Psychoanalytic/Psycho-dynamic Psychotherapy for Children and Adolescents Who Have Been Sexually Abused: A Systematic Review

1.1 DESCRIPTION OF THE CONDITION

The sexual abuse of children and adolescents is 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 contact and non-contact abuse (Peters 1986). Contact abuse can be further subdivided into penetrative and non-penetrative sexual abuse. Penetrative sexual abuse includes oral, vaginal and anal penetration (Glaser 2002). Non-penetrative sexual abuse includes touching, kissing and masturbation. Non-contact sexual abuse includes deliberate exposure of breasts or genitalia or witnessing a sexual act, either live or in films and photographs in print or electronic form.

Finkelhor's 1994 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 was felt to reflect 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). More recently, a meta-analysis of prevalence rates of child sexual abuse between 1980 and 2008, including 331 independent samples with a total of over nine million participants, estimated a worldwide rate of self-reported sexual abuse of 18% amongst female participants and 7.6% of male participants (Stoltenborgh 2011). 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 can occur alongside other forms of abuse and neglect (Mullen 1994; Ney 1994) and a wide variety of other disadvantages (for example, 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 discernible impact (one review of 45 studies looking at the impact of sexual abuse on children found four studies that 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); 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 dependent on the developmental stage 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 on the victim (Tyler 2002). Another important factor is the reaction of primary carer(s) to a disclosure of abuse. Where adults around the child fail to acknowledge the abuse and fail to support the victim, the outcome for the child is likely to be worse.

Many children and adolescents 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 and adolescence or beyond (‘sleeper effects’) (Putnam 2003). Intervention studies sometimes exclude asymptomatic victims as their inclusion is likely to cause an underestimation of the overall 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) and occupational, social and sexual difficulties (Mullen 1994).

1.2 DESCRIPTION OF THE INTE RVENTION

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 (for example, 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. Such conflicts are generally held to originate from difficulties in past relationships and experiences (for example, 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 (for example, humour or altruism), but others may be developmentally immature and harmful (for example, 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 thoughts, feelings, behaviours (actions) and relationships (McQueen 2008). Eventually therapy aims to help people have a better understanding of unconscious difficulties about which they may previously have been unaware and this is thought to allow resolution of their problems.

Psychoanalytic/psychodynamic 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: up to five times a week. If the therapy is with a child, parents or carers are often provided with parallel supportive work, which is vital to help them understand and manage their children's behaviour safely (McQueen 2008).

Psychodynamic psychotherapy can be brief, lasting only a few sessions, but it can also last for months or even years, particularly when the hope is for deep resolution of difficulties affecting the whole personality (such as in psychoanalytic psychotherapy). 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 or adolescent's safety. If conservative measures are not sufficient in order to protect them, the potential benefit of removing them from the home in order to protect their safety has to be balanced against the risk of their secondary traumatisation through separation from their family, particularly if the suspicion of abuse is subsequently proven to be unfounded. When their safety is ensured, good practice then involves providing them with an adult with whom they can talk about the abuse and their feelings (Glaser 1991). For children or adolescents who develop symptoms, treatment should be tailored to the developmental stage and needs of the individual (Finkelhor 1995; Ramchandani 2003). For many health professionals psychoanalytic/psychodynamic psychotherapy has been the psychotherapeutic treatment of choice. More recently Cognitive Behavioural Therapy (CBT), particularly Trauma-focused CBT, has become more prevalent and there are many studies evaluating this, but the evidence, although in favour of CBT, is “more equivocal than some reviewers would suggest, including those who have themselves conducted trials” (Macdonald 2012).

1.3 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; Midgley 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 to unconsciously behave towards the therapist in the same way that they experienced earlier relationships (for example, with 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, and play 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). 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 (Schore 1994; Amini 1996; Schore 1997; Gabbard 2000; Westen 2002a;

Westen 2002b). In fact there is a rapidly growing evidence base (Midgley 2011) and research within the world of neurobiology and neuroimaging is increasingly providing experimental evidence for many of the psychoanalytic concepts (Beutel 2003).

1.4 WHY IT IS IMPORTANT TO DO THIS REVIEW

In commenting on a Cochrane systematic review of cognitive behavioural interventions for children and adolescents who have been sexually abused (Macdonald 2012), 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 (randomised controlled trials) of psychoanalytic/psychodynamic psychotherapy for children and adolescents who have been sexually abused. This is in contrast to a greater availability of research relating to the effectiveness of other psychotherapies (especially CBT). However, it is important to mention that this is changing and there are ongoing trials for psychoanalytic/psychodynamic psychotherapy for children and adolescents with other mental health problems (for example, Goodyer 2011) and also for adults who have been sexually abused as children or adolescents.

If psychoanalytic/psychodynamic psychotherapy is to continue to receive funding from state healthcare systems and private health insurance companies for treating children and adolescents who have been sexually abused, there is a need to to evaluate the available literature. This review sets out to serve that purpose.

3.1 CRIT ERIA F OR CONSID ERIN G STUDIES FOR THIS REVIEW

3.2 TYPES OF PARTICIPANTS

Children and adolescents up to age 18 years who have experienced sexual abuse at any time prior to the intervention. The participants had to be symptomatic at the time of entry into the study.

3.3 TYPES OF INTERVENTIONS

Interventions of any duration, delivered to individuals and/or groups, described by the authors as psychoanalytic/psychodynamic or that, in the judgement of the review authors, describe the use of predominantly psychoanalytic/psychodynamic interventions. The following forms of psychotherapy using psychoanalytic/psychodynamic principles would have been considered for inclusion: child psychotherapy, child and adolescent psychotherapy, child analysis, child psychoanalysis, Freudian therapy, Jungian therapy, Kleinian therapy, Winnicottian therapy, brief psychodynamic psychotherapy and object relations based therapy. Studies where psychodynamic/psychotherapy is delivered as an adjunctive treatment, such as alongside medication, will be included (for example, psychoanalytic/psychodynamic interventions plus medication versus medication alone).

Studies may or may not include separate parallel supportive work with parents or carers of participants. Studies may or may not include family work (i.e. parents or carers seen together with participants).

3.4 TYPES OF OUTCOME MEASURES

Adverse outcomes

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Suicide

3.5 SEARCH METHODS FOR IDENTIFICATION OF STUDIES

3.6 DATA COLLECTIO N AND A NALYSIS

3.6.1 Selection of studies

The two authors (BP and WT) independently screened titles and abstracts retrieved from the searches against the eligibility criteria stated above. For studies that appeared to be eligible RCTs or quasi-RCTs, the full reports were obtained and inspected to assess their relevance against the inclusion criteria. At all stages, reasons for inclusion and exclusion of articles were noted. The review authors were not blinded to the name(s) of the study author(s), their institution(s) or publication sources at any stage of the review. Disagreements in most cases were resolved through consensus. In the one case that consensus could not be reached (Trowell 2002), we sought further information from the study author. Copies of 20 articles were obtained and read independently by the same authors against the inclusion criteria as detailed in the review protocol. The study selection process is presented in Figure 1.

OPEN IN VIEWER

1:

Study flow diagram

4.1 DESCRIPTION OF STUDIES

See: Characteristics of excluded studies

4.2 RISK OF BIAS IN INCLUDED STUDIES

Not applicable as we did not find any studies suitable for inclusion in the review.

4.3 EFFECTS OF INTERVENTIONS

Not applicable as we did not find any studies suitable for inclusion in the review.

5.1 SUMMARY OF MAIN RESULTS

Our review did not find any randomised trials comparing psychoanalytic/psychodynamic psychotherapy with either treatment as usual or a no treatment/waiting list control for children or adolescents who have been sexually abused.

5.2 OVERALL COMPLETENESS AND APPLICABILITY OF EVIDENCE

The lack of randomised and quasi-randomised studies is perhaps surprising given that many children and adolescents have been treated in this way and for many health professionals it would still would be considered the psychotherapeutic treatment of choice.

There are likely to be many reasons for the lack of randomised controlled trials, but there is a strong case for arguing that psychodynamic/psychoanalytic psychotherapy has traditionally favoured the case study as a way of richly elaborating the complexity of each case (Kennedy 2005). There has been some reluctance in the field to engage with the demands of modern healthcare for a scientific evidence base (Midgley 2011). This reluctance may have been partly due to a perception that psychoanalytic/psychodynamic psychotherapy does not lend itself well to empirical evaluation and that it does not fit comfortably within a scientific framework. However, there are many who would challenge this point of view and consider it very important to add empirical studies to the established tradition of case studies to bring about an even greater understanding of the intervention.

5.3 QUALITY OF THE EVIDENCE

The lack of eligible studies emphasises the need for future methodologically rigorous studies that aim to examine, where possible, the absolute effects of psychoanalytic/psychodynamic psychotherapy for children and adolescents who have been sexually abused. Such studies should try to address the methodological issues (for example, comparison conditions, method of randomisation and allocation concealment) that we identified in some of our excluded studies and their reporting should follow CONSORT guidelines.

5.4 POTENTIAL BIASES IN THE REVIEWPROCESS

In this review, we focused only on sexual abuse; however, sexual abuse rarely occurs in isolation (McQueen 2008). Children and adolescents who experience sexual abuse can be subjected to other forms of abuse and neglect as well as a wide variety of other adversities. By dividing victims into groups of different forms of abuse, we may be creating artificial groups; it may be more appropriate to put all victims of childhood maltreatment together. All forms of abuse tend to be intentional, repetitive and personally directed and can be particularly problematic when perpetrated by somebody in a caring role for the victim. Different forms of abuse may have more in common with each other than other traumatic incidents such as road accidents or natural disasters (Cohen 2006). However, most therapies including psychoanalytic/psychodynamic psychotherapy have developed specific theoretical models and treatment approaches for specific forms of abuse (Cohen 2006). Therefore it makes sense for research to evaluate interventions for these specific forms of abuse, such as in this review.

5.5 AGREEMENTS AND DISAGREEMENTS WITH OTHER STUDIES OR REVIEWS

We are not aware of any other reviews that specifically address this intervention in this population. There have been other reviews that look more broadly at all psychotherapeutic interventions for children and adolescents who have been sexually abused or focus on a single intervention type other than psychoanalytic/psychodynamic psychotherapy (Skowron 2005; Cohen 2006; Avinger 2007; Hetzel-Riggin 2007; Sánchez-Meca 2011; Macdonald 2012) and one meta-review (Coren 2009). Of the reviews looking at more than one intervention type, only one psychoanalytic/psychodynamic randomised controlled trial has been identified (Trowell 2002) and therefore the review authors could not come to any definitive conclusions about the intervention (Coren 2009).

The randomised controlled trial that compared individual psychodynamic psychotherapy with psychoeducational group therapy for 71 girls who had been sexually abused (Trowell 2002) was excluded from our review as it had an active comparison intervention and could not be described as a control group (i.e. treatment as usual, no treatment or waiting list). However, both interventions in the trial appeared to be effective. Individual psychodynamic psychotherapy had a greater impact on manifestations of PTSD following sexual abuse at a variety of different time points - effect sizes were mostly in excess of 0.50 (meeting Cohen's criterion of medium effect). Therefore, even though this study has not been included in this review, it would support the continued use of psychodynamic psychotherapy in this population, but conclusions would still need to be tentative due to the small sample size.

6.1 IMPLICATIONS FOR PRACTICE

Whilst we have not been able to identify any relevant studies in this review, it is important to remember that this does not mean that the intervention does not work in this population. However, it could make it more difficult to justify the continued use of psychodynamic/psychoanalytic psychotherapy for child and adolescent victims of sexual abuse.

6.2 IMPLICATIONS FOR RES EARCH

Well-implemented randomised controlled trials with no treatment/waiting list control conditions or treatment as usual control conditions should provide the least biased estimates of the efficacy of the intervention and therefore we chose to only include studies using these conditions. We also wanted to remain consistent with the Cochrane review of cognitive behavioural interventions for children and adolescents who have been sexually abused (Macdonald 2012). However, it is reasonable to expect that randomised controlled trials in this area are likely to look at the relative (not absolute) effects of psychodynamic/psychoanalytic psychotherapy. Randomisation (particularly to no treatment control conditions) may not be feasible or ethical given that the focus is on children and adolescents who have been sexually abused (Ammerman 1998; Skowron 2005). We point to Trowell et al's RCT (Trowell 2002), which was refused ethical approval for a no treatment control and so used an active comparison intervention instead. Therefore, future systematic reviews may need to pragmatically include randomised controlled trials that compare psychodynamic/psychoanalytic psychotherapy with active comparisons (such as CBT) and such findings will still be informative to clinicians and policymakers. In preparing future updates of this review, we will consider including quasi-experimental studies that meet some minimum quality threshold and trials that compare the effects of psychodynamic/psychoanalytic psychotherapy with alternate forms of therapy.

More generally, it is clear that randomised controlled trials of psychodynamic/psychoanalytic psychotherapy for children and adolescents who have been sexually abused are urgently needed. It is important to stress that these would need to be high quality in their design and use clinically referred participants, rather than samples specifically recruited for research (Weisz 1987). As pointed out by Macdonald 2012, particular attention would need to be given not only to the general areas of study design such as quality of randomisation, but also to whether or not asymptomatic children and adolescents should be included. The risk of including such children and adolescents is that they would reduce the ability of a study to show any statistically significant difference, if there is one. There is also the ethical issue of whether it is appropriate to put an asymptomatic child or adolescent through a psychotherapeutic intervention.

Those designing future studies should think carefully about which outcome variables are appropriate. There should probably be more standardised outcome variables that enable results of different studies to be directly compared. In addition, outcome variables should be better suited to reflect some of the broader aims of psychoanalytic/psychodynamic psychotherapy (Hodges 1999), such as a change in the structure of personality or the development of a more coherent sense of self. By simply focusing on symptoms - which are then reflected in corresponding outcome variables - treatments can become too focused on a change in symptoms. Though these symptoms may end up being successfully treated, the person may still feel that more profound difficulties persist. Symptoms “may remain or increase whilst profound change is taking place” (Boston 1993). This is often well understood in the commonly held idea that ‘things get worse before they get better‘. Psychoanalytic theory includes the idea of people having to painfully work through conflicts and grieve loss in their treatment. For example, before being able to recover, a child or adolescent victim of sexual abuse may have to gradually acknowledge the distressing idea that an admired or loved family member has abused the power of their position in the family. Furthermore, by simply focusing on symptoms and looking only at shorter term treatments, there is a risk that we miss underlying change and only measure symptoms at a time when as they are getting worse before they get better later in treatment.

Another important area of future studies should be to include outcomes that could identify potential harm to the child or adolescent as a result of the intervention. There are critics of psychoanalytic/psychodynamic psychotherapy who believe that it can be harmful to people. By including this outcome variable in future studies, professionals would be able to either highlight a link or dispel such fears.

Where possible, future studies should look at longer term interventions and they should ensure that the follow-up of participants continues for at least one to two years (if not more) after the end of the intervention, particularly in order to try to measure how long any improvements last for, or even whether improvements continue beyond the end of the intervention. There is evidence that the therapeutic gains following psychoanalytic/psychodynamic psychotherapy may be maintained and even increase following the termination of the intervention (Shedler 2010). It would also be important to compare briefer forms against longer term treatment to see if there is any difference. Where possible, though, the interventions should initially compare more closely to clinical practice (i.e. therapy once or twice a week for at least one year) and should include parallel or family work with the parents or carers. In fact, one study has suggested that psychoanalytic/psychodynamic psychotherapy without parallel work with the parent or carers may be counterproductive (Szapocznik 1989).

Traditionally, much research in psychoanalytic/psychodynamic psychotherapy has occurred in groups, but most clinical practice uses individual treatment (Hodges 1999). Therefore, it would be helpful to look at whether individual and group therapy have different outcomes, but research should focus on individual treatment where possible.

It would be interesting to investigate the covariance of effect sizes with other treatment characteristics (for example, experience and training of the therapist, therapeutic relationship, number of sessions, attrition rates) or participant characteristics (for example, effect of developmental level, severity and chronicity of the abuse, co-occurence with other forms of abuse or neglect, ongoing prosecution or court procedures) (Coren 2009).

We agree with Macdonald's final recommendation in her Cochrane review of cognitive behavioural interventions for children and adolescents who have been sexually abused (Macdonald 2012) that observational studies would help us get a better idea of how symptoms develop and then perhaps diminish over time. This would help us to think carefully about who should be receiving an intervention and whether one is needed at all.

Further examination of the process of psychoanalytic/psychodynamic psychotherapy for this population and what aspects bring about change is also needed. This would greatly help therapists to increase the effectiveness of the intervention (Llewelyn 2001).

7.1 CONTRIBUTIONS OF AUTHORS

The review was conceived by BP who also wrote the background, discussion and conclusion. The methods and results sections were written by WT. Both authors offered comments to all sections of the review. BP co-ordinated the work of producing the protocol and the review. The initial search strategy was designed and run by Jo Abbott in close collaboration with BP; the search strategy was later updated and run by Margaret Anderson (Trials Search Co-ordinator at CDPLPG).

7.2 DECLARATIONS OF INTEREST

Ben Parker - is the lead clinician and a consultant child and adolescent psychiatrist on an adolescent inpatient unit at the Priory Hospital Chelmsford. He has an interest in working with victims of abuse and trauma and has experience in psychoanalytic psychotherapy. BP received funding for travel and study leave to attend two Cochrane training days from South West London and St George's Mental Health NHS Trust.

William Turner - is a Counselling Psychologist with a particular interest in the evaluation of psychotherapeutic interventions.

10.1 CHARACTERISTICS OF INCLUDED STUDIES

10.2 CHARACTERISTICS OF EXCLUDED STUDIES

10.3 CHARACTERISTICS OF STUDIES AWAITING CLASSIFICATION