Doing Child and Adolescent Psychotherapy: Adapting Psychodynamic Treatment to Contemporary Practice (2nd Edition), (Book Review)

Author:  Bromfield, Richard
Publisher:  Wiley
Reviewed By:  Christopher Pagano, PhD, Fall 2008, XXVIII, No. 4, pp. 38-40

In the interests of full disclosure, I was a supervisee of Dr. Bromfield during my psychology internship in the early 1990s. That said, I am delighted to have the opportunity to review the second edition of his book, Doing Child and Adolescent Psychotherapy. Bromfield is an articulate spokesperson for the powerful and important work of psychodynamic psychotherapy with children and adolescents, and someone who has weathered changes in the healthcare climate, adapting psychodynamic work without sacrificing its core ideals. The book’s new subtitle, “adapting psychodynamic treatment to contemporary practice,” refers to Bromfield’s attempts to accommodate to the forces of managed care and the related call for evidence-based research of psychotherapy. Bromfield adds crucial chapters to this edition, including on parent work, family work (mainly with siblings) and consultation to schools and other agencies.

While these chapters are valuable additions, his chapter on managed care and evidence-based treatment is quite limited, giving the reader just a flavor of the ways that he integrates cognitive-behavioral approaches into his work for selected patients. I feel that what Bromfield accomplishes in this revised edition is not his stated goal of a fair and comprehensive review and comparison of evidence-based (i.e., short-term and manual-based) treatments to psychodynamic approaches, nor does he fully describe the integration between these two approaches. Rather, he shows us again the power and value of psychodynamic work and reinforces, in this new addition, the necessity of bringing on board the full range of supports in the child’s life in order to sustain and nurture the crucial internal work that the child achieves in therapy.

Bromfield’s strength is in his vivid, accessible, jargon-free descriptions of what actually happens in child psychotherapy sessions. An excellent book for beginning child clinicians and a useful refresher for experienced ones, he guides the reader through the multiple and often challenging roles of the child therapist, including the fundamentals of developing an alliance, understanding defenses against affects and impulses, grasping relational patterns that naturally emerge in the transference, and the value of working in displacement. Bromfield’s clinical examples are filled with emotionally moving connections established between child and therapist, connections that ultimately (though not always) lead to insight and change. He demonstrates how his persistent curiosity and deep patience repeatedly pay off, sometimes at surprising moments, as these therapist qualities allow the child to acknowledge painful realities of loss, rage and fear.

Bromfield also reveals his keen eye for the depth beneath the surface, gently encouraging the child, whether through play or talk, to take ownership of difficult to acknowledge feelings, wishes and fears. He underlines the importance of being acutely attuned to the child’s shifts in affect and attention while at the same time not presuming to know the thoughts, feelings, motives or conflicts beneath the surface. His clinical vignettes are powerful examples of psychodynamic psychotherapy in action as he helps the child or adolescent patient gain an awareness of transference projections and internal struggles. He shows how the therapist must create a deeply respectful environment of acceptance of strong feelings and deeply held wishes and fears in order to allow the child to make a similar courageous move to take ownership of these feelings and impulses, sometimes resulting in unexpected discoveries. He conveys his respect for the child’s need to protect certain vulnerable feelings, patiently allowing them to feel comfortable enough to share them, through whatever means necessary, noting that “over time—and with our support and respect for the important adaptive and protective functions these self-deceits serve—our patients often speak words [and gain] insights leading to more genuine ways of being” (p. 41).

Bromfield’s belief in the value of play as a transitional space as a means to help children “learn to master and reconcile what they think, feel and imagine on the inside with the stresses, truths, and limitations of the outer world they must live in and comply with” (p 137) is richly supported by his numerous clinical examples. He shows how working in displacement can help a child gain comfort with the conflicts between her inner and outer world and become more integrated and flexible in how she copes with these often dueling realities. As he puts it, the therapist’s informed titration of emotional confrontation gradually allows the child to “psychically stretch,” expanding their awareness of themselves and others and developing more adaptive skills and allowing natural development to proceed.

Bromfield’s sensitive attention to issues of connection, love and dependency as they relate to the inevitable reality of loss and separation in all relationships is beautifully handled throughout the book. He is acutely attuned to a child’s fears of intimacy expressed through withdrawal and retreat in the beginning stages of therapy, respecting the child’s need to protect himself. He uses this awareness to help children, especially reluctantly engaged adolescents, understand the complex balance between their needs and fears and helps them to acknowledge longings and losses that are difficult to bear.

A hallmark of Bromfield’s work (see also Playing for Real, 1992) is his ability to articulate psychodynamic and psychoanalytic thought free of jargon, accessible to clinician, parent and educators alike. He takes complex concepts like transference and simplifies them, showing how a child constructively recreates formative yet painful and unresolved relationships in her relationship with the therapist, showing the reader why it is important to foster and support transference distortions. He also shows how transference sometimes functions as a projection of the child’s harsh superego, actively allowing the description of the child’s experience of being hated and criticized by the therapist while simultaneously helping the child to see how she constructs relationships based on inaccurate assumptions about how people view her from a critical perspective.

While he adds important new chapters on parent, family and sibling work and consultation to schools, I would argue that these areas are important unrelated to changes in the healthcare climate. These chapters are valuable because we know that children exist only in the context of a larger system of care and that these systems need to nurture and challenge the child according to her current needs in order for the work of psychotherapy to flourish. Bromfield’s handling of these areas is distinctive in that it shows his deep respect for parents and other providers, and demonstrates his skill at using empathy and jargon-free language to build an alliance in which gentle confrontation is accepted and pays dividends. Like the classic “Ghosts in the Nursery” (Fraiberg, 1975), Bromfield shows how helping a child understand and appropriately respond to their child’s developmental needs often involves insight into their own motives, emotions and childhood hurts.

His new chapter on medication is thoughtfully cautious, with appropriate warnings about drug companies and their influence on clinicians, something that was only very recently reported on in the New York Times as a potentially huge hidden influence on child psychiatrists. While his review of medication is not meant to be a course in child psychopharmacology, his wariness of jumping into medication too quickly is a refreshing voice in light of the prevailing denial of real and highly concerning side effects that many psychotropic medications unleash on children.

While the subtitle suggests that this new addition looks at integrating psychodynamic treatment with other approaches, I found new chapter on managed care and evidence-based therapy lacking in thoroughness and limited in scope. While he does capture some of the valuable criticisms of psychoanalytic work brought to the fore by the managed care and brief therapy movements (e.g., the overemphasis on the individual and the internal world to the detriment of the influence of family, peers, culture, race, religion and society; the self-deluding tendency of traditional psychoanalytic thought where it’s easy to “see what we want to see” and nothing more; the “stern withholding and patriarchal” analytic approach and the tendency to blame parents for a child’s severe disorder such as autism) he does not fully evaluate the benefits of other approaches to treatment. He gives some barebones outline of some of the research, shows that this is not his specialty and instead gives some valuable references for the reader to pursue. I think that this chapter’s greatest value comes in his attempts to show how he integrates other theoretical and clinical perspectives into his work as needed. Here too, however, he does not go far enough, from my perspective, in showing how an integrated approach to treatment looks and works.

Turning back to his strength, I think that Bromfield nicely weaves together the Winnicottian holding environment with the Kleinian respect for powerful wishes, destructive impulses and fears (e.g., a child revealing that his deepest fear and heaviest guilt is rooted in his having once stated “I wish my sister was dead” or another child who reveals that the source of his self-directed rage and misbehavior is his belief that “it was my fault that X abused me, I should have done…”). He does this to help children come to terms with and accept their deepest feelings, showing them as it were that these feelings and wishes can be given voice and exposed without fear of retribution “to see it like it is and to see themselves as they are” (p 40) whatever this entails. The resultant freeing up of psychic energy is profound for these children. My only concern with these kinds of vignettes is that they are presented in a way that makes it appear that once the secret truth is finally revealed after years (perhaps) of delicate and gentle archeological digging, psychic energy is freed up and the cure naturally flows forth.

Overall, I have few criticisms of this book. Perhaps the aspect that I found most underplayed is the role of the therapist’s affective and experiential resonances that naturally arise in the course of play therapy and therapy in general with children and adolescents. These resonances, which relational and intersubjective analytic theorists place great value in (e.g., Slade and Wolf, 1994; Lyons-Ruth, 2006) are, in my experience, crucial sources of information that can guide the therapist’s participation in and understanding of the relational dynamics as they unfold. Since knowing how and when to use these experiences is often quite complex, it may be that Bromfield chose not to go to this level of detail for fear of sacrificing his all-important emphasis on listening and letting the child’s internal world unfold at her own pace. Nonetheless, it is my experience that deep empathy involves aspects of the therapist injecting feelings into the play or other forms of displacement (e.g., fictional children who have faced similar challenges as the patient), as a kind of trial balloon, rooted in his or her own resonances as a participant in the play or the relationship. This involvement by the therapist can be a crucial factor in moving the child towards enhanced insight as well as a model for how to handle and communicate complex, vulnerable feelings.

Another drawback is that at times the vignettes seemed too short, something that leaves the reader without a clear window into the evolving patterns across a treatment. Sometimes the shortness of the examples leaves the reader with a sense of resolution too simply achieved, with one crucial interaction seeming to magically shift the entire treatment. While the merits of providing brief examples is that he can focus on ideas and provide ample support for them, this approach loses the depth that he achieved in his initial book on child therapy (1992) where he devoted an entire chapter to each patient, following the treatment from beginning to end. While this occurs rarely in the book, there is an occasional failure to state the age of the child about whom he is speaking, something that makes it more challenging for the reader to quickly locate the child in a developmental framework, especially important given the brevity of the example.

Overall, this is an excellent book on psychodynamic psychotherapy, with value for the new and seasoned clinician alike. Bromfield’s deep respect for how a child learns to feel loved, protected and communicates her needs in a difficult world, shines through brightly. He shows how the clinician must enter their world, building an alliance by providing a safe environment while simultaneously picking up on the nuances of relational messages that are often subtlety conveyed. His numerous examples demonstrate the myriad of ways in which confrontation, insight and change can occur. Finally, his carefully constructed bibliography and informative endnotes provide an excellent resource for child clinicians, keeping alive the rich tradition of psychodynamic clinicians who have walked deep into the child’s world and taken with them profound and lasting insight into how change and development occur.

Christopher Pagano

References

Bromfield, R. (1992). Playing for real: The world of a child therapist. New York: Dutton.
Fraiberg, S. (1975). “Ghosts in the nursery”: A psychoanalytic approach to the problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry, 14, 387-421.
Lyons-Ruth, K. (2006). Play, precariousness, and the negotiation of shared meaning: A developmental research perspective on child psychotherapy. Journal of Infant, Child, and Adolescent Psychotherapy, 5, 142-159.
Slade, A. and Wolf, D.P. (1994). Editors. Children at play: Clinical and developmental approaches to meaning and representation. New York: Oxford University Press.

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