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METHODOLOGY
The literature search was conducted in October
2011 using MEDLINE, EBM Reviews (evidencebased medicine), PubMed, PsycINFO, ERIC (education), Social Work Abstracts, and PEP-WEB
(psychoanalytic electronic publications). The
search in MEDLINE combined the search terms:
child OR youth AND psychodynamic psychotherapy OR psychoanalytic psychotherapy OR psychoanalysis yielding 10454 results
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DEFINITIONS
Psychodynamic psychotherapy is based on the
core propositions of psychoanalytic theory6-9 derived from clinical observations. Research in experimental psychology and cognitive neuroscience provides the empirical foundation for these
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DESCRIPTION OF PROCEDURE
Psychodynamic psychotherapy for children may
be brief (6 to 20 sessions), moderate in length (21
to 60 sessions) or long-term (100 or more sessions). The framework of psychodynamic psychotherapy seeks to establish predictability,
which is reflected by meeting at a regular time
and place. Additionally, arrangements address
the plans for work with the parents or caregivers,
confidentiality issues, the goals of treatment and
the anticipated course of the treatment. The role
of other treatments or interventions, such as
medication or tutoring, is discussed. The therapist needs to be able to speak and play at the
childs developmental level, couching the communications the therapist wishes to make in
terms the child can understand.
Psychodynamic psychotherapy progresses
through three stages: the opening phase, the
middle phase, and the closing phase (commonly
known as the termination phase). Many psychodynamic psychotherapies are open-ended
treatments in which the length of treatment is
determined by the childs progress in meeting
the goals of treatment and by the childs ability to
maintain improvements despite on-going stressors. In long-term therapies the middle phase is
significantly longer than either the opening or
termination phases. In brief dynamic psychotherapies, in which the termination time is set from
the start, tasks of the termination phase are
addressed throughout the treatment.
Specific therapist tasks are integral to each
phase. These tasks may roughly be divided between those that shape the therapist-patient relationship, those that more directly facilitate the
patients self-understanding and change, and
those that pertain to the therapists work with the
parents or primary caregivers.
Classically, psychodynamic therapy emphasizes letting the child take the lead in deciding
what to do in a given session. This non-directive,
flexible approach is aimed at maximizing the
childs self-expression and ownership of the process. The therapist seeks to join the child as an
interested observer-participant. Psychodynamic
theory provides a structure for the therapists
thinking and planned interventions. These interventions can be adapted to a particular patient.
Opening phase:
The opening phase includes the initial contact
and evaluation, the formulation of the case,14 and
the establishment of the routines and the ar-
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HISTORICAL REVIEW
Little Hans, Sigmund Freuds 1909 report of a
5-year-old child who was actually treated by his
own father under Freuds guidance, is the first
reported psychotherapeutic treatment of a child.16
Hermione Hug-Hellmuth17 published the first
report on therapy using play and drawings to
communicate with children. Melanie Klein,18
Anna Freud,19 Berta Bornstein20 and Erik Erikson21 developed multiple conceptualizations for
the use of play in the treatment of children. David
Levy reported on brief, focused play therapy in
1939 to the American Orthopsychiatry Association.22 Levy emphasized education of the parents
and the treatment of the child was quite brief.
The major formative influence on child psychodynamic psychotherapy was the ego psychology of the mid-twentieth century.15,23 Additional
influences include attachment research,24-29 cognitive and learning theory,30,31 research on temperament,32 and mentalization.33
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namic play therapy for anxiety and psychodynamic therapy for conduct problems.40
In recent years, improved research design for psychotherapy efficacy research is adding to the existing
knowledge about effectiveness and efficacy.41-47
Studies of Time-Limited Psychodynamic
Psychotherapy
According to Cicchetti et al.,48(rct) toddlers of
depressed mothers show a higher incidence of
insecure attachment. Such children who received
45 weekly sessions of therapy with a focus on
changing their self and maternal representations
developed secure attachments equal to those of
the toddlers of non-depressed mothers. Jellinek
et al., similarly demonstrated improved maternal
function in traumatized parents towards their
toddlers.49(cs)
Kernberg and Normandin50,51 developed a
manual for 30 sessions of weekly play therapy for
sexually abused children. The treatment focuses
on transforming the experience of trauma into a
memory of trauma, facilitating reflective functioning, and transforming traumatic play into
normal play. Preliminary findings indicate significant reduction of symptoms, improved relatedness, and normalization of play.
Toth et al.,52(rct) in a randomized controlled
study of maltreated preschool children stratified
into three treatments: psychodynamic preschooler-parent psychotherapy (PPP), psychoeducational home visitation (PHV), and community
standard care (CS) and a comparison group of
non-maltreated, normally developing children
(NC), found that the PPP group evidenced a
greater decline in maladaptive maternal representations and more positive expectations of the
mother-child relationship.
Muratori et al.,53(ct) in a 2-year follow up of
psychodynamic psychotherapy for internalizing
disorders in children, studied the efficacy of a
time-limited (11-week) combined individual and
parent-focused psychodynamic psychotherapy
for children compared with treatment as usual in
the community. At the 2-year follow-up, the
Child Behavior Checklist results indicated that
psychodynamic psychotherapy acted on both internalizing symptoms and externalizing dimensions. Attention, delinquent, and aggressive scales
demonstrated significantly improved mean scores
for the study group relative to the comparison
group. Moreover, the active treatment condition
reduced comorbidity and resulted in less frequent
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FREQUENCY OF THERAPY
Frequency of therapy may be a significant variable. Heinicke and Ramsey-Klee62(ct) compared
children with learning problems seen four times
a week for one year with children seen once a
week by the same analyst. Both groups improved
equally in reading and spelling, but in an 18month follow-up the higher-frequency group demonstrated significant differences. Children seen
four times weekly showed higher self-esteem and
greater capacity for appropriate peer relations.
They were freer to express a wider variety of
affects. They were judged to be more autonomous and assertive. They had greater capacity to
reflect about their behavior and motives. The
defense mechanisms they used were more balanced, flexible, and mature (Table 1).63
RECOMMENDATIONS
Recommendation 1. Psychodynamic psychotherapy requires training in psychodynamic
theory and techniques. [CS]
The therapist should be knowledgeable regarding child development and acquainted with
the range of psychodynamic theories (e.g., ego
psychology, object relations theory, attachment
theory, and self psychology). Clinical experience
should be acquired under supervision. Optimally
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TABLE 1
NORMAL
Humor:
Anticipation:
Suppression:
Sublimation:
NEUROTIC
Repression:
Undoing:
Projection:
Introjection:
Isolation:
Somatization:
Regression:
Negation:
Turning into the opposite/
reaction formation:
Turning against the self:
Intellectualization:
Rationalization:
BORDERLINE
Splitting:
Denial:
Idealization:
Devaluation:
Projective Identification:
Omnipotent control:
Acting out:
PSYCHOTIC
Deanimation:
Animation:
Hypochondriasis:
Constriction:
Im taking some distance to see it from different perspectives, to master it while having fun.
Ill think ahead of time to be better prepared to handle it effectively.
Ill put it on hold for the time being, to return to it at a better moment.
Im lifting myself above the conflict, while still dealing with it.
As I am holding it in, Im not looking, Im not seeing, and I dont want to be aware of it.
I am placing it and then taking it away.
I am spitting, eliminating, discarding.
I am mouthing, swallowing, absorbing.
I am separating one feeling (or idea) from another.
Im expressing it in body language so as not to be aware of it.
I am turning backward. I am going back.
I am not seeing.
I am turning my back. I am putting forward one side of my experience rather than the other.
Im hitting myself. Im destroying what I build.
I am changing my experience into one of thoughts.
Im giving possible reasons other than the real one.
Two aspects of ones emotional life are experienced as independent from each other.
I am closing off.
The object is high above, while I am way below.
The object is down below, while I am way above.
The object (or experience) is outside. I am actively holding it at arms length so that it does
not return into me.
I must keep everything and other people in check.
I express it by action rather than in words.
It
It
It
It
Dismantling:
It
Fusion:
Autistic encapsulation:
Dispersal:
It
It
It
Note: These are defined operationally as narratives for easier recognition through verbal communication and through play themes. For classical definitions,
refer to Moore and Fine.94 Source: Kernberg P. Mechanisms of defense: development and research perspectives. Bull Menninger Clin.
1994;58:55-87.63 Copyright Guilford Press. Reprinted with permission of The Guilford Press.
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addressed to preconscious contents (i.e., contents that are accessible if attention is focused
on them), and continuing on to interventions
aimed at unconscious contents (i.e., contents
not easily accessible to the childs awareness).
The following interventions can be made
directly or within the play metaphor.
4. Supportive Interventions. Supportive interventions include educational statements, suggestions, or expressions of encouragement, reassurance, and empathy.
5. Facilitative Statements. Through facilitative interventions the therapist initiates, enhances, or
maintains the exchange with the child either
through invitations to continue his/her communications or by reviewing what has transpired in the session or in previous sessions.
a) Invitations to continue convey the therapists emotional availability and ongoing
interest. They also encourage the child to
verbalize experiences and events in the
session. Invitations to continue can be
open-ended, or the therapist may choose a
particular topic from the childs conversation and request expansion or additional
information on that specific topic.
b) In review statements the therapist paraphrases, summarizes, or integrates what
the child has said or done. By mirroring
back the childs experience, the therapists
verbalizations confirm and validate the
childs subjective experience, model selfobservation and sequential thinking, and
support the integrative functions of the
childs mind.
6. Clarifications. Through clarification the therapist expands the childs awareness into the
preconscious realm (i.e., what is knowable if
attention is focused on the particular topic).
Clarifications consist of preparatory statements and look at statements.
a) Preparatory statements focus the childs attention on the possibility of new meanings
in his/her comments, affects, play, and nonverbal behaviors. The statement alerts the
child to what is going on and that there
may be other meanings to be discovered.
The therapist provides a stimulus for selfobservation and self-assessment. Subsequent interventions provide opportunities
for the child to identify with the therapists function, strengthening the childs
ego so that the child acquires the capacity
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Mode of Intervention
Also important to effective verbal intervention is
the mode in which the therapist expresses the
intervention.88
a) In the direct mode the therapist refers to the
childs immediate appearance or behaviorYou look upset today.
b) In the therapist-related mode the therapist
refers to the childs perceptions of the
therapist in terms of the transferences of
past relationships that the child has begun
to reenact with the therapistI believe
you are seeing me as a police officer who
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Recommendation 14. The therapist must maintain objectivity and an attitude of consistency
and realistic hopefulness and neutrality. [CS]
The therapists empathy needs to extend to
each member of the family, without taking
sides, so that the child does not feel scapegoated and the parents do not feel criticized by
the therapist.
The therapists capacity to maintain objectivity
depends on his/her ability to be aware and keep
separate his/her own personal issues. Moreover,
the therapist has to be aware of how patients or
parents transferences to the therapist may elicit
reactions in the therapist that may contribute to
the loss of objectivity in the case.92 Self-reflection
and consultation enable the therapist to regain
objectivity.
PARAMETER LIMITATIONS
AACAP Practice Parameters are developed to
assist clinicians in psychiatric decision-making.
These parameters are not intended to define the
sole standard of care. As such, the parameters
should not be deemed inclusive of all proper
methods of care nor exclusive of other methods
of care directed at obtaining the desired results.
The ultimate judgment regarding the care of a
particular patient must be made by the clinician
in light of all of the circumstances presented by
the patient and his or her family, the diagnostic
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