the health of the body, good relations with the external world, and peace with superego. Although ego includes all the mental capacities for engaging with external reality, it also focuses on internal reality. As with id, there is no single psychodynamic approach to describing or organizing all the phenomena that can be subsumed in the concept of ego. One approach divides basic categories of ego functions into reality testing, object relations, regulation of affect, thought, defensive activity, autonomous functions, and synthetic or integrative functions. Work with children requires examining each of these functions in the context of the child’s age and developmental accomplishments.

In the broad range of psychological theories, defensive ego activity and the capacity for object relations are conceptualizations of mental functioning most uniquely attributable to psychodynamic theory. Defense is a term describing ego efforts to protect against internal dangers. From experience with loved persons on whom the child is entirely dependent for survival, the child internalizes the displeasure expressed by the caretaker toward unacceptable drive derivatives, such as biting the nipple when nursing, and identifies with the pleasure expressed toward socially acceptable drive derivatives, such as biting and chewing finger foods. Ego is challenged to restrain prohibited expressions and promote approved expressions of inner urges once this process of internalizing permissions and prohibitions has begun. Psychoanalytic observations reveal how fear of the disappearance or loss of the loved caretaker, the “object” of object relations, generates a need for defensive maneuvers. The psychological maneuver by which the inhibition is accomplished is termed a mechanism of defense. The fear shifts from fear of loss of the object itself to fear of loss of the object’s love with increasing ego maturity and development in an environment of “good enough” parenting. Fear of loss of body integrity, often referred to as castration anxiety, enters the signaling system with further development. Finally, as superego functions and ego ideals develop, unpleasant affects of shame, guilt, and remorse stimulate restraint. Intense anxiety and mobilization of powerful and often primitive defenses occur when coping capacities are on the verge of being overwhelmed by massive overstimulation or frustration, for example, with acute or chronic trauma or the upsurge of urges associated with the onset of puberty.

Defense mechanisms are typically unconscious, automatic, psychological processes. The individual does not consciously choose to institute a defense; however, an individual can learn to recognize defensive activity as it occurs through dynamic psychotherapy, psychoanalysis, or self-analysis (28). Anna Freud’s classic The Ego and the Mechanisms of Defense (6) enumerated several patterns of defense already in the analytic literature: regression, repression, reaction formation, isolation, undoing, projection, introjection, turning against the self, reversal, and sublimation. To these she added: turning passive to active, denial, intellectualization, displacement, identification with the aggressor, and altruistic surrender. Following that publication, effort was devoted to developing a comprehensive catalog of defense mechanisms. Clinical observation eventually led to the conclusions that any aspect of ego functioning may be used in the service of defense and the attempt to delineate a comprehensive list of specific mechanisms was impossible and potentially misleading in its reductionism. Nonetheless, children use certain mechanisms with sufficient frequency that it is of value to psychodynamic child therapists to be able to recognize them in the clinical situation (Table 6.2.4.1).

Controversy exists both within dynamic child psychiatry and between dynamic and descriptive psychiatry regarding the degree to which defensive activity and internal conflict involve such “autonomous” ego functions as perception, motility
(walking, eye–hand coordination), intention, intelligence, logical thought, speech, and language. “Autonomous” ego functions were conceptualized by Heinz Hartmann (29) as relatively resistant to disturbance by intrapsychic conflict. It is clear that many disturbances in this area have their origins in constitutional variations in brain functioning. However, it is also clear from clinical material that in many children and adults these presumed autonomous functions are impacted by conflict and defense; this is no surprise to psychiatrists familiar with the way cognitive function is impaired by defensive denial. The challenge to the child and adolescent psychodynamic therapist is in the differential diagnosis. Psychological testing by a professional skilled in elucidating this distinction can be very useful.

Superego, the moral agency in the tripartite model, encompasses conscience, morality, critical self-observation, self-punishment, and the holding up of ideals (30). Although available to consciousness as moral precepts and ideals, superego functions are predominantly unconscious, out of awareness. Superego is built out of the child’s desire to please adults, fear of displeasing adults and thereby losing their approval and affection, experiences of consequences from the physical and social world, and identification with the models of self-control and moral values presented by important adults. There is continuing development of a set of standards, ego ideal, epitomizing the individual’s beliefs of what is right, good, or desirable. Superego can be effective in controlling behavior in conformance with this ideal only to the degree that ego capacities have developed to be deployed in thwarting and channeling unacceptable impulses. When misbehavior is the presenting complaint about a particular child, the clinician must evaluate whether the behavioral expectations of the adults are “age appropriate.” The clinician also pays attention to the meaning of the behavior rooted in the child’s anxiety and conflict over drive derivatives.

Superego is a concept that describes an internal, intrapsychic phenomenon derived from relationships, especially with caregivers, and experiences with the external world. The clinician observes superego functions by attending to the affects signaling pleasure and displeasure. When thought and behavior conform to the internalized standards of the developing ego ideal, the child shows pleasure in performance of daily tasks, self-esteem, happiness, or contentment. The child displays signs of humiliation, shame or guilt, and low self-esteem when thought and behavior disappoint the strictures of internalized standards and superego functions. Children frequently externalize blame as a defense against the painful affect when negative affect or a sense of being bad is unbearable. Unfortunately, when the child lies or blames others, adults may assume that the child does not know he was naughty, whereas the child does know but cannot tolerate the knowing. Children frequently express their guilt through enactments in which their behavior brings about a punishment. For example, a child struggling with urges to injure a new sibling may become accident-prone.

An interesting finding from psychoanalysis is that the harshness and rigidity of an individual’s superego is not directly proportional to the parent’s severity or the child’s experiences with the parent but rather to the intensity of the aggressive wishes and relative weakness and immaturity of the individual’s ego and defenses. Parental harshness is thought to weaken superego functions because when the parent’s aim is to inflict a punishment that hurts the child, either physically or through deprivation, the child becomes focused on the external struggle with the parent and is distracted from the internal struggle with shame, guilt, or remorse.

Although ego psychologists have focused on defensive ego functions, an alternative metapsychology has developed under the rubric of object relations theory. Freud’s emphasis on early experience as a source of both psychopathology and transference focused interest on the earliest relationships of the human infant and toddler. This emphasis and the observational studies of young children that it spawned (31,32,33) have reaped extensive benefit for our understanding of the mental health needs of children. Although loosely anchored in the tripartite model of the mind, psychoanalytic object relations theories as defined by Kernberg are:

Object relations theories use a metapsychology organized around the concept of an internal representational world, a world which is only gradually differentiated in the course of development (35). The child constructs representations that enable him or her to perceive sensations arising from various sources, to organize and to structure them in a meaningful way. It is useful to make a distinction between representations and images. A representation is a more or less enduring organization or schema constructed from a multitude of images, each derived from a multitude of experiential impressions. Sandler gives the example of a child who experiences many images of his or her mother— mother feeding, mother talking, mother preparing food, and so on— out of which gradually is created the mother representation encompassing the entire range of mother images, all bearing the label “mother.”

The object relations metapsychological construct of the intrapsychic representational world provides a conceptual framework for the processes of internalization. Identification is the coalescence of a self-representation with an object representation, or a change in the self-representation so that the object representation is duplicated. En route to a stable identification are temporary identifications and imitations with transitory changes in self-image. The object representation used as a model in identification may be based to a degree on fantasy rather than wholly on real attributes of the object from which it derived. Identification, with its duplication of the object representation within the self-representation, is seen as a step in the loosening of the dependency tie to the object.

In psychodynamic therapy special attention is given to understanding and manipulating the impact of the patient–therapist relationship on the patient’s intrapsychic structures and functions. A basic concept of transference “refers to the way in which the patient’s view of and relations with his childhood objects are expressed in his current perceptions, thoughts, fantasies, feelings, attitudes, and behavior in regard to the analyst (36).” The therapist can observe the transference by looking for distinctive types: transference of habitual ways of relating, current relationships, and past experiences (36). It is particularly useful to examine and utilize transference onto the therapist of defensive functions. Transference is frequently used as a general term for the patient’s attitudes and behavior toward the therapist and as such includes externalizations, which Anna Freud specifies as:

Therapists’ interventions differ with each therapist’s assessment of transference phenomena. Brenner points out that the phenomenon of transference is not unique to the therapeutic relationship but rather “every object relation is a new edition of the first, definitive attachments of childhood (37).” In essence, psychodynamic theory proposes that psychologically significant relationships contribute to the individual’s perceptions,
thoughts, fantasies, feelings, attitudes, and behavior in all future relationships.

The patient’s experience of the therapist is not limited to the transference. A portion of the therapeutic action of psychodynamic therapy is thought to rest in the experience of the real relationship with the therapist. The child even more than the adult has receptivity for new experiences. The psychodynamic therapist provides the child or adolescent with a new object with new potentials for internalization. The therapist strives to cultivate specific qualities, some of which may be novel to the child. These include a respectful attitude toward the child, particularly toward the child’s thoughts and feelings, as well as the protection of the child’s confidences from intrusion by parents or teachers. The therapist strives to be reliable and predictable in the arrangements made for meeting with the child. Most significantly, the psychodynamic therapist establishes a relationship with the child that is largely unilateral in its focus so that the events of the therapy evolve primarily from the child. Unlike the relationship with parents or peers, in which there is a necessary and healthy reciprocity, the focus on the child in the relationship with the psychodynamic therapist allows the internal world of the child to dominate the transactions (38). The therapist as an interested and thoughtful observer becomes a model for the child’s development of the capacity for self-observation, a capacity termed observing ego. For children who have deficits in reflective function, the therapist’s respect for the child’s mental life and implied recognition that it is uniquely the child’s is important in helping the child to develop this capacity.

Although the primary focus in the patient–therapist relationship is tipped toward the patient, psychodynamic theory does address the therapist’s experience of this relationship. Countertransference refers specifically to intrapsychic conflicts stirred in the therapist by the patient. Generically, countertransference refers to all the reactions of the therapist to the patient. Detection of countertransference requires a “constant internal vigilance of the psychiatrist, who notes the emergence of powerful positive and negative feelings toward the patient and reflects on the possible origin of those feelings in the context of past relationships (1).” Marshall (39) operationalizes the definition of countertransference into two categories: a) reactions arising from the therapist’s unresolved internal conflicts; and b) natural reactions to a patient’s provocative behavior. Winnicott (40) dubbed this second type objective countertransference, objective in the sense that virtually everyone would find the patient’s behavior provocative. The challenge to the therapist when the objective countertransference is recognized is to construct a response that is both honest and therapeutic. Marshall suggests that either type of countertransference may occur consciously or unconsciously. By definition, the therapist, at least initially, is unaware of unconscious self-derived responses. Table 6.2.4.2 lists behaviors that signal the presence of unconscious therapist-derived countertransference. Many of these same factors may be purposefully instituted as adaptations of technique, parameters, when clinically warranted. The therapist’s task is to prevent countertransferences from distorting the treatment.

Treatment alliance and working alliance are terms used to refer to “all the factors that keep a patient in treatment and which enable him to remain there during phases of resistance and hostile transference (36).” Resistance is a conceptualization of the psychological mechanisms that cling to the intrapsychic status quo and seek to prevent change. In essence, resistance is a defense against affects, undesirable self-representations, or unwanted drive derivatives that are stirred and moved toward awareness by the therapeutic process. Inherent in the treatment alliance is the patient’s awareness of internal difficulties and an acceptance of the need to be helped. Children with very fragile self-esteem may refuse to enter into therapy because they cannot tolerate the recognition of their difficulties.