Description of the condition

The sexual abuse of children and adolescents is a significant worldwide problem (De Mause 1991), the scale of which was largely unrecognised until the late 1970s (Finkelhor 1994a). Sexual abuse is traditionally divided into contact and non‐contact abuse (Peters 1986). Contact abuse can be further subdivided into penetrative and non‐penetrative sexual abuse. Penetrative sexual abuse includes oral, vaginal and anal penetration (Glaser 2002). Non‐penetrative sexual abuse includes touching, kissing and masturbation. Non‐contact sexual abuse includes deliberate exposure of breasts or genitalia or witnessing a sexual act, either live or in films and photographs in print or electronic form.

Finkelhor's 1994 review of prevalence studies of child sexual abuse in 21 countries (mainly English‐speaking and North European) reported rates ranging from 7% to 36% in women and 3% to 29% in men. Such variation was felt to reflect differences in the methodologies of studies, such as the definition of sexual abuse used, rather than substantive differences in the rate of childhood sexual abuse (Finkelhor 1994a). Adjusting for sample‐related variation, response rates and differences in definitions, Gorey and Leslie estimated a rate of 16.8% for women and 7.9% for men from 16 cross‐sectional North American community sample surveys (Gorey 1997). More recently, a meta‐analysis of prevalence rates of child sexual abuse between 1980 and 2008, including 331 independent samples with a total of over nine million participants, estimated a worldwide rate of self‐reported sexual abuse of 18% amongst female participants and 7.6% of male participants (Stoltenborgh 2011). Men make up the vast majority of abusers (85% to 90%) (Glaser 2002) and the majority of sexual abuse is perpetrated by either family members or acquaintances (Finkelhor 1994b). 

Importantly, sexual abuse is an event or a series of events; it is not a disease or medical condition (Finkelhor 1995). It often comes to the attention of services due to psychological consequences, which can be remarkably heterogeneous in their nature. This heterogeneity is partly because sexual abuse rarely occurs in isolation: it can occur alongside other forms of abuse and neglect (Mullen 1994; Ney 1994) and a wide variety of other disadvantages (for example, parental mental illness or substance abuse, child disability or illness, economic deprivation etc). 

The psychological effects of sexual abuse can range from significant symptoms and emotional distress to little discernible impact (one review of 45 studies looking at the impact of sexual abuse on children found four studies that estimated from 21% to 49% of victims to be free of symptoms (Kendall‐Tackett 1993)). The most common childhood effects of childhood sexual abuse include symptoms of post‐traumatic stress disorder (PTSD) and sexualised behaviour (Kendall‐Tackett 1993); other common effects are aggressive or disturbed behaviour, depression, anxiety, low self‐esteem, guilt, fear, eating disorders, self‐harm, suicidal ideation and suicide, substance misuse and relationship problems (Browne 1986; Beitchman 1991; Cotgrove 1996; Tyler 2002). Effects are often dependent on the developmental stage of the victim. Overall, the severity of abuse, use of force and the victim’s relationship to the perpetrator appear to have the greatest influence on the degree of impact of the sexual abuse on the victim (Tyler 2002). Another important factor is the reaction of primary carer(s) to a disclosure of abuse. Where adults around the child fail to acknowledge the abuse and fail to support the victim, the outcome for the child is likely to be worse.

Many children and adolescents who are sexually abused go on to experience a wide range of serious adverse effects in adulthood and some only begin to develop symptoms in later childhood and adolescence or beyond (‘sleeper effects’) (Putnam 2003). Intervention studies sometimes exclude asymptomatic victims as their inclusion is likely to cause an underestimation of the overall effect of the intervention for symptomatic victims. It is also unlikely for an asymptomatic victim to receive psychotherapy in everyday clinical practice; however, the possibility of an asymptomatic victim having ‘sleeper effects’ needs to be kept in mind. A higher than average rate of childhood sexual abuse is reported by adults suffering personality disorders and other psychiatric illnesses (Zanarini 1989; Brown 1991; Bulik 2001; MacMillan 2001), and besides intrapsychic difficulties, they experience a wide range of physical symptoms (Arnold 1990) and occupational, social and sexual difficulties (Mullen 1994).

Description of the intervention

Psychoanalytic and psychodynamic psychotherapy have their origins in the work of Freud (1856 to 1939) but the practice of psychoanalytic and psychodynamic psychotherapy for children and adolescents gained impetus through the theoretical interest and practice of Anna Freud and Melanie Klein (Daws 1987). Nowadays there are a variety of different approaches (for example, Kleinian, Freudian) under the umbrella of psychoanalytic and psychodynamic psychotherapy. These terms are often used synonymously (Gabbard 2005), but psychodynamic psychotherapy sometimes refers to a briefer form of therapy where the therapist is more active and focuses on a particular problem, rather than difficulties affecting the whole personality.

Despite there being different schools of psychoanalytic/psychodynamic psychotherapy used for a wide range of psychological problems, there are some common theoretical concepts: psychoanalytic/psychodynamic therapy involves a therapist listening to an individual and observing their behaviour. People are referred or seek help when they are in conflict over aspects of themselves or their relationships. Such conflicts are generally held to originate from difficulties in past relationships and experiences (for example, sexual abuse). These conflicts are thought to cause anxiety or psychic pain and are pushed out of consciousness and into the unconscious through the use of defence mechanisms (Bateman 2000). Some defence mechanisms may be helpful (for example, humour or altruism), but others may be developmentally immature and harmful (for example, denial, splitting, projection). Psychoanalytic/psychodynamic psychotherapy attempts to explore, through talking, play (with younger children) and the formation of a therapeutic relationship, how earlier experiences influence and perhaps seriously distort current thoughts, feelings, behaviours (actions) and relationships (McQueen 2008). Eventually therapy aims to help people have a better understanding of unconscious difficulties about which they may previously have been unaware and this is thought to allow resolution of their problems.

Psychoanalytic/psychodynamic therapy is usually one‐to‐one, but it can be done with families or with groups. One‐to‐one therapy tends to happen at a fixed time once or twice a week, but occasionally it can be more intensive: up to five times a week. If the therapy is with a child, parents or carers are often provided with parallel supportive work, which is vital to help them understand and manage their children’s behaviour safely (McQueen 2008).

Psychodynamic psychotherapy can be brief, lasting only a few sessions, but it can also last for months or even years, particularly when the hope is for deep resolution of difficulties affecting the whole personality (such as in psychoanalytic psychotherapy). When funded by state healthcare systems, insurance companies or for research purposes, therapy may be offered for a fixed amount of time (usually up to one or two years in the UK) and may target a particular problem, but it can sometimes be more open‐ended, especially when paid for privately. Therapists have usually completed a lengthy training, which includes undergoing their own psychoanalytic/psychodynamic psychotherapy. When providing treatment therapists tend to get outside supervision from a more experienced therapist.  

Following recognition or disclosure of sexual abuse, the first priority is ensuring the child or adolescent's safety. If conservative measures are not sufficient in order to protect them, the potential benefit of removing them from the home in order to protect their safety has to be balanced against the risk of their secondary traumatisation through separation from their family, particularly if the suspicion of abuse is subsequently proven to be unfounded. When their safety is ensured, good practice then involves providing them with an adult with whom they can talk about the abuse and their feelings (Glaser 1991). For children or adolescents who develop symptoms, treatment should be tailored to the developmental stage and needs of the individual (Finkelhor 1995;Ramchandani 2003). For many health professionals psychoanalytic/psychodynamic psychotherapy has been the psychotherapeutic treatment of choice. More recently Cognitive Behavioural Therapy (CBT), particularly Trauma‐focused CBT, has become more prevalent and there are many studies evaluating this, but the evidence, although in favour of CBT, is "more equivocal than some reviewers would suggest, including those who have themselves conducted trials" (Macdonald 2012).

How the intervention might work

There are a variety of theories about how the intervention actually works but, as with other forms of psychotherapy, the relationship between therapist and patient is felt to be important (Gabbard 2005; Midgley 2005). Insight (conscious understanding) of unconscious conflicts is thought to be particularly significant (Traux 1973). Insight is gained through interpretations offered by the therapist based on what the patient says and their behaviour. The patient is encouraged to talk about whatever comes to their mind ('free association'), but some therapists are more active and may ask questions. Therapists usually reveal very few details about themselves so that they are a 'blank screen'. The patient is thought to unconsciously behave towards the therapist in the same way that they experienced earlier relationships (for example, with a parent or an abuser), which also involves them re‐experiencing some of the original anxieties and distress. The transfer of feelings from previous relationships onto the therapist ('transference') allows the therapist to hypothesise about the unconscious conflicts and defence mechanisms of the patient. The therapist can then begin to give interpretations of the unconscious conflicts and defence mechanisms, helping the patient to gain conscious understanding of these.

Play is seen as the primary way for younger children to communicate their unconscious conflicts. The child expresses himself or herself through imaginative and symbolic play, drawing and games, providing the therapist with a window to understanding the child's anxieties, conflicts and defences. Children also talk while they play, and play provides a safe background for talking about painful subjects. While interpretation is important, the primary agent of change is "enhancing the child's symbolic, imaginative and mentalising capacities by increasing the range, depth and emotional richness of his play" (Target 2005). Through play they become able to express their internal conflicts at a more developmentally mature level and this is thought to be curative (Passey 1994; Target 2005; Emanuel 2006).

Eventually, in psychoanalytic/psychodynamic psychotherapy, the relationship with the therapist and the new understanding of the self is thought to be internalised and neural networks based on earlier childhood relationships and experiences are modified (Schore 1994; Amini 1996; Schore 1997; Gabbard 2000; Westen 2002a; Westen 2002b). In fact there is a rapidly growing evidence base (Midgley 2011) and research within the world of neurobiology and neuroimaging is increasingly providing experimental evidence for many of the psychoanalytic concepts (Beutel 2003).

Why it is important to do this review

In commenting on a Cochrane systematic review of cognitive behavioural interventions for children and adolescents who have been sexually abused (Macdonald 2012), which confirmed “CBT’s potential as a means of addressing the adverse consequences of child sexual abuse”, Eamon McCrory observed there is a “need for evaluation of other therapeutic approaches, notably psychodynamic psychotherapy” (McCrory 2007).

To date, there has not been a systematic review of high quality evidence (randomised controlled trials) of psychoanalytic/psychodynamic psychotherapy for children and adolescents who have been sexually abused. This is in contrast to a greater availability of research relating to the effectiveness of other psychotherapies (especially CBT). However, it is important to mention that this is changing and there are ongoing trials for psychoanalytic/psychodynamic psychotherapy for children and adolescents with other mental health problems (for example, Goodyer 2011) and also for adults who have been sexually abused as children or adolescents.

If psychoanalytic/psychodynamic psychotherapy is to continue to receive funding from state healthcare systems and private health insurance companies for treating children and adolescents who have been sexually abused, there is a need to to evaluate the available literature. This review sets out to serve that purpose.