For many years psychoanalytic and psychodynamic therapies have been considered to lack a credible evidence base. Partly this has been due to a degree of reluctance among psychodynamic practitioners to support the kind of empirical research that would help to establish such an evidence base, while other approaches – especially cognitive behavioural therapy – appear to have been more active. But partly it is due to the fact that the research which has been done has not been gathered together and widely disseminated.
In the field of treatment of adults, the situation has finally begun to change, with the publication of a series of important reviews and meta-analyses culminating in the landmark summary by Jonathan Shedler on ‘The efficacy of psychodynamic psychotherapy’, published in the American Psychologist in 2010.1 This paper concluded that effect sizes for psychodynamic therapies are at least equal to those of other forms of treatment long-regarded as ‘evidence-based’, and that patients who receive such treatment not only appear to maintain their therapeutic gains after treatment ends, but in many instances continue to improve after treatment ends.
While the situation may have changed in relation to the treatment of adults, research examining the efficacy and effectiveness of psychodynamic treatments for children and adolescents has lagged behind. In 2004 Eilis Kennedy was commissioned by NHS London to undertake a systematic review of the literature,2 and in 2011 (with support from the Association of Child Psychotherapists) I joined her to update and revise the review. In conducting such a systematic review of the research, our intention was to provide as complete a picture as possible of the existing evidence base for individual psychodynamic psychotherapy for children aged between 3 and 18, thereby enabling more refined questions to be asked regarding the nature of the current evidence and gaps requiring further exploration.
This systematic review identified 34 separate studies that met criteria for inclusion, including nine randomised controlled trials (RCTs), the so-called ‘gold standard’ of outcome research. The findings indicated that there was some evidence to support the effectiveness of psychoanalytic psychotherapy for children and young people, although many of the studies reported in the review were small-scale, often lacking in carefully selected control groups, thus making it difficult to draw any firm conclusions with confidence.3 In 2017 we updated the review and, although only six years had passed, 23 new outcome studies were identified, of which five were randomised controlled trials.4 We are currently working on a further update for publication. Having completed a systematic search of the databases, 37 papers published since January 2017 were identified, comprising 28 distinct studies. This indicates an impressive rise in the amount of research being done in this field, and our initial assessment of the quality of studies also indicates that more recent studies tend to be larger in size, and better designed. A good example is the IMPACT study, an NIHR-funded randomised controlled trial, led by Professor Ian Goodyer from the University of Cambridge, which investigated the effectiveness of psychological therapies in the treatment of adolescent depression. When comparing Short-Term Psychoanalytic Psychotherapy (STPP) with Cognitive Behavioural Therapy (CBT) and a Brief Psychosocial Intervention (BPI), no significant differences were found in clinical effectiveness or total costs, although the results suggested that CBT may have the highest probability of cost-effectiveness.5 Studies such as this have had an impact on NICE guidelines, with the latest revision of NICE guidelines for the treatment of depression in young people identifying psychodynamic therapy as a treatment option, alongside other approaches such as Interpersonal Therapy (IPT) for adolescents, to be considered if the first line treatment of individual CBT is unsuitable.6
We have not yet completed our synthesis of the findings of the latest update of our systematic review with the earlier findings, but we hope – perhaps for the first time – to be able to draw some conclusions about what the evidence tells us regarding the effectiveness of psychodynamic therapy with children and young people. Although the amount of research is still tiny, the growth in the quantity and quality of research is encouraging. This is partly, we suspect, because of the increasing number of child psychotherapy trainings which have built links to university departments, facilitating a better link between academics and researchers. Increasing dialogue has led to better communication, if not to complete agreement.
Child psychotherapy practice and outcome research may still be separated by a significant gulf; but there is at least a bridge between them, and indications of increased movement in both directions!
1 Shedler, J. (2010) The efficacy of psychodynamic psychotherapy. Am Psychol, 65(2), 98-109. doi: 10.1037/a0018378.
2 Kennedy, E. (2004) Child and adolescent psychotherapy: a systematic review of psychoanalytic approaches. London: North Central London Strategic Health Authority.
3 Midgley, N. and Kennedy, E. (2011) Psychodynamic psychotherapy for children and adolescents: a critical review of the evidence base. Journal of Child Psychotherapy, 37(3), 1-29. doi: 10.1080/0075417X.2011.614738.
4 Midgley, N. et al. (2017). Psychodynamic psychotherapy for children and adolescents: an updated narrative review of the evidence-base. Journal of Child Psychotherapy, 43(3), 307-329. doi: 10.1080/0075417X.2017.1323945.
5 Goodyer, I. et al. (2017) Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial. Lancet Psychiatry, 4, 109-119. doi: 10.1016/S2215-0366(16)30378-9.
6 National Institute for Health and Care Excellence (2019) Depression in children and young people: identification and management, NICE guideline [NG134]. NICE: https://www.nice.org.uk/guidance/ng134.