Psychodynamic psychotherapy for children is based on a range of assumptions concerning mental functioning that have gradually evolved over the past 100 years out of the theories of Sigmund Freud. As these assumptions have been widely reviewed, we need to provide only a very brief introduction here.

Psychodynamic child clinicians assume that:

The roots of child psychoanalysis lie in Freud’s observation of young children, most notably of the young Anna Freud’s wishful dream for strawberries,⁽²⁹⁾ his grandson’s separation game,⁽³⁰⁾ and his case study of Little Hans, a 5-year old with a phobic disorder who was treated by his physician father under Freud’s supervision.⁽³¹⁾

Play therapy, incorporating both an insight-oriented interpretive approach and the developmental assistance perspective, was introduced by Hermine Hug-Helmuth.⁽³²⁾ Thereafter, two women, in strong opposition but frequently making reference to each other, established the field: Anna Freud⁽³³⁾ and Melanie Klein.⁽³⁴⁾

Klein’s approach was to regard children’s play as essentially the same as free association with adults; that is, motivated by unconscious fantasy and activated by the relationship with the therapist (transference). The child’s anxiety required verbalization (interpretation) if it was to be addressed. The focal point of therapy was the verbalization of anxieties concerning destructive and sadistic impulses, whilst the child’s external relationships (with parents, teachers, etc.) were seen as peripheral and irrelevant.

A key construct was the notion of projective identification.⁽³⁵⁾ This term referred originally to the infantile tendency to project unwanted aspects of the self on to another person. The clinician, by understanding the child’s perception of her as a person, could gain valuable insights about conflictual aspects of the child’s experience of himself. Bion⁽³⁶⁾ described how the ‘container’s’ capacity to understand and accept the projections could be critical both to successful therapy and to normal development. More recently, Kleinian child analysts have been less likely to offer early interpretations of deeply unconscious material; defences beyond projective identification are more commonly considered.^{(17, 37)}

Strongly influenced by Melanie Klein, Donald Winnicott firmly endorsed her emphasis on the impact of the first years of life on childhood psychopathology.⁽³⁾ However, he also introduced new techniques (e.g. drawing) and various theoretical innovations, including the identification of a transitional space between self and other where the subjective object and the truly objective object could simultaneously be recognized.⁽³⁸⁾ The notion of transitional space, an intermediate area between the intrapsychic and the interpersonal, was critical to the development of an interpersonal^(39,40) and intersubjectivist⁽⁴¹⁾ approach within psychoanalysis.

Along this continuum, Anna Freud was perhaps most concerned with the child’s developmental struggle with a social as well as an internal environment. Her background as a teacher may have led her to be as concerned with children’s actual external circumstances as with their unconscious worlds.⁽⁴²⁾ Her focus was restricted to complications and conflicts arising from the child’s libidinal impulses and, unlike Melanie Klein, she rarely focussed on innate aggression. The interpretation of defence was central to her technique.⁽⁴³⁾ Her approach paid careful attention to limitations on the child’s cognitive capacities (ego functioning) and had as its explicit aim the restoration of the child to a normal developmental path.⁽⁴⁴⁾ Her concern with normal development led her to evolve a model of pathology as a disturbance of normal developmental processes, and she developed a systematic analysis of such anomalies using the concept of developmental lines.⁽⁴⁵⁾ Her propositions are in many respects consistent with modern developmental psychopathology.⁽⁴⁶⁾ Developmental help is aimed at facilitating the forward movement of the psychological processes that underpin social cognition and interpersonal function, and which include mentalization, impulse control and emotion regulation, symbolization and the use of metaphor, and the capacity for play.^(47,48) Notwithstanding the curious historical fact that Anna Freudian, Kleinian, and Winnicottian approaches all originated in London, the Anna Freudian approach came to dominate child therapy in the United States,⁽⁴⁹⁾ whereas in the United Kingdom and in Latin America Melanie Klein’s approach proved more popular.⁽⁵⁰⁾ Two comprehensive and detailed histories of the field have been provided.^(51,52)

Techniques of child therapy differ considerably depending on the degree of pathology manifested by the child. Two sets of technique may be distinguished: those with single diagnosis, usually involving anxiety, are offered what most would recognize as ‘classical’ forms of psychodynamic, insight-oriented therapy. Those with multiple diagnoses, severe behavioural problems and/or emergent personality disorders⁽⁵³⁾ require a different psychodynamic treatment approach. These will be discussed separately.