PROTOCOL: Psychoanalytic/psychodynamic psychotherapy for children and adolescents who have been sexually abused

Description of the condition

Although the so-called universality of the incest taboo had for a long time led people to believe that sexual abuse of children was a minor problem, it is in fact a significant worldwide problem ( De Mause 1991 ), the scale of which was largely unrecognised until the late 1970s ( Finkelhor 1994a ).

Sexual abuse is traditionally divided into non-contact and contact abuse ( Peters 1986 ), with contact abuse subdivided into penetrative and non-penetrative sexual abuse. Non-contact sexual abuse includes deliberate exposure of breasts or genitalia or witnessing a sexual act, either live or in photographs or films. Non-penetrative sexual abuse includes touching, kissing and masturbation. Penetrative sexual abuse includes oral, vaginal and anal penetration ( Glaser 2002).

Finkelhor's review of prevalence studies of child sexual abuse in 21 countries (mainly English-speaking and North European) reported rates ranging from 7% to 36% in women and 3% to 29% in men. Such variation reflects differences in the methodologies of studies, such as the definition of sexual abuse used, rather than substantive differences in the rate of childhood sexual abuse ( Finkelhor 1994a ). Adjusting for sample-related variation, response rates and differences in definitions, Gorey and Leslie estimated a rate of 16.8% for women and 7.9% for men from 16 cross-sectional North American community sample surveys ( Gorey 1997 ). Men make up the vast majority of abusers (85 to 90%) ( Glaser 2002 ) and the majority of sexual abuse is perpetrated by either family members or acquaintances ( Finkelhor 1994b ).

Importantly sexual abuse is an event or a series of events. It is not a disease or medical condition ( Finkelhor 1995 ). It often comes to the attention of services due to psychological consequences which can be remarkably heterogeneous in their nature. This heterogeneity is partly because sexual abuse rarely occurs in isolation: it often occurs alongside other forms of abuse and neglect ( Mullen 1994 ; Ney 1994 ) and a wide variety of other disadvantages (eg parental mental illness or substance abuse, child disability or illness, economic deprivation etc).

The psychological effects of sexual abuse can range from significant symptoms and emotional distress to little discernable impact (one review of 45 studies looking at the impact of sexual abuse on children found four studies which estimated from 21% to 49% of victims to be free of symptoms ( Kendall-Tackett 1993 )). The most common childhood effects of childhood sexual abuse include symptoms of post-traumatic stress disorder (PTSD) and sexualised behaviour ( Kendall-Tackett 1993 ) but other common effects are aggressive or disturbed behaviour, depression, anxiety, low self-esteem, guilt, fear, eating disorders, self-harm, suicidal ideation and suicide, substance misuse and relationship problems ( Browne 1986 ; Beitchman 1991 ; Cotgrove 1996 ; Tyler 2002 ). Effects are often dependant on the developmental age of the victim. Overall the severity of abuse, use of force, and the victim's relationship to the perpetrator appear to have the greatest influence on the degree of impact of the sexual abuse to the victim ( Tyler 2002 ).

Many children who are sexually abused go on to experience a wide range of serious adverse effects in adulthood and some only begin to develop symptoms in later childhood or beyond (‘sleeper effects’). Intervention studies sometimes exclude asymptomatic victims as they are likely to underestimate the effect of the intervention for symptomatic victims. It is also unlikely for an asymptomatic victim to receive psychotherapy in everyday clinical practice, however the possibility of an asymptomatic victim having ‘sleeper effects’ needs to be kept in mind. A higher than average rate of childhood sexual abuse is reported by adults suffering personality disorders and other psychiatric illnesses ( Zanarini 1989 ; Brown 1991 ; Bulik 2001 ; MacMillan 2001 ) and besides intrapsychic difficulties, they experience a wide range of physical symptoms ( Arnold 1990 ), occupational, social and sexual difficulties ( Mullen 1994 ).

Description of the intervention

Psychoanalytic and psychodynamic psychotherapy have their origins in the work of Freud (1856 to 1939) but the practice of psychoanalytic and psychodynamic psychotherapy for children and adolescents gained impetus through the theoretical interest and practice of Anna Freud and Melanie Klein ( Daws 1987 ). Nowadays there are a variety of different approaches (eg Kleinian, Freudian) under the umbrella of psychoanalytic and psychodynamic psychotherapy. These terms are often used synonymously ( Gabbard 2005 ), but psychodynamic psychotherapy sometimes refers to a briefer form of therapy where the therapist is more active and focuses on a particular problem, rather than difficulties affecting the whole personality.

Despite there being different schools of psychoanalytic/psychodynamic psychotherapy used for a wide range of psychological problems, there are some common theoretical concepts: psychoanalytic/psychodynamic therapy involves a therapist listening to an individual and observing their behaviour. People are referred or seek help when they are in conflict over aspects of themselves or their relationships which are problematic. Such conflicts are generally held to originate from difficulties in past relationships and experiences (eg sexual abuse). These conflicts are thought to cause anxiety or psychic pain and are pushed out of consciousness and into the unconscious through the use of defence mechanisms ( Bateman 2000 ). Some defence mechanisms may be helpful (eg humour, altruism), but others may be developmentally immature and harmful (eg denial, splitting, projection). Psychoanalytic/psychodynamic psychotherapy attempts to explore, through talking, play (with younger children) and the formation of a therapeutic relationship, how earlier experiences influence and perhaps seriously distort current feelings, actions and relationships ( McQueen 2008 ). Eventually therapy aims to help patients have a better understanding of difficulties about which they may previously have been unaware and this is thought to allow resolution of their problems.

Therapy is usually one-to-one, but it can be done with families or with groups. One-to-one therapy tends to happen at a fixed time once or twice a week, but occasionally it can be more intensive and up to five times a week. Parents/carers are often provided with parallel supportive work which is vital to help parents/carers to understand and manage their children's behaviour safely ( McQueen 2008 ).

Therapy can be brief, lasting only a few sessions, particularly when working with young children or focused on a particular problem. It can also last for months or even years, particularly when the hope is for deep resolution of difficulties affecting the whole personality. When funded by state healthcare systems, insurance companies or for research purposes, therapy may be offered for a fixed amount of time (usually up to one or two years in the UK) and may target a particular problem, but it can sometimes be more open-ended, especially when paid for privately. Therapists have usually completed a lengthy training which includes undergoing their own psychoanalytic/psychodynamic psychotherapy. When providing treatment therapists tend to get outside supervision from a more experienced therapist.

Following recognition or disclosure of sexual abuse, the first priority is ensuring the child's safety. If conservative measures are not sufficient in order to protect the child, the potential benefit of removing a child from the home in order to protect their safety has to be balanced against the risk the secondary traumatisation of the child through such separation from their family, particularly if the suspicion of abuse is subsequently proven to be unfounded. When the child's safety is ensured, good practice then involves providing the child with an adult with whom they can talk to about the abuse and their feelings ( Glaser 1991 ). For children who develop symptoms, treatment should be tailored to the developmental age and needs of the individual child ( Finkelhor 1995 ; Ramchandani 2003 ).

How the intervention might work

There are a variety of theories about how the intervention actually works but, as with other forms of psychotherapy, the relationship between therapist and patient is felt to be important ( Gabbard 2005 ; Midgely 2005 ). Insight (conscious understanding) of unconscious conflicts is thought to be particularly significant ( Traux 1973 ). Insight is gained through interpretations offered by the therapist based on what the patient says and their behaviour. The patient is encouraged to talk about whatever comes to their mind (‘free association’), but some therapists are more active and may ask questions.

Therapists usually reveal very few details about themselves so that they are a ‘blank screen’. The patient is thought likely to unconsciously behave towards the therapist in the same way that they experienced earlier relationships (eg a parent or an abuser), which also involves them re-experiencing some of the original anxieties and distress. The transfer of feelings from previous relationships onto the therapist (‘transference’) allows the therapist to hypothesise about the unconscious conflicts and defence mechanisms of the patient. The therapist can then begin to give interpretations of the unconscious conflicts and defence mechanisms, helping the patient to gain conscious understanding of these.

Play is seen as the primary way for younger children to communicate their unconscious conflicts. The child expresses himself or herself through imaginative and symbolic play, drawing and games, providing the therapist with a window to understanding the child's anxieties, conflicts and defences. Children also talk while they play which provides a safe background for talking about painful subjects. While interpretation is important, the primary agent of change is “enhancing the child's symbolic, imaginative and mentalising capacities by increasing the range, depth and emotional richness of his play” ( Target 2005 ). Thus through play they become able to express their internal conflicts at a more developmentally mature level and this is thought to be curative ( Passey 1994 ; Target 2005 ; Emanuel 2006 ).

Eventually, in psychoanalytic/psychodynamic psychotherapy, the relationship with the therapist and the new understanding of the self is thought to be internalised and neural networks based on earlier childhood relationships and experiences are modified ( Amini 1996 ; Schore 1994 ; Schore 1997 ; Gabbard 2000 ; Westen 2002a ; Westen 2002b ).

Why it is important to do this review

In commenting on a Cochrane systematic review of ‘Cognitive behavioural interventions for children who have been sexually abused’ ( Macdonald 2006 ), which confirmed “CBT's potential as a means of addressing the adverse consequences of child sexual abuse”, Eamon McCrory observed there is a “need for evaluation of other therapeutic approaches, notably psychodynamic psychotherapy” ( McCrory 2007 ).

To date, there has not been a systematic review of high quality evidence (ie randomised controlled trails) of psychoanalytic psychotherapy for young people who have been sexually abused. This is in contrast to greater availability of evidence for other psychotherapies (especially CBT).

If psychoanalytic/psychodynamic psychotherapy is to continue to receive funding from state healthcare systems and insurance companies, there is a need to continue to review the available literature as new research is published. This review sets out to serve that purpose.

Criteria for considering studies for this review

Search methods for identification of studies

Data collection and analysis