Dynamic Psychotherapy for the Treatment of Depression in Youth

RACHEL Z. RITVO

KEY POINTS

To undertake dynamic therapy with a depressed child or adolescent, clinicians need to know the basic principles of dynamic psychology, the dynamics of depression, be able to construct a dynamic formulation, and be competent in structuring therapy and using dynamic therapy techniques.
The dynamic formulation focuses on understanding the patient in terms of psychodynamic psychology, the dynamics of depression, and the current developmental challenges. A dynamic formulation is akin to the patient’s personal story told from a psychologically minded perspective.
For children and adolescents, the dynamic formulation should always include the developmental challenges facing the patient.
The dynamics of depression arise from threats to relationships and/or to self-esteem. Anger and rage in response to these threats may be masked by the depressive sadness and slowing of behavior.
Traditionally, dynamic therapy has been an individual therapy, but increasingly there are models for dyadic treatments of the child and parent together.
Dynamic therapy has customarily been long term and open ended, but increasingly there are models for brief focused dynamic therapy for depression in children and adolescents.
Dynamic therapy is expressive, that is, aimed at allowing patients to express as much of their feelings as they are comfortable and able to express. Thus patients need to feel secure in the treatment setting. Clinicians need to maintain an empathic, nonjudgmental attitude and to hold the young person’s feelings of anger, pain, loss, and so on.
Dynamic therapy for children can be done through play.
Psychodynamic psychotherapy is hypothesized to work through the caring, understanding relationship that is established between therapist and patient, through the insight gained by the patient into the psychological roots of the depression, and through the development of more mature, adaptive defenses and internal representations.
Dynamic therapy can be used in conjunction with medication and additional psychosocial interventions.

Introduction

Shannon, 3 years old, is referred for evaluation because she is biting her peers and caregivers at her child-care center. Observing Shannon at the center, the evaluator notices Shannon spends long periods of time alone in a corner, wrapped in her “blankey,” sucking her thumb, and watching the other children at play, the very image of a sad, depressed preschooler. Shannon’s parents reported that Shannon’s life had been disrupted recently by an unusual number of stressors: Her mother went back to work for the first time in her life and Shannon went to child care, a baby brother was born 9 weeks earlier, a new nanny had been hired for the brother, the family had moved to a new house, and the parents were experiencing threats of downsizing at their jobs.1

What distinguishes Shannon’s sadness from normal sadness? The normally sad child might be subdued at child care but would not be sitting off in the corner day after day. Shannon might be diagnosed as having an adjustment disorder with depressed mood, rather than major depression, if she had only been symptomatic for a few weeks and an active, albeit ineffective, coping process was evident. Shannon’s symptoms are severe. She has been at child care for nearly 3 months and is increasingly withdrawn. She takes no pleasure in peers, her irritability and sadness spill over at home, and developmental progression in toileting and sleep routines has halted or even regressed. Major depression is the appropriate diagnosis.2

The consultant offered several interventions: The couple works to reduce marital stress, stabilizing bedtime and other routines, special time with each parent, and a behavior program to decrease the biting at child care. In addition, he met with Shannon weekly for one-on-one dynamic play therapy. That dynamic therapy gave Shannon a chance to express her feelings of anger and sadness over all the changes in her life and to master those feelings in the play setting. Additionally, the therapist provided a reliable, caring person who attended to Shannon’s feelings, helped her understand them, and, by getting to know Shannon’s feelings better, could help her parents understand them too.

EMPIRICAL EVIDENCE FOR PSYCHODYNAMIC TREATMENT OF DEPRESSION IN YOUTH

Psychodynamic approaches to the treatment of emotional and behavioral disturbances of childhood and adolescence have developed over the past 100 years, beginning with Freud’s report on “Little Hans” in 1909.3 A systematic retrospective chart review of 763 cases treated at the Anna Freud Centre in London identified 352 youths with emotional disorders.4 Nearly three quarters of these patients showed improvement in adaptation at the end of treatment. Children younger than 11 years were more likely than older children to be fully in remission at discharge. Youths with more severe pathology did better in psychoanalysis (four or more sessions per week) than with less frequent (one or two) sessions per week.

Research studies testing manualized psychodynamic psychotherapy for depressed and anxious youth have only recently been undertaken. Muratori et al.5 used an active treatment versus community services model to examine the short- and long-term effects of time-limited psychodynamic psychotherapy for children meeting DSM-IV criteria for depressive and anxiety disorders. The psychodynamic treatment condition achieved an effect size of 0.73 on the Children’s Global Assessment Scale (C-GAS). From end of treatment to 2-year follow-up, youth who received psychodynamic therapy showed continued improvement on the Child Behavior Checklist (CBCL). This continued improvement after completion has been found in adults treated with psychodynamic psychotherapy6 and is referred to by Muratori et al.5 as a “sleeper effect.”

Time-limited (30 sessions) psychodynamic psychotherapy for youths 9 to 15 years of age with major depression, dysthymia, or both was compared with family therapy in a randomized multisite trial that enrolled 72 patients.7 At the end of treatment, 74.3% of cases in individual treatment were no longer clinically depressed. At follow-up 6 months after treatment, 100% of youths in the psychodynamic treatment group were not clinically depressed. Drawing on the extensive clinical material recorded in the course of the studies, Trowell et al.8 published a qualitative analysis of two patients that provides a rich elaboration of the dynamics of depression in childhood and the stresses experienced by therapists providing time-limited treatment to severely distressed youths.

Although there are too few efficacy studies of psychodynamic therapy for children and adolescents to do a meta-analysis, there are sufficient studies in adults. Leichsenring et al.,6 in a meta-analysis of 17 studies of short-term psychodynamic psychotherapy (STPP) for treatment of specific psychiatric disorders, found STPP to be effective. The Anna Freud Centre chart review4 suggested that long-term intensive psychodynamic psychotherapy is more effective than shorter treatments. This finding has not been tested further in youths, but a 3-year randomized effectiveness trial has compared long- and short-term psychodynamic psychotherapy with solution-focused therapy in a sample of 326 adult outpatients seeking treatment for mood disorder (84.7%) or anxiety disorder (43.6%).9 Although no significant difference in outcome was noted between the short-and long-term therapies in the first
2 years, by the third year patients in the long-term treatment group showed statistically significant (14% to 37%) lowering of symptom scores on the Hamilton Depression Rating Scale, Beck Depression Inventory, Symptom Check List Anxiety Scale, and the Hamilton Anxiety Rating Scale.

HOW TO USE DYNAMIC PSYCHOTHERAPY

A therapist needs three basic skill sets to undertake a dynamic therapy with a depressed child or adolescent:

Knowledge of the basic principles of dynamic psychology and the dynamics of depression
Ability to construct a dynamic formulation
Competence structuring therapy and using dynamic therapy techniques

BASIC PRINCIPLES OF DYNAMIC PSYCHOLOGY

“There is more than meets the eye.” Conscious thoughts, feelings, and behaviors are determined by complex mental processes (e.g., memories, beliefs, wishes, defenses) that are outside of conscious awareness.
Symptoms, thoughts, and behaviors are “overdetermined;” that is, they arise from more than one unconscious source. Thus every communication or behavior has multiple meanings.
Templates (usually called internal representations) of relationships and of the “real world” are built from the child’s experience with parents, siblings, other significant persons, and the “real world.” These internal representations, largely unconscious, shape the child’s basic assumptions and expectations.
Transference is the repetition or reenactment, in a relationship with a new person, of the internalized relational patterns of past experience with parents or other significant persons. Transference in the patient–therapist relationship provides an opportunity to observe, understand, and revise these internalized relational patterns in the here-and-now of the sessions.
Internal, usually unconscious, conflicts occur in a person’s mind between competing urges, impulses, and desires and between these drives and internalized parental and societal prohibitions.
Defenses are unconscious patterns of thought or behavior that maintain psychological balance (homeostasis) and reduce anxiety and awareness of internal conflict10,11 (Table 11.1).
Emotions are signals. Dynamic psychology is particularly interested in signals of internal distress, conflict, and loss of internal balance. Anxiety and depression are typical affect signals of internal distress.

TABLE 11.1 DEFENSES COMMONLY EXHIBITED BY CHILDREN IN PSYCHODYNAMIC THERAPY

Denial	The disavowal of intolerable external reality factors or of urges, thoughts, feelings, and wishes.
Displacement	The transfer of emotions, ideas, or wishes from the original object to a more acceptable substitute.
Externalization	The attribution of internal conflicts to the external environment and a search for environmental solutions. In therapy, the therapist is used to represent the patient’s problem.
Reaction formation	The adoption of affects, ideas, or behaviors that are the opposites of impulses harbored either consciously or unconsciously.
Repression	The exclusion of unacceptable ideas, fantasies, affects, or impulses from consciousness. Repressed material emerges in disguised form in thought, speech, and actions.
Suppression	The conscious effort to control and conceal unacceptable impulses. Suppression is the exception to the rule that defenses are unconscious processes.
Somatization	The transfer of tension from drives or affects into disturbances of bodily functions or rhythms.
Turning passive to active	The management of affects and impulses stirred by a passive experience with a more powerful “other” by playing out in action or story the active “other’s” role. This includes identification with the aggressor.
Information from Edgerton J, Campbell RJ, eds. American Psychiatric Glossary. Washington, DC: American Psychiatric Press; 1994, Freud A. The Ego and the Mechanisms of Defense. New York: International Universities Press; 1936, and Freud A. Normality and Pathology in Childhood: Assessments of Development. New York: International Universities Press; 1965.

These principles are common to all psychodynamic and psychoanalytic treatments. In the United States, the term psychoanalysis is used only for treatments that occur three or more times per week and are performed by a clinician trained in psychoanalysis. Psychoanalysis, where available, might be offered to a child or adolescent who is engaged in psychotherapy but has not improved with a less intensive treatment. In other parts of the world “psychoanalysis” may refer to any therapy based on these principles.

THE DYNAMICS OF DEPRESSION

The dynamic precipitants of depression can be conceptualized as disruptions and frustrations occurring in one or both of two parallel lines of personality development: the line of development of stable, mutually-satisfying interpersonal relations (the anaclitic line) and the line of development of a realistic and positive self-identity (the introjective line)12, 13, 14 (Table 11.2). Depressed youths are struggling to contain anger, disappointment, frustration, and shame or guilt.

TABLE 11.2 DYNAMICS OF DEPRESSION

Interpersonal/Anaclitic Symptoms	Self-Critical/Introjective Symptoms
•Fears of abandonment •Helplessness •Weakness •Depletion •Clinging •Demanding attention •Rage •Sadness	•Worthlessness •Guilt •Sense of failure •Rage •Sadness