Psychodynamics in child psychiatry in Sweden,1945–85: from political vision to treatment ideology

Abstract

In this article, changing treatment ideologies and policies in child psychiatric outpatient services in Sweden from 1945 to 1985 are examined. The aim is to discuss the role played by psychoanalytic and psychodynamic thinking in this process of change. When mental health services for children were introduced in the mid-1940s, psychoanalytic thinking was intertwined with the social democratic vision of the Swedish welfare state in which children symbolized the future. In practice, however, treatment ideology was initially less influenced by psychoanalytic thinking. From the early 1960s, child psychiatric services expanded and the number of units increased. By then, the political vision had disappeared, but a treatment ideology began to evolve based on psychodynamic theories, which became dominant in the 1970s.

Keywords

Child psychiatry childhood history outpatient services psychiatric treatment ideology psychoanalytic child therapy Sweden 20th century

This study was inspired by a recent academic debate on therapeutic treatment in the psychiatric services.¹ At issue was cognitive behavioural therapy (CBT) versus psychodynamic approaches. Swedish professionals and researchers from the psychiatric field were highly engaged in the academic dispute, but representatives from the child psychiatric services were absent. In an effort to understand this absence, we analyse the development of treatment ideologies in child psychiatric services in Sweden during the period 1945 to 1985.

The debate mentioned above was stimulated by a literature review of the evidence supporting treatment methods for depression, carried out by the Swedish Council on Health Technology Assessment (Statens beredning för medicinsk utvärdering) (SBU, 2004). Cognitive and/or behavioural treatment approaches had proved to be as effective as medical/psychiatric treatments, while the empirical support for psychodynamic methods was weaker (SBU, 2004: 39–40). This conclusion prompted a debate on psychodynamic therapy versus CBT – a debate similar to well-known international counterparts, dating back to the 1950s, when the British psychologist Hans Eysenck argued that there was no evidence supporting the curative effects of psychoanalysis (see, e.g., Eysenck, 1952; see also Eysenck, 1985; Lambert, 2004; Wampold, 2001). The international academic conflict has, since Eysenck’s time, also included the issue of psychiatric treatment for children and the pros and cons of psychodynamic approaches, as opposed to CBT, for treating children with mental problems (Levitt, 1957; Rous and Clark, 2009). However, a significant feature of psychiatric services for children in Sweden seems to be a lack of discussion and conflicts among researchers and professionals about different therapeutic approaches.

Previous research on the development of child mental health services internationally demonstrates variations in the establishment of such support in different countries depending on socio-political and professional traditions. The philanthropic endeavours of the US Child Guidance Movement and the Child Study Movement in the early twentieth century created an intellectual legacy which in turn was moulded by specific national and domestic ideological concerns in countries throughout Western Europe (Horn, 1989; Jones 1999; Ludvigsen and Seip, 2009; Parry-Jones, 1989; Richardsson, 1989; Stewart, 2006, 2009; Thom, 1992). This shared intellectual inheritance was also intertwined with the various national precursors to psychiatric provision for children. A range of child psychiatric disorders were discussed clinically and scientifically before World War II, but child psychiatry as a medical specialty remained an undefined field until the post-war period, when it was first acknowledged as a distinct scientific field (see, e.g., Baethge, Glovinsky and Baldessarini, 2004; Evans, Rahman and Jones, 2008; Parry-Jones, 1989; Smuts, 2006). Furthermore, the development of child guidance services and child psychiatric services for children in post-war Western Europe was closely related to the structure and character of the respective national welfare systems (see, e.g., Hendrick, 2003; Jönsson, 1997; Ludvigsen, 2010; Ludvigsen and Seip, 2009). The treatment ideology and policy for children in child psychiatric services are also related to social and cultural constructions of childhood (Hendrick, 1997; Lindenmeyer and Sandin, 2008; Sandin, 2003; 2011; Sealander, 2003, 2004; Turmel, 2008; Zetterqvist Nelson, 2011).

Historical research of mental health services for children in Sweden provides a tentative explanation for the lack of controversy. Several studies suggest that psychodynamic child therapy has had a dominant position in the field (Bergenheim, 1990; Johansson, 2003; Jönsson, 1997; Luttenberger, 1989; Qvarsell, 1985, 1993; see also practitioners’ recollections in Karlén, 1985), which could indicate a lack of alternative and challenging treatment approaches. However, previous research does not explain how that dominance was established and maintained during the period. The aim of this study is to examine the position of psychodynamic thinking in the development of mental health services for children and youth in Sweden and discuss which factors contributed to its assumed ideological dominance.

Methodological considerations

This study has the international perspective as its point of departure, since this shows how national contexts create specific conditions in the development of mental health services for children and youth. We will discuss the Swedish socio-political context in which ideas and theories of treatment methods expanded, not for comparative purposes but to illuminate the specificities of the Swedish context. In our analysis, outpatient services, the dominant form of care, are the main focus.

The term ‘ideology’ refers to dominant beliefs and ideas, which have gained status as self-evident and indisputable. In the analysis we also relate how children and childhood were construed and re-construed in descriptions of treatment methods for children with alleged mental health problems. Our examination of changing ideologies in outpatient services in Sweden starts in 1945, the year in which the Child and Youth Psychological Service (Psykisk barna- och ungdomsvård) was initiated; it continues to 1985, when an extensive evaluation of the services was published. During this period, the organization had grown from one clinic to roughly 30 clinics nationwide.

Most of the material we analyse consists of Swedish Government Official Reports and policy documents that deal with child mental services in Sweden in this period, the result of a wide range of official government inquiries and studies. For our analysis of the ideological processes involved in the development of psychiatric treatment policies for Swedish children, we use surveys and official statistics from a number of child psychiatry departments and outpatient units, as well as data on the number of professionals working in child psychiatry. Background material is provided by clinical textbooks and professional and scientific journals, as well as some biographies of the people involved. The analysis is based on a close reading of the arguments and conceptual patterns in psychiatric and psychological treatment policies in the light of their socio-historical context. We shift between political contexts and organizational issues, which are relevant to treatment ideology and policy, and scrutinize documents outlining treatment ideologies and policies. We also identify important and influential individuals who contributed to articulating treatment alternatives or to changing treatment policies.

We found three distinct periods in the development of child psychiatric services: 1945–59, marked by the social democratic government’s political visions of a new kind of mental health service for children; 1960–68, when the services were re-named Child and Youth Psychiatry Services and all county councils were obliged to offer psychiatry services to children and families in need of them; 1969–85, when there was a change in the overall goal of the organization, which despite the radical ideas of the time progressed towards a more apolitical and individualized approach.

1945–59: a new type of service

The first step towards introducing child psychiatric services in Sweden was outlined by a government inquiry in a Swedish Government Official Report published in 1944 (SOU 1944/30). Entitled the Youth Inquiry (Ungdomskommittén), this was commissioned by the government in 1939 in response to rising levels of youth delinquency and crime. The so-called ‘youth problem’ had been on the government’s agenda as a major social issue since the mid-1930s (SOU 1944/30: 11). Among local social child welfare initiatives designed to support parents of children with problems, advice bureaus and child counselling centres had been founded in the 1920s and 1930s in the larger Swedish cities. With the appointment of the Youth Inquiry, the government made the youth problem a national issue, and it began its work in 1939, though it was delayed for two years by the outbreak of World War II. When the Inquiry was reconvened at the end of 1941, its goals were reformulated (SOU 1944/30: 12). Instead of investigating crime defined as the acts of specific groups of young people, i.e. juvenile delinquents, the social dimension of delinquency was now addressed. The Inquiry’s organizers argued that the young people in question should not be viewed as a group of failed individuals. Instead, the rising level of youth crime was a sign of the failure of society to care for its young members.

The Youth Inquiry published 12 wide-ranging Swedish Government Official Reports. The first was an outline of a new kind of mental health service for children and young people, called the ‘Psykisk barna- och ungdomsvård’ (Child and Youth Psychological Service [hereafter PBU]; SOU 1944/30). This was followed by 11 official reports on subjects such as the youth labour market, youth leisure activities, and sexual behaviour. The symbolic meaning of the ‘Child and Youth Psychological Service’ reflects the significance ascribed to psychological knowledge in this new approach to the ‘youth problem’. It was not a moral problem or a biological problem; it was a social problem that could be solved with a psychological understanding of the influence of family environment and emotional relationships. Based on this Swedish Government Official Report (SOU 1944/30), in February 1945 the Swedish Minister of Social Affairs signed a government bill with proposals for setting up the new service.²

The designation ‘psychological service’ conveyed that this health service was neither ‘psychiatric care’ nor ‘child guidance’ – it was a new type of service. Furthermore, it was planned that this new form of mental health service would be located at local hospitals, as part of the national health services, and like the hospitals would be controlled by its own county councils (landsting).

In 1945 Sweden was divided into 20 such county councils. These councils were distinct from the municipal administration, except for the three municipalities of Stockholm, Gothenburg and Malmö. Each county council was responsible for organizing its own health service – one which followed national governmental guidelines and gave due consideration to the specific needs of the region. The national authority responsible for the health service was the National Medical Board (Medicinalstyrelsen). Consequently, the decision to create a new kind of mental health service for children and young people, to be run by the county councils, implied a determination to move away from previous child guidance work, which had been carried out under the aegis of the municipal child welfare boards.

A radical vision of society and childhood

The placing of the PBU under the county councils’ health care organizations was in line with social democratic strategy at the time, mirroring its vision of health care for all people on equal terms and run by a strong nation-state (Berge, 2007). At this stage only one independent clinic offering child and youth psychological services had been established, run by Värmland county council, though in the larger cities similar clinics existed in paediatric departments or, in some instances, in psychiatric departments. During the first trial period, the county councils which volunteered to develop child and youth psychological services received earmarked financial support from central government and were obliged to follow central directives. The fact that the funding was earmarked was an indication of the importance accorded to the initiative. Ten years after the service was started in 1945, a total of 10 county councils, including the municipalities of Stockholm, Gothenburg and Malmö, had established PBU clinics or, in some cases, smaller units with only outpatient care.

In the early 1950s the service was evaluated by another, smaller commission, the Mental Health Care Sub-Commission (Mentalsjukvårdsdelegationen). This was part of a larger government inquiry commissioned in the early 1950s to look into the condition of the national medical health services in general (SOU 1957/40: 5–6). Their work resulted in yet another Swedish Government Official Report, with a broad and thorough analysis of the current state of the PBU. The main message was that these services must be offered by all county councils, and must therefore be incorporated into the national medical health services (SOU 1957/40: 183–5). In the next section we will discuss the more specific ways of defining mental problems and treatment issues characteristic of this period.

Psychoanalytic frame of reference

The PBU had two main tasks: first, to prevent mental problems among children by offering expertise and knowledge to professionals and parents; and second, to identify and treat problems of afflicted children. The preventive mission was placed first, a reflection of the politicians’ and experts’ political visions.

The ways in which mental health and mental problems in childhood were described and defined in these early Swedish Government Official Reports from 1944 and 1957 were multifaceted. The environmental perspective was strong in the descriptions of children’s problems, and even though it was not always made explicit, it was combined with references to psychoanalytic thinking. Positive emotional relationships with adults during childhood were described as decisive for the proper social and psychological adjustment of children and youths (SOU 1944/30: 20–8). It was not only a question of education to ensure that children learned the proper rules and good habits; their proper social adjustment was also based on mental processes (pp. 21–2). As the authors of the report argued, child-adult relations were played out in the ‘emotional field’ (p. 21), a rhetorical basis to which the Inquiry then returned in discussions on social maladjustment and ‘faulty’ psychological development. In the report’s description of various mental problems in childhood, concepts such as ‘emotional conflicts’, ‘pleasure’ and ‘displeasure’, ‘envy’ and ‘neurotic’ hinted at a psychoanalytic frame of reference (pp. 20–4). Furthermore, the authors argued that children’s bonding with significant individuals in their environment is emotional in character, and that such bonds are directed towards not only parents but also ‘teachers, staff at child institutions, friends, etc.’ (pp. 22–3). Expressions such as ‘neuroticization’ recur, as do descriptions of how a negative relationship with one significant adult in the child’s life, for example the mother, resurfaces in other relationships with a ‘similar character’, for example a female teacher. A concrete example is also provided of ‘the child who steals from his employer, who actually represents what for the child is the unpleasant father’ (p. 22).

In the PBU Inquiry’s Swedish Government Official Report in the late 1950s (SOU 1957/40), a similar approach was evident. The Inquiry also stressed the need to ‘psychologically clarify’ the mental processes that lay behind any problem in a child’s development. It urged professionals in the field to go beyond ‘theories of learning’ or ideas of ‘habit formation and moral education’ (SOU 1957/40: 21) and instead to ‘go deeper’, meaning deeper into the ‘mental processes’ in the ‘area of emotions’. To approach psychological problems in children as related to inner emotional conflicts, caused by specific circumstances in a child’s social environment, was a new way of thinking, as stated by the 1957 Inquiry. The challenge, it continued, was to find the main cause of the problems and initiate change.

However, despite the use of psychoanalytic thinking to explain children’s psychological problems and ailments of various kinds in the 1944 and 1957 Swedish Government Official Reports, psychoanalytically oriented child therapy as a form of treatment was still rare in practice. Psychoanalytical thinking did not appear in descriptions of treatment approaches and was not present in the treatment policies outlined. This is understandable, since psychoanalytic child therapy in Sweden was at that time primarily carried out by a small group of trained professionals at the Erica Foundation in Stockholm, where both advice and treatment for children and training for child therapists were offered (Zetterqvist Nelson, 2011). The Foundation would play an important role in the development of psychoanalytical therapy for children in Stockholm and in Sweden generally, but in the 1950s it had a minor role in the development of child and youth psychological services. However, psychoanalytical thinking attracted intellectuals of various professions with close relations to the Social Democratic Party. One of these was the paediatrician Gustav Jonsson, who was to become the first head of a PBU clinic in Karlstad, Värmland.³

Jonsson played a key role in the first years of the PBU’s existence (Bergenheim, 1994; Vinterhed, 1980). He began to practise in the late 1930s as a paediatrician, after a period of working in forensic psychiatry. Jonsson (1985: 136) wrote in his biography how this made him realize that ‘the psychopath is the former problem child’. Rejecting biomedical psychiatry and eugenic theories as far too conservative, instead he chose psychoanalysis and its way of defining childhood and youth problems as resulting from detrimental psychosocial relations in childhood. Jonsson was also a long-standing member of the Socialist Doctors (Socialistiska läkare). Their vision of fighting against detrimental social conditions and for increased social welfare as steps towards improved health, both physical and mental, fitted well with the social democratic utopian goal of a society in which not only physical ill health but also mental and psychological ill health could be engineered away (see also Stewart, 1999, on the British Socialist Medical Association). Jonsson was to serve as one of the experts on the Youth Inquiry. From his extensive study of children and youths who had come to the attention of the municipal social child welfare, he concluded that at an early stage these children had displayed psychological symptoms. Jonsson’s report was attached to the Swedish Government Official Report on the PBU (SOU 1944/30: 178–261). These findings, it was argued in the Inquiry, strengthened and underpinned the government plans to create a new kind of psychological health service. Jonsson was central in the outlining of the PBU, but his views and ideas were not unique. An interest in psychoanalysis was common among intellectual and professional groups engaged in the creation of mental health services for children and youths. However, this radical stance was less visible in the range of treatment offered by the new mental health services.

A pragmatic approach to treatment

Besides the preventive mission of the PBU, the organization was also tasked with identifying and treating emotional problems facing children in Sweden. In their early years, the new service units followed in the footsteps of previous child guidance activities offered by the social services and school health services (Bergenheim, 1990; Jönsson, 1997; Qvarsell, 1985, 1993). Advice and counselling for parents of children with so-called ‘adjustment problems’, learning difficulties or behavioural issues such as truancy, and collaboration with schools, dominated their daily caseloads (SOU 1944/30: 59–77; see also Beskow, 1952; Jonsson, 1985). For the first 10–15 years, problems were largely defined in terms of ‘social maladjustment’, ‘behavioural problems’ and ‘psychological developmental deviancy’. The different kinds of treatment offered by the units were mostly of a social and psycho-educational nature, while individual treatment of children was rare. It was more common that the adults surrounding the child in question were addressed.

However, in the 1950s the range of psychological treatments was extended, and the treatment discourse began to change. In the 1957 Swedish Government Official Report on PBU (SOU 1957/40), treatments were discussed in far greater detail than in the previous report of 1944. The treatment discourse now included terms such as ‘the talking treatment’, ‘heilpedagogical treatment’, ‘insulin coma treatment’ and ‘medical treatment’, as well as a variety of expressions based on the concept of ‘therapy’, such as ‘psychotherapy’, ‘climate therapy’, ‘group therapy’ and ‘movement therapy’ (SOU 1957/40: 24–6). A similar discourse was evident in the first Swedish textbook on child psychiatry, Elementär barnpsykiatri, published in 1959 by child psychiatrist Anna-Lisa Annell (1959: 300–17). Thus, new kinds of treatment alternatives had begun to expand during the 1950s and in this development two approaches were particularly important. One of them was an emerging psychiatric discourse, while the other one was psychoanalytic in origin. We will return to the first one, after a short description of the psychoanalytic approach developed at the Erica Foundation in Stockholm.

The Erica Foundation was founded by Hanna Bratt (1874–1959) in 1934, and it remains an influential institution for child therapy training today (Bergenheim, 1990; Blomberg and Carlberg, 2004; Boëthius Kihlbom and Orrenius, 1994; Bratt, 1945). The activities at the Foundation reflected the intellectual currents of the time in much the same way as did those of the PBU. The behaviour of so-called ‘difficult children’ was explained in terms of social and environmental processes rather than along moral and constitutional lines. Instead of punishing or reconditioning children, the idea was to change their psychological development.

The intellectual tradition was psychoanalytical, and during the 1940s a handful of Swedish pioneers, including Gudrun Seitz, Allis Danielsson and Gunnar Harding, developed and consolidated the Erica method, a psychoanalytically informed child therapy method (Zetterqvist Nelson, 2011). The Erica Foundation offered training programmes for different professional groups, special teachers, social workers and psychologists, who intended to do psychological work with children. When child psychotherapy training was formally recognized by a 1955 Swedish Government Official Report on ‘Psychological Training and Research’ (SOU 1955/11: 26), the Erica Foundation was designated as a leading centre in the country for the training of child psychotherapists. In this way, it came to play an important role in the development of a psychoanalytical child therapy treatment approach in Sweden.

During the same years, in a medical context, a child psychiatric discourse began to take shape, whose identity and existence was more uncertain in several respects.

An emergent and ambivalent child psychiatric discourse

In 1951 child psychiatry was recognized as a medical specialty, followed in 1958 by the appointment of the first Professor of Child Psychiatry, Sven Ahnsjö, at Karolinska Institute, Stockholm (Löfqvist, 1983). The concept of ‘child psychiatry’ had won acceptance and was at times even used interchangeably with the Swedish term for ‘Child and Youth Psychological Service’. In the 1957 PBU Inquiry (SOU 1957/40), a psychiatric discourse began to emerge in various ways. Perhaps the least obvious was the way the treatment alternatives were framed in the report. One section dealt with child mental problems and diagnostic categories. Irrespective of the kind of problem, each was framed as a medical issue and for each a specific treatment was suggested (SOU 1957/40: 25–6). The concept of diagnosis and treatment served as a model here, even though the problems outlined were more social or psychological in character.

The psychiatric discourse also appeared in a more straightforward way. The Inquiry’s medical experts, who in most cases specialized in paediatrics, discussed specific conditions such as child schizophrenia and childhood psychosis. These conditions, they asserted, were problematic and difficult to understand without a psychiatric frame of reference. This led to the introduction of a new medical category: mentally ill children (SOU 1957/40: 119), which also began to appear in scientific articles and textbooks (Ahnsjö, 1954; Annell, 1959). In this context, a specific issue was raised, namely whether mental hospitals for children were needed. In this regard, the Inquiry commissioned a special survey to establish the number of children with ‘grave psychiatric disorders’ in Sweden – taking it for granted that such disorders could be defined in such a manner. Based on this, they concluded that there was a need for a mental hospital for children (SOU 1957/40: 119–40; see also Zetterqvist Nelson, 2009). This suggestion was never taken any further, but the mere fact that it was proposed is significant.

By the late 1950s, a way of talking about psychiatric problems in childhood had therefore appeared, even though the terminology was used with notable caution. For instance, an article in the influential Swedish medical journal Svenska läkartidningen by Ahnsjö about ‘schizophrenia in children’ began with the following words: ‘It seems probable that for every child psychiatrist, child schizophrenia has been a problem, perhaps to the extent of questioning whether it exists.’ (Ahnsjö, 1954: 1605). His comment as to whether the condition actually existed exemplifies a hesitancy over the use of psychiatric discourse for children despite its recent acceptance. Even after the PBU (Child and Youth Psychological Service) was renamed, in 1960, to Child and Youth Psychiatry Services, the uncertainty and ambivalence with regard to child psychiatric classifications and treatment persisted in the years to follow, as we shall see.

1960–8: the expansion of the Child and Youth Psychiatry Services

Not only was there a change of name to ‘Barn- och ungdomspsykiatriska verksamheten’ (Child and Youth Psychiatry Services [hereafter BUP]) in 1960, but all its units were granted state funding, and it had by now become a mandatory part of the burgeoning National Health Services (Memorandum, 1959). Two years later the National Medical Board issued standard instructions (Normalinstruktion, 1962: 17) outlining the main tasks of the BUP. These were more or less in line with formulations of the PBU’s tasks, with their strong emphasis on prevention, as well as containing instructions for treating affected children and young people (Memorandum, 1959: 4).

As already noted, the 1960s were characterized by an immense expansion in child psychiatric care in terms of actual clinical units, from just one unit in 1945 to 10 in 1960, 13 in 1965, 27 in 1968, and 30 in the 1970s. By that point, reorganizations of existing clinics had begun, with for instance the creation of special inpatient units in the larger cities, specifically designed for children and young people with grave psychiatric problems. Yet despite the sheer size of the expansion, it started from a very low level, and the cost was less than state spending on working-class children’s summer camps, for example.⁴

The 1960s also saw the beginning of a huge increase in professionals working in child mental health. In the mid-1950s the total number of professionals involved in child diagnostics and child treatment, making up the child psychiatric teams in outpatient units across Sweden, was 47 child psychiatrists, 32 psychologists, 13 child therapists, 23 teaching assistants and 46 social workers (SOU 1957/40: 48).⁵ By 1975 there were 146 posts for child psychiatrists, 261 for child psychologists and 234 for child psychiatric social workers (Socialstyrelsen, 1980: 26–7). This shows the increase in the numbers of professionals in child psychiatric provision in general, primarily in the non-medical professions such as psychology and social work associated with outpatient services. By now the child psychiatry discourse had gained acceptance in medical circles, and had been given the designation ‘child psychiatry’. However, it was not integrated into the ideological commitment of the new organization. In these years of expansion, it was the child psychoanalytic perspective that began to take shape as a main treatment ideology. As already mentioned, child psychologists were a growing professional group, who were, moreover, also recognized by the medical authorities as qualified to carry out child psychiatric treatment because of their child expertise (Eriksson, 1997). The theoretical basis for most of them was child psychology and, more specifically, child psychoanalytic theory.

A prominent individual in this development was the psychologist and child therapist Inga Sylvander (1920–2001), whose approach represents this change in treatment ideology (Gieser, 2009; Rigné, 2002). Sylvander was trained as child therapist at the Erica Foundation in the 1940s and was then appointed as the first psychotherapist at the child guidance service in Stockholm. In an article published in the Danish journal Nordisk psykologi, Sylvander (1962) presented a new approach in child therapy. The article concerns child psychotherapy with a six-year-old boy. An important feature of this new approach was the emphasis on ego function, originally inspired by Anna Freud’s writings (Geissman and Geissman, 1998: 251–70; Ludvigsen and Seip, 2009: 18). Ego psychology was characterized by its rejection of the view that the ego is ‘the helpless rider of the id horse’ (Sylvander, 1962: 110), which was characteristic of the European psychoanalytical tradition. Instead Sylvander drew on American representatives of the approach, such as Eric H. Ericson and David Rapaport (Roazen, 1980). Her discussion of ego psychology in relation to child therapy emphasized how the aim of psychotherapy was to assess and support child ego development. The diagnostic procedure that preceded any choice of therapeutic intervention consisted of an evaluation of the ego strength, in order to judge whether the patient needed supportive therapy or insight-oriented therapy (Sylvander, 1962: 112).

In the following decades Sylvander published many influential books and articles on child psychotherapy (see, e.g., Sylvander 1973, 1978, 1982, 1983), all based on the ego psychological approach. These works were used in the training of psychologists and child therapists. In addition, Sylvander was elected chair of the Swedish Society of Psychologists (Psykologförbundet) between 1972 and 1982 and she was involved in the foundation of the Swedish National Federation Psychotherapy Centre (Föreningen Psykoterapicentrum) (Öfwerström and Rosengren, 1971: 259–60). Sylvander’s work made her a central figure in the development of psychodynamic therapy as the main treatment approach in child psychiatric care in Sweden in the 1960s.

Ambivalence about child psychiatry

The status of the child psychiatry discourse was more precarious. The Mental Health Care Sub-Commission (Mentalsjukvårdsberedningen), which was commissioned in the early 1950s to oversee Sweden’s mental health services, produced a memorandum dated 14 March 1968 summarizing the development of child psychiatric services from their earliest beginnings to the present (Memorandum, 1968). The sections dealing with diagnostic processes and treatments (Memorandum, 1968: 37–8) drew on an unpublished paper written by the child psychiatrist Anders Torold, who represented a radical tradition within child psychiatry at the time. He argued in favour of a ‘critical social psychiatry’, one that directed criticism towards what he termed the hegemonic position of expertise and professionals in child psychiatry as in other welfare and health services (Torold, 1976). It was, he argued, an expertise based on a scientific tradition that valued objectivity and evidence, which in turn represented a hierarchical and repressive society with all its inherent injustices. The alternative, according to Torold, was to take seriously the idea of political consciousness. By doing so, he contended, we allowed psychotherapy to become the main alternative in psychiatric treatment. It was a therapeutic approach rhetorically outlined with emancipatory aims and a rejection of diagnostic practices.

The 1968 memorandum also criticized contemporary diagnostic classifications in child psychiatry for being unsystematic because of competing theoretical schools, and for being based on classifications used in adult psychiatry without paying heed to child developmental issues (Memorandum, 1968: 36–8). The alternative, it was argued, was a ‘multidimensional perspective’ on the diagnostic process that went beyond individual symptoms to consider aspects of the child’s life such as heredity, somatic status, age, biology and social milieu. If diagnostic approaches were used, they should be of a descriptive character.

Ironically, this critical discussion in the memorandum was immediately followed by a presentation of child and youth psychiatric conditions, mostly in terms of a descriptive definition but also including aetiological definitions. Without going into detail here, the point is that an extensive presentation of contemporary diagnostic categories was framed by a critical discussion of the same, which resulted in an ambivalent approach towards diagnostic classification similar to that adopted in previous decades (Memorandum, 1968: 38–45).

1968–85: Child and Youth Psychiatry Services in a new radical context

Torold’s radical views were part of a broader ideological movement which started in 1968. It was a process of radicalization that began to permeate the public sector as it continued to grow (see, e.g., Luttenberg, 1989; Ohlsson, 2008). The psychiatric services and mental hospitals, and their coercive approach towards mental patients, were strongly criticized in public debates and the media. Anti-authoritarian, client-oriented approaches were presented as alternatives, often with a strong emphasis on psychodynamic theories as a contrast to previous biological-medical thinking that, according to its critics, had dominated Sweden’s psychiatric wards and mental hospitals.

The government authorities were quick to adopt these new approaches. A report from the National Board of Health and Welfare in 1973 on the state of psychiatric care and mental hospitals outlined the ideology of the so-called new psychiatry (Socialstyrelsen, 1973). Organizationally speaking, the focus was on outpatient care, with geographical proximity the goal, along with treatment programmes based on a psychodynamic approach combined with a multi-dimensional view of the causes of mental disorders. In this context, the psychodynamic perspective was launched as an important alternative first and foremost to biomedical psychiatry, but also to treatment methods based on behavioural learning theories (see also Cullberg, 1971). What mattered ideologically was the notion of the human being as a dynamic subject, in contrast to allegedly mechanistic views of both biologically-oriented psychiatry and behavioural approaches. How did the BUP fit into this new ideological context of political radicalism?

Child psychiatric provision was hardly dealt with at all in the 1973 report, being limited to a short, two-page description (Socialstyrelsen, 1973: 73–4). But this short section deemed the activities positive, not least in comparison with what was described as the harsh conditions of mental hospitals and psychiatric care for adults. Both a psychodynamic notion of human subjectivity, and emphasis on a multi-dimensional perspective in assessing psychological and psychiatric ailments were mentioned favourably as characteristics of child psychiatric care. Furthermore, the strong position of the psychodynamic treatment approach was highlighted. Given the overall message of the report, this amounted to implicit approval. So even if there was slight criticism of the time costs of child psychiatric assessments and treatment programmes, as a whole the report treated child psychiatric care quite positively (Socialstyrelsen, 1973: 74). Indeed, the word ‘new’ in the term ‘new psychiatry’ was not new in relation to the BUP organization and its precursors. The visions of a new child and a democratic society in the political ideological development of the PBU, which permeated the Swedish Government Official Reports of 1944 (SOU 1944/30) and 1957 (SOU 1957/40), predated by 20 years the visions of ‘new psychiatry’ in the 1968 and 1973 reports. However, in this time of political radicalism, developments in child and youth psychiatry began to take a new direction, most obviously in its outpatient treatment ideology.

Changing mission

In the 1970s the goals of the child psychiatric services were reformulated in ways that were significant to this new ideological direction (Socialstyrelsen, 1980: 11–12; see also SOU 1985/14: 57). The content was the same as before, stressing both the preventive societal mission and the task to identify and treat individual children. But what had previously been defined as the second goal in policy guidelines was now rated the first, namely to identify, treat and relieve psychological disturbances in children and the young, a change which mirrored the new direction taken by the BUP. This is illustrated by an extensive survey of ongoing child psychiatric provision carried out in 1975 by the Swedish National Board of Health and Welfare, based on questionnaires sent out to all professionals at a total of 70 clinical units. The report, published in 1980, was written by a group of experts in child psychiatry, child psychology and social child welfare, and was on ‘Child and Youth Psychiatric Services in Sweden’ (Socialstyrelsen, 1980). Responses to the questionnaires from the professional groups revealed a situation in which outpatient care suffered from a lack of physicians: out of a total of 146 posts, 25 had not been filled full-time. The number of psycho-logists totalled 261 with only a few vacant posts, and social workers up to 234, with 10 vacancies (Socialstyrelsen, 1980: 27). The responses to questions about daily practices in child psychiatric outpatient units document a situation in which the professionals, the majority non-medical, in those units had largely shaped their daily practices as they saw fit (pp. 44–54). Firstly, they rejected formal medical diagnostic classifications such as the World Health Organization’s International Classification of Diseases in favour of a description of children’s problems, giving ‘functional descriptions’ rather than ‘concise classifications’ (pp. 47–8). These descriptions were primarily based on anamnestic talks with children and parents, sometimes in combination with psycho-diagnostic testing procedures, even though many of the clinical units reported a decline in the use of diagnostic methods over the previous five years (p. 52). The diagnostic procedures carried out by professionals were embedded in psychodynamic discourse. In practice, the diagnosis of the child’s problems was defined as part of the treatment plan and was accordingly continuously updated relative to the treatment process.

The introduction to the report’s section dealing with diagnosis and treatment noted, ‘To identify and demarcate the problems is a prerequisite for adequate treatment. Diagnostic thinking should permeate and pervade the treatment processes.’ (Socialstyrelsen, 1980: 44). This approach differed from diagnostic procedures based on medical classifications. The medical approach had been strongly rejected in the ‘new psychiatry’ discourse, and in a similar manner the BUP demonstrated an opposition to medical diagnostic thinking. The anti-diagnostic thinking encouraged by the radical ideas of the day was amplified by the treatment ideology of the ego psychological school and its way of seeing diagnostic categories as a continuous part of the therapeutic process. This implied that the diagnosis was established in the therapy room with only the therapist and child/parents present. In this situation the professional’s definition of the problem in actual daily practice was privileged by virtue of their position and status. Furthermore, a common thread in descriptions of diagnostic procedures and treatments was the emphasis on ‘talking’. If we look specifically at what kinds of talking treatment were carried out, the most common for both children and teenage patients were ‘ego-supportive psychotherapy’, ‘supportive contact’ and ‘insight therapy towards specific goals’ (Socialstyrelsen 1980: 52, 103–4). For younger children, psychotherapy nearly always implied seeing children and their parents in parallel. Alternative treatments that were reported in the questionnaire included ‘behaviour modification’ and ‘relaxation’, ‘suggestion treatment’, ‘casework’ and, less frequently, ‘psychoanalytic treatment’ (p. 52).

The professional groups responsible for outpatient treatment in Swedish child psychiatric units stressed psychotherapeutic talk as their main tool, with regard to both diagnostic procedures and treatment, but they also reported a lack of formal training. The survey responses revealed a situation in which the majority of child psychiatrists, psychologists and social workers lacked formal therapeutic training. There was clearly a great demand for psychotherapy training, and the training most sought after was in individual child therapy and family therapy (Socialstyrelsen, 1980: 112–13). This lack of training mirrored the training situation at a national level, since formal therapy training at the universities had not yet been initiated (Gieser, 2009).

So while the BUP had ‘grown up’ in the sense of becoming a mandatory part of the national health services, their professional competence had not developed at the same speed. The pragmatic approach to treatment of the 1950s was long gone. Instead there was a growing influence of psychodynamic thinking, but bearing in mind the primary aim of the work – to identify problems and offer therapeutic treatment – it was still very early days when it came to professional training.

Towards a dominant psychodynamic treatment ideology

The specific position of psychodynamic thinking in policy documents of the time was evident in the descriptions of treatment options. It was also a self-evident starting point when other issues were put on the agenda. For instance, in the above quoted report on ‘Child and Youth Psychiatric Services in Sweden’ (Socialstyrelsen, 1980), the introduction to a section on child psychiatric diagnosis and treatment began with a statement that a child psychiatric perspective implied the comprehensive assessment of the child and her or his family situation, as well as other aspects of their lives such as schooling, social life, genetics, and so on. However, this formulation was followed by the assertion: ‘Symptoms for a serious disturbance that originated in early age and for an age-specific crisis may sometimes be the same, even though the need for intervention in both these cases is entirely different.’ (Socialstyrelsen, 1980: 44). The sentence conveys two important concepts: that of ‘disturbance’ and that of ‘early age’, the latter referring to child development as a process of evolution towards higher developmental stages, against which a ‘disturbance’ can take place. Disturbance was a concept from the ego psychological framework implying an obstacle to the child’s development, which in turn could be the result of social, societal, environmental or biological factors. Therefore, in talking about ‘disturbances’ the differentiation between ‘early’ and ‘late’ disturbances was important; ‘… a disturbance at an early stage requires extensive interventions’ (p. 45). In other cases, the ‘disturbance’ could take the form of a transitory psychological crisis, requiring a shorter intervention. Furthermore, it was stated that, irrespective of cause, the main aim of the therapeutic session was to create possibilities for the child or young person to come to terms with the therapist, and create a fruitful relationship, and thus be able to overcome a pathological disturbance. In these descriptions a psychodynamic point of view was taken for granted and concepts like ‘ego strength’ and ‘developmental level’ were used as if they were self-evident concepts, not needing closer definition (p. 44).

In Swedish Government Official Reports, policy documents, textbooks and other material outlining the treatment of child psychiatric problems, such disorders were also defined as primarily related to the child’s inner psychological world, be it conscious or unconscious. The psychodynamic approach was an individualizing approach but it did not contest the emphasis on a so-called multidimensional perspective on children and young people, which is demonstrated in the quote below from a Swedish Government Official Report about BUP in 1985.⁶

Psychological disturbances in childhood and youth can generally be defined as a result of disturbances in the individual’s conditions of personal growth and development. Such conditions can be constitutional or intrapsychological in nature, or anchored in or outside the family’s circumstances. Irrespective of the objective localization of these conditions – within or outside the individual – they affect in some way the individual’s conscious or unconscious psychological world. It is by means of this influence that they have a disturbing effect on the individual’s development. (SOU 1985/14: 57, italics added).

Social and cultural factors were discussed, but always in relation to how they may affect the child’s inner psychological world. Thus the psychological dilemma was related to the individual child, irrespective of external factors such as family and school situation, social class, and so on. According to the explanatory framework provided by ego psychology, the inner world of children was therefore moulded in childhood in such a way as to determine their psychological well-being as they developed into youth and adulthood. The inner world of a child admitted to a child psychiatric outpatient unit was considered the main focus in any diagnostic assessment and therapeutic process.

The adherence to psychodynamic theory was also evident in more general descriptions of children. In a section entitled, ‘A little on children’s needs and development’ (SOU 1985/14: 29–38), a psychodynamic framework is used as the accepted conceptual approach for explaining child development and children’s needs. Brief mention is made of the American psychologist and child therapist Margaret Mahler, as well as the father of ego psychology, Erik H. Erikson, yet there is no reference to alternative theories or ideas when children, child development or psychological problems are discussed.

The ego psychological framework, now augmented by Mahler’s object relation theory and ideas of separation individuation, therefore remained the dominant discourse in discussions about problems and treatment alternatives, but it did not go unchallenged. It was called into question by newcomers in the field of treatment ideologies, family therapists.

Family therapy treatment as a challenge

The psychodynamic treatment ideology was challenged by alternative ways of thinking about psychological disturbances and problems, primarily by family-oriented therapeutic work (Socialstyrelsen, 1980: 54, 98; SOU 1985/14: 63, 67). With its origins in the USA, mostly in in-patient psychiatric care, and articulated by child psychiatrists, this approach encouraged a move to redefine child and youth psychiatric problems in a more socially oriented explanatory frame. Children and young people’s problems and symptoms should be related to familial interactions rather than to the inner life of the child or youngster (Weinstein, 2002).

The introduction to this new approach in the Swedish Government Official Report of 1985 illustrated the dominant position of psychodynamic thinking: ‘Psychological disturbances can be described and treated through different theoretical frameworks. A family dynamic approach is generally accepted within the child psychiatric activities.’ (SOU 1985/14: 63, italics added). The acknowledgement of different theoretical frameworks stands in contrast to the way psychodynamic thinking was taken for granted elsewhere by the Inquiry. But the new family therapy approach to treatment consisted of a range of different versions, as reported in the 1975 survey, from psychoanalytic and communicative/structural to more eclectic approaches (Socialstyrelsen, 1980: 54). So even if family treatment was a new ideology in treatment discussions and policies, in comparison with the individualizing trend of psychodynamic thinking in child therapy it was not a unified approach. Also, the professionals who adhered to it mostly lacked formal training and could not seriously challenge the dominance of the psychodynamic tradition. Family therapy treatment was an alternative, but it was used to a lesser extent and mainly carried out in the inpatient wards (Socialstyrelsen, 1980: 105–6).

Concluding discussion

In the present article the historical development of treatment ideology and policy in Swedish child psychiatric outpatient activities between 1945 and 1985 has been presented. Psychodynamic thinking had a special position in the development of treatment ideology and policy, but not in a straightforward sense. Characteristic of the first period, 1945–59, was the strong ideological commitment to changing society in order to provide better social conditions for children and young people. Its mission to prevent mental problems, by disseminating expert psychological knowledge and insights about the social nature of child mental problems, was based on a radical political discourse closely intertwined with psychoanalytic theory. The latter was presented as ground-breaking because of its way of explaining child psychological problems. Psychoanalytic thinking challenged the ideas of authoritarian education and authoritarian child-rearing. Instead, children were seen as emotional beings with strong bonds to the adults in their surroundings, be it parents or other family members or teachers and other important adults. In the visionary outlines of a new kind of mental health service, psychoanalytically informed concepts and explanations were adopted and used ideologically, often without theoretical references, as if they were the only alternative to the allegedly old and conservative approach to children and child mental health problems.

However, at first, psychoanalytic ideas were not a self-evident part of treatment practice. A pragmatic tradition that had developed in municipal social child welfare services and school health services still dominated the practice of treating child and youth psychological problems. The professionals gave advice to parents and did psychometric assessments, and dealt with a great number of social child welfare issues related to placement in institutions and school situations. But new approaches began to appear that addressed the treatment of children’s mental health problems differently. One of them was psychoanalytic child therapy with its specific aim to treat children. It was developed in Sweden during this period, primarily at the Erica Foundation in Stockholm, which also provided formal training. In this context, psychoanalysis was used in practice and was not only part of a political vision. The other approach was psychiatric thinking, outlining specific child psychiatric disorders and their treatments. The renaming of the organization from the Child and Youth Psychological Service to Child and Youth Psychiatry Services in 1960 was a sign of the formal recognition of the latter discourse. Despite the new designation, in practice many professionals including the child psychiatrists themselves maintained a critical distance from psychiatric diagnostic classifications.

In the 1960s child psychiatric activities became mandatory for all county councils, and the services expanded accordingly. Psychodynamic child therapy became a more common alternative within child psychiatric outpatient care, ideologically based on ego psychological theories. It was mostly carried out by child psychologists as a professional group, who increased in numbers and influence during these years. When the anti-psychiatric approach was introduced in adult psychiatry in the late 1960s, defining mental problems as related to the social environment, it was in reality similar in content to the ideas underpinning the outlines of the early PBU. Furthermore, the radical changes also launched psychodynamic therapy as a central treatment alternative. Ironically, by 1968 the political vision of the Child and Youth Psychological Services – with psychoanalytic thinking as a central element in defining children (as emotional beings, dependent on social relations), rhetorically reinforcing the preventive role of the services – had already begun to fade. The treatment ideology of child psychiatric outpatient activities had instead become increasingly influenced by the American ego psychological treatment thinking, with its focus on the individual child and her or his inner emotional world as the central point of therapeutic change. Thus, the ideological heritage of the former psychoanalytic thinking lived on, but instead of being allied to a political discourse of change, with a new vision of childhood, it had by now become part of a treatment ideology focusing on the child as an individual and more specifically, her or his inner world as the prime target of change. In this way, psychoanalytic and, later, psychodynamic, thinking played a significant role in the development of Child and Youth Psychiatry Services in the period 1945–85, first as a political vision, and then slowly transforming into a treatment ideology, with a seemingly non-threatened dominant position, without explicit links to political visions for children.

Footnotes

Notes

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