Child Psychodynamic Psychotherapy Research Articles

The use of mentalization-based techniques in online psychodynamic child psychotherapy

Objective: Psychodynamic child psychotherapy is an evidence-based approach for a range of child mental health difficulties and needs to constantly adapt to meet the needs of children. This study is the first to investigate whether the use of mentalization-based interventions (i.e., a focus on promoting attention control, emotion regulation, and explicit mentalization) predicted a good therapeutic outcome in online psychodynamic child therapy sessions conducted during the COVID-19 pandemic. Methods: The sample included 51 Turkish children (M age = 7.43, 49% girls) with mixed emotional and behavioral problems. Independent raters coded 203 sessions from different phases in each child’s treatment using the Mentalization-Based Treatment for Children Adherence Scale (MBT-CAS). Results: Multilevel modeling analyses showed children with higher emotional lability benefited more from attention control interventions compared to those with lower emotional lability. Discussion: Interventions that focus on developing the basic building blocks of mentalizing may be effective components of therapeutic action for online delivery of psychodynamic child psychotherapy, especially for children with greater emotional lability.

Who Is Treating the Children? Training Child and Family Psychoanalytic Psychotherapists in China

ABSTRACT This article traces the development and evolution of The Psychodynamic Couple and Family Therapy Continuous Training Program in Beijing, China since its founding in 2009 as a two-year series of four immersion experiences in couple therapy training. The program’s learning components include a live clinical demonstration, didactic lectures, and small process learning groups. In the past 10 years, program faculty opted to include a child and family focus to address the relative absence of child psychodynamic psychotherapy training in China and the increasing mental health needs of Chinese children. Research on the training’s effectiveness is presented, highlighting the importance of the live clinical demonstration to the group’s learning, and supporting the importance of showing clinical theory and technique in action. Required adaptations from an in-person to an online training format owing to COVID are discussed. Examples drawn from the clinical demonstration, small process learning groups, and later emerging consultation groups are offered to show applications of the training model, challenges in learning, and cultural differences. The author contends that this training program and its extensions rely on the strong working alliance of its founders and illustrate the value of cross-cultural collaboration in training and treatment efforts.

The Role of Common and Specific Factors in Child Psychodynamic Psychotherapy: A Grouped Cases Study

ABSTRACT There is a growing evidence-base that suggests the effectiveness of the psychodynamic therapies for children, but the mechanisms by which the results are achieved still demand clarification. This study aimed to analyze the role of specific and common factors in the process of psychodynamic psychotherapy for school-age children and their association with psychotherapies outcomes. A longitudinal, repeated-measures design, based on the systematic case-study method was adopted. 204 sessions from four child psychotherapies were analyzed in terms of the therapists’ techniques, the therapeutic alliance, the use of the reflective functioning approach and the role of the symbolic play in the sessions. The outcomes were assessed based on mothers’ reports about children’s symptomatic improvement. Correlational, discriminant and regression analyses were used to examine the associations and the role of each factor in those therapeutic processes. The results indicated that the use of psychodynamic techniques and a stronger therapeutic alliance impacted more significantly the symptomatic improvement. The factor that presented more changes over time was the therapeutic alliance, increasing in two cases and decreasing in one of them, which did not show clinically significant symptomatic improvement. Common and specific factors walked together in these treatments, and both were important to produce clinically significant improvements.

Introduction to the Section: Widening the Scope of Psychodynamic Child and Adolescent Psychotherapy Research: Recent Applications and New Directions

ABSTRACT Recent developments in psychodynamic work with children and adolescents have made empirical research a higher priority in the field. In order to support the evidence-base of psychodynamic child and adolescent psychotherapy, more research is needed to identify the underlying therapeutic processes that make psychodynamic psychotherapy effective for different kinds of children and adolescents and contribute to the literature on therapeutic mechanisms of change. Drawing on the expertise of a range of contributors, this special section describes recent child and adolescent psychodynamic psychotherapy research illustrating a range of quantitative and qualitative methodologies that have been developed to investigate different clinical phenomena, processes of psychotherapy and outcome. These papers will serve as a vital resource helping researchers and clinicians develop clinically relevant research agendas to improve clinical practice and care with children and adolescents.

Bringing Reflective Functioning to the Community: Aspects of psychotherapy process in the Group Attachment Based Intervention

ABSTRACT This special section dedicated to papers concerned with change processes in psychodynamic child and adolescent psychotherapy poses a set of interesting questions. What makes an intervention psychodynamic? How do we measure psychotherapy process? How can we bring psychodynamically-oriented treatment to a wider community, especially those that would not otherwise have access? These questions highlight the rich dialogue that can take place when we draw on psychoanalytic constructs and techniques to inform clinically relevant research, and then extrapolate these, to bring treatment to where they are desperately needed.

Operationalized psychodynamic diagnosis in childhood and adolescence (OPD-CA): Changes across psychodynamic child and adolescent therapy

Psychodynamic therapies are effective in reducing mental health symptoms. However, little is known in terms of changes in the core psychodynamic concepts, like the structural level, interpersonal relatedness, and intrapsychic conflicts. The current study focused on these psychodynamic concepts – measured with the Operationalized Psychodynamic Diagnosis in Childhood and Adolescence (OPD-CA) – over the course of therapy and its relation to therapy outcome. Additionally, the OPD-CA axis treatment prerequisites was tested as a predictor of outcome. Therapists assessed the OPD-CA as well as the level of psychosocial impairment of 146 patients (aged M = 12.7 years, 62% female) at the beginning and end of therapy as part of a larger study on the effectiveness of psychodynamic psychotherapy. Structural level, interpersonal relations, and conflicts improved significantly over the course of therapy. Positive outcome was predicted by communicative abilities, positive self-relatedness and a high conflict level at the beginning of therapy as well as the improvement of these variables during therapy. Among the treatment prerequisites, only the subjective level of psychosocial impairment and the intrapsychic resources were predictive of outcome. Psychodynamic psychotherapy for children and adolescents may improve central psychodynamic concepts like structural level, interpersonal relations, and conflicts.

Parental reflective function and children's attachment-based mental state talk as predictors of outcome in psychodynamic child psychotherapy.

Mentalization, operationalized as reflective function, is defined as the capacity to understand behavior in terms of mental states. Mentalization can be self-focused (i.e., mentalizing that focuses on one's own thoughts and feelings) or other-focused (i.e., mentalizing that focuses on others' thoughts and feelings). Some studies in adult psychotherapy show the importance of patients' mentalization capacity for treatment outcome; however, this has not yet been investigated in psychodynamic child psychotherapy. This study aimed to investigate whether baseline parental reflective function (PRF) and children's mental state talk (MST) predicted changes in emotional and behavioral problems in psychodynamic child psychotherapy. The sample included 60 Turkish school-age children (Mage = 7.90, SD = 1.35, 43.3% girls) with internalizing (18.3%), externalizing (5%), and comorbid (56.7%) problems, and 20% of the children were in the nonclinical range. The mothers were interviewed using the Parent Development Interview, which was coded for PRF (self- and child-focused). Children were administered an attachment-based story stem task, coded for MST (self- and other-focused). The Brief Problem Monitor was administered every month over the course of treatment for a total of 366 sessions. Multilevel modeling analyses indicated that mothers' child-focused PRF and children's self-focused MST predicted changes in problem behaviors. Parents' mentalization about their children and children's mentalization about their own internal states could be predictors of treatment response in psychodynamic child psychotherapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychodynamic Psychotherapy for Children as a Trauma-Informed Intervention

This article outlines the underpinnings of a psychodynamic approach for the treatment of childhood trauma through strengthening the implicit emotion regulation system. Childhood trauma impairs the functioning of the emotion regulation system, where deficits are common in children with post-traumatic stress disorder (PTSD). Difficulties with emotion regulation arise out of disruptions in the development of neurobiological pathways through the interaction of constitutional determinants with environmental factors, including the child's relationships with caregivers and the broader environment. We propose that a therapeutic focus on traumatized children's defenses can overcome the damaging reverberations of trauma. This approach may bypass the difficulties of high attrition rates, expense, and limited generalizability characteristic of skills training-based modalities. An illustration of an intervention to help children address unbearable emotions in traumatic experiences through defense interpretation is presented. The manualization and study of this approach within a project titled Regulation Focused Psychotherapy for Children (RFP-C) presents a unique opportunity to contribute to the evidence-based canon of treatments for children with histories of trauma.

Psychodynamic technique and therapeutic alliance in prediction of outcome in psychodynamic child psychotherapy.

This study is the first to investigate the effect of psychodynamic technique (PT), therapeutic alliance, and their interactions with outcome in psychodynamic child psychotherapy. The sample comprised 79 Turkish children (mean age = 6.86 years, 38% girls) with discrete internalizing (22%), discrete externalizing (11%) and comorbid internalizing and externalizing (67%) problems. Independent raters coded 359 sessions from different phases of treatment using the Child Psychotherapy Process Q-Sort for PT and Therapy Process Observational Coding System-Alliance Scale. Problem-assessment measures were collected at intake and every 10th session in treatment using the Children's Behavior Checklist and Brief Problem Monitor. Multilevel modeling analyses indicated that the PT and therapeutic alliance interacted such that more use of the PT in the context of high therapeutic alliance predicted less problem behaviors, whereas in the context of low therapeutic alliance PT predicted more problem behaviors. This relationship was moderated by problem comorbidity such that for children with comorbid problems, though a strong therapeutic alliance was indicated, an increase in PT use did not have a significant effect. Findings suggest that the use of psychodynamic interventions is indicated in the context of a strong therapeutic alliance, especially for children with noncomorbid problems. Psychodynamic interventions may have an adverse effect if a therapeutic alliance is not established. For children with comorbid problems, keeping the relationship strong is important. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Multimodal affect analysis of psychodynamic play therapy

Objective: We explore state of the art machine learning based tools for automatic facial and linguistic affect analysis to allow easier, faster, and more precise quantification and annotation of children’s verbal and non-verbal affective expressions in psychodynamic child psychotherapy. Method: The sample included 53 Turkish children: 41 with internalizing, externalizing and comorbid problems; 12 in the non-clinical range. We collected audio and video recordings of 148 sessions, which were manually transcribed. Independent raters coded children’s expressions of pleasure, anger, sadness and anxiety using the Children’s Play Therapy Instrument (CPTI). Automatic facial and linguistic affect analysis modalities were adapted, developed, and combined in a system that predicts affect. Statistical regression methods (linear and polynomial regression) and machine learning techniques (deep learning, support vector regression and extreme learning machine) were used for predicting CPTI affect dimensions. Results: Experimental results show significant associations between automated affect predictions and CPTI affect dimensions with small to medium effect sizes. Fusion of facial and linguistic features work best for pleasure predictions; however, for other affect predictions linguistic analyses outperform facial analyses. External validity analyses partially support anger and pleasure predictions. Discussion: The system enables retrieving affective expressions of children, but needs improvement for precision.

Updates on the Status of a Research Program on Psychodynamic Child Psychotherapy: An Addendum

ABSTRACT This addendum will provide an update on the status of a naturalistic process-outcome psychotherapy research program developed at Istanbul Bilgi University Psychotherapy Center, a university-based outpatient mental health clinic. The research program investigates treatment processes in psychodynamic child psychotherapy, with a particular focus on psychodynamic techniques, mentalization processes, therapeutic alliance and symbolic play. The research is integrated in the treatment context, with detailed baseline clinical assessment and therapeutic process tools that are meant to inform clinical practice. The aim of the research is to provide preliminary answers about the effective components of psychodynamic child psychotherapy. The details of the research set-up, the development of the program and findings from studies will be shared.

Mentalization, session-to-session negative emotion expression, symbolic play, and affect regulation in psychodynamic child psychotherapy.

Internalizing and externalizing problems have been related to negative emotionality, and affect regulation deficits in several studies. Certain psychodynamic models of treatment use children's symbolic play activity as a medium to mentalize negative emotions in order to develop children's affect regulation. However, the complex associations among these constructs and their associations with outcome have not been examined. This study aimed to investigate, first, whether average mentalization practices in treatment, as well as session-to-session expression of negative emotions and symbolic play predict gains in affect regulation and, second, whether changes in these variables are associated with clinically significant change in symptoms and global function. The sample included 40 outpatient children, who underwent long-term psychodynamic treatment. Nine hundred seventy-five sessions were coded for children's symbolic play, affect expression (anger and dysphoric affect), and affect regulation characteristics, and each treatment was scored for average adherence to mentalizing principles. Time Series Panel Analyses (TSPA) indicated session-to session use of symbolic play predicted gains in affect regulation. A significant 2-way interaction indicated that dysphoric affect expression in high mentalization adherent treatments was associated with higher affect regulation than in low adherent treatments. Partial correlation analyses indicated that mentalization adherence in treatment was associated with symptomatic improvement at trend level of significance, and changes in affect regulation and symbolic play were significantly associated with gains in global function. Findings point to the importance of use of symbolic play, and dysphoric affect expression in the context of mentalization practices for gains in affect regulation and outcome. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Effects of long-term psychodynamic psychotherapy on life quality in mentally disturbed children

Objective: Long-term psychodynamic psychotherapy for children aims not only at improving symptoms but also at changing the quality of life. To our knowledge, no studies exist to date that focused on both aspects. In this paper, we investigated changes in problem behavior and health-related quality of life based on long-term psychodynamic psychotherapy with children suffering from emotional and behavioral disorders. Method: We investigated 76 children in the treatment group and analyzed pre- and post-treatment symptoms. Furthermore, we compared the outcome data with a control group of 27 children of similar age and diagnoses who received no psychotherapy, both under routine care conditions. The children included in the study were treated on average for 66 sessions. Parent and adolescent ratings on the Achenbach Scales and the Quality of Life Inventory for Adolescents were compared before and after treatment. Results: We found a highly significant improvement of internalizing symptomatology based on parent ratings with a large effect. Different from prior investigations based on short-term psychodynamic psychotherapy we found changes in quality of life with large effects. Conclusion: These findings indicate that long-term psychodynamic treatment can improve life quality in children beyond symptom change.

Mentalization in Child Psychodynamic Psychotherapy

Mentalization has been considered a common factor across therapeutic processes, inherent to all effective treatment models. However, empirical findings and evidence about the presence and relevance of the construct for use in child psychodynamic psychotherapy processes are scarce. To contribute to filling this gap, the aim of this study was to analyse three children's psychotherapies in regards to the similarity of the treatments to the mentalization process prototype. This study is exploratory, longitudinal and descriptive, and is based on the systematic case studies procedure. Three school‐age children and their therapists participated. Two hundred and seventy‐three sessions were coded with the Child Psychotherapy Process Q‐Set and analysed according to their similarity to the mentalization process prototype. The results showed that it was possible to identify the presence of elements based on the mentalization approach in child psychodynamic psychotherapy. In addition, the presence of the therapist's mentalizing attitudes was associated with increased feelings of security and a greater connection of emotions to experiences. The results corroborated the propositions that enhancing mentalization is an implicit process in child psychodynamic psychotherapy, and suggested the importance of acknowledging and understanding the essential elements that compose the treatment models.

Therapeutic alliance trajectories and associations with outcome in psychodynamic child psychotherapy.

This study investigated therapeutic alliance (TA) trajectories, their demographic and symptomatic predictors, and associations with outcome in psychodynamic child psychotherapy. The sample included 89 Turkish children (Mage = 6.87, SD = 2.11, 46% girls) with internalizing (37.11%), externalizing (21.14%), and comorbid (38.20%) problems; 12% of the children were in the nonclinical range. Independent raters coded 328 sessions from different phases of treatment using the Therapy Process Observational Coding System-Alliance Scale. Outcome measures were collected at intake and termination (Children's Behavior Checklist and Teacher Rating Form). Multilevel growth curve modeling indicated that TA showed a quadratic trend (high-low-high) over the course of treatment. The shape-of-change methodology indicated three subgroups following a stable pattern, a slow and an accelerated quadratic TA trajectory. Externalizing problems (teacher report) negatively predicted average TA strength. Boys and children with internalizing problems showed a declining TA trajectory, whereas children with externalizing problems (teacher report) showed an upward TA trajectory. Multivariate multiple regression analyses showed that the average TA (i.e., intercept) and the positive quadratic slope (the high-low-high pattern) positively predicted changes in internalizing and externalizing problems (teacher report). This study was the first to show the course of TA development in psychodynamic child psychotherapy, identify a number of child characteristics that facilitate and impede TA. Investigating both the strength and patterns of TA development when examining associations with outcome is important. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Development of Brazilian prototypes for child psychodynamic psychotherapy and cognitive-behavioral therapy.

This study developed Brazilian psychodynamic psychotherapy (PDT) and cognitive-behavioral therapy (CBT) prototypes for children with internalizing disorders (ID) and externalizing disorders (ED). Eighteen Brazilian experts in PDT (n = 9) and CBT (n = 9) rated the 100 items of the Child Psychotherapy Q-Set (CPQ) describing a hypothetical typical session based on their respective theoretical backgrounds for children with ID. They then rated the same items describing a hypothetical typical session for children with ED. A Q-type factor analysis with varimax rotation was performed. Expert correlations were high within each theoretical approach and each diagnostic category. The factor analysis identified three independent factors. CBT ratings concentrated on one factor, while PDT ratings loaded onto one factor describing treatment of children with ID and another factor describing treatment of children with ED. The sole CBT prototype reflected a general conceptualization of this approach and was undifferentiated regarding treatment of children with ID and ED. The PDT prototype for children with ID provided evidence of a process focused on interpretation, while the PDT prototype for children with ED characterized a supportive process with attention to the therapeutic relationship. This infers greater variation in the PDT setting for children with different conditions.

Resilience, Defense Mechanisms, and Implicit Emotion Regulation in Psychodynamic Child Psychotherapy

Resilience is associated with the internal capacity for the regulation of unpleasant emotions in the face of adversity. These self-regulatory processes, linked with both explicit and implicit emotion regulation systems, have wide ranging implications for overall psychological health. Child psychotherapy can be conceptualized as helping children adapt more effectively to the external environment and develop a more comfortable sense of self as a result of improved emotion regulation and, thus, greater resilience. Most available treatments for youth promote resilience by addressing the explicit emotion regulation system. These treatments include helping parents improve their parenting skills or helping youth modify dysfunctional thinking patterns. In these treatments there is less consideration of the key role of implicit emotion regulation in the enhancement of resilience. The psychodynamic construct of defense mechanisms offers an observable and measurable manifestation of implicit emotion regulation. Thus, addressing the nature of a child’s maladaptive defense mechanisms in the clinical situation can strengthen the implicit emotion regulation system without explicitly instructing the parent or the child to act in a more pro-social manner. This paper utilizes a Regulation Focused Psychotherapy for Children (RFP-C) model to describe how iterative, systematic interpretation of children’s maladaptive defense mechanisms can target the implicit emotion regulation system. This intervention aims to improve the capacity for self-regulation, increase the flexibility of responses to the environment, promote proactivity towards change, and improve interpersonal relatedness. As a result of increases in these adaptive implicit emotion regulation capacities, there is a resultant increase in resilience, especially for children who respond to stressful events with externalizing behaviors. A brief clinical illustration is provided.

Mudanças na psicoterapia psicodinâmica de crianças na visão de pais e mães

No campo da pesquisa em psicoterapia psicodinâmica das crianças, uma questão aberta é como avaliar sistematicamente as mudanças e quais se consideram fundamentais. Não se têm levado a cabo análises qualitativas acerca da visão de país e mães. O objetivo deste estudo foi investigar a percepção de pais e mãessobre as possíveis mudanças em suas crianças durante suas psicoterapias. O estudo teve enfoque qualitativo, descritivo, longitudinal. Os participantes foram país e mães de quatro crianças, assistidos na clínica privada por três psicoterapeutas treinados em psicoterapia clínica.Eles responderam regularmente ao questionário de pergunta aberta que se centrou nas mudanças percebidasno curso do processo terapêutico. Os resultados mostraram que os pais têm identificado mudanças no curso da psicoterapia de seus filhos, que eles não eram lineais e não se limitaram à melhoria sintomática. Também se identificaram mudanças no funcionamento mental das crianças e sua adaptação à realidade, e nas relações interpessoais.Se discutiu a importância da participação dos pais na psicoterapia das crianças e o seguimento de sua visão acerca do processo terapêutico. Eles podem proporcionar feedbacks importantes que contribuem para o progresso do tratamento.Palabras-chave: psicoterapia psicanalítica, mudanças, crianças.

Different perspectives in measuring processes in psychodynamic child psychotherapy

ABSTRACTThe aim of this study was to explore how different measurements can contribute to understanding processes of change in psychodynamic child psychotherapy. The Child Psychotherapy Q-Set (CPQ) was compared with the child psychotherapist’s description of the psychotherapy process, systematically collected every three months during therapy, and with the Feeling Word Checklist-24 (FWC-24) completed after each session. The aim was also to examine how these three different measurements together could describe change over time and how they were mirrored in the relationship between child and psychotherapist. The following questions were formulated: (1) What interaction structures can be identified with the CPQ? (2) How does the therapist describe the process in psychotherapy and how do therapists’ feelings appear using the FWC-24? (3) How do the different measurements enrich one another and contribute to the understanding of the psychotherapeutic process? (4) How can the therapy be described compared to a hypothetical psychodynamic child psychotherapy prototype session? A videotaped child psychotherapy was analysed in its entirety. The CPQ provided a picture of the psychotherapist’s and the child’s actions and interactions, which complemented the subjective image of the psychotherapist when filling out questionnaires and the FWC-24. Analyses of the interaction between the child and the psychotherapist indicated the importance of creating a supportive and secure environment to achieve a feeling of psychological closeness, before working with the child’s problems. The analysis of the therapy highlights the importance of the psychotherapist’s meta-competence, i.e., overarching competencies that psychotherapists need to use to guide any intervention, what interventions to use, and when they are suitable.

Interaction structures as predictors of outcome in a naturalistic study of psychodynamic child psychotherapy

Objective: The first aim of this study was to identify interaction structures (IS), which refer to clusters of items characterizing the course of psychotherapy in terms of reciprocal interaction patterns between the therapist and the child, secondly to assess their trends over the course of treatment, and finally investigate which IS predict outcome in long-term psychodynamic child psychotherapy.Method: The sample included 52 children with externalizing and internalizing problems. 192 sessions were rated with the use of the Child Psychotherapy Q-Set (CPQ). Outcome was assessed with the Child Behavior Checklist (CBCL) Total Problems, and Children’s Global Assessment Scale (CGAS).Results: A principal components analysis resulted in four IS, theoretically named Therapeutic Alliance, Children’s Emotion Expression, Child -Centered Technique and Psychodynamic Technique. Multilevel Modeling (MLM) analyses indicated significant linear growth on Psychodynamic Technique. Multiple regression analyses indicated that Psychodynamic Technique positively predicted changes on CBCL Total Problems and CGAS. In contrast, Child-Centered technique negatively predicted change on CBCL Total Problems, however follow up interaction analyses showed that externalizing children who received more Child-Centered technique showed more improvement on this scale.Discussion: Findings point to empirically derived components of psychodynamic child psychotherapy and provide preliminary answers about which aspects may facilitate change.