The limitations of studies on time-limited psychodynamic therapy for children and young people
A common and problematic thread that links research and outcome studies of psychotherapy for children and young people, is the fact as mentioned earlier, that the adolescent is in most cases the primary subject of study. In the research quoted above, identification of the adolescent or young person as the patient with a diagnosable mental illness or psychological/emotional difficulty lies at the core of the inquiry. This immediately takes the presenting problem out of the family and social context. We may argue that in adult psychotherapy, the adult brings themselves to therapy and takes responsibility for their problem and its treatment. Children and young people as minors however, are in a completely different situation and the psychological problems they present have significant meaning well beyond their individual selves.
When we examine the various child and adolescent outcome studies, we find that they do not perceive the interaction between the young person and their parents as being of central significance. This is both with respect to the treatment model, as well as with respect to how this model may influence outcome. Thus in the case of the IMPACT study, seven separate sessions are offered to parents versus 28 to the young person. This does not appear to be part of an interactive process. It is difficult to avoid the observation that in these research models, parents are relegated to the margins of their children’s treatment as well as their experience. It may therefore not be surprising that the outcomes of these studies are less positive than they might be. The problem appears to be that the method of inquiry here unnecessarily restricted, is a more significant contributor to the research outcome, than the quality of the data gathered. The method of inquiry also replicates what is essentially an adult centric model. Regrettably, whilst the proponents of psychodynamic psychotherapy are anxious to maintain their relevance through research and outcome studies, their employment of reductionist research methodologies do not serve the task well as it leads to what may be described as a methodological entrapment.
Additionally, a research inquiry such as the IMPACT study, attempts to service a number of different agendas simultaneously, some of which are clearly not compatible. There is first the need to prove the superiority of one mode of treatment over another for depression, namely psychodynamic psychotherapy versus cognitive behavioural therapy. Second, it would appear that the professional interests of the principal investigator Goodyer (2014) lie in a completely different direction, which is that of neuroscience. This is reflected in the Study Protocol (Goodyer, 2011) which states, ‘We will also determine whether time to recovery and/or relapse are moderated by variations in brain structure and function and selected genetic and hormone biomarkers taken at entry’. Thus, the design of the study required the participants additionally, to comply with submitting saliva samples for investigation of the hormone cortisol, as well as undergoing magnetic resonance imaging.
Given his reference to the disappointing initial findings of the IMPACT study, Goodyer (2014) has made it clear that he considers ‘behavioural phenotyping’ and ways of developing understanding of ‘endocrine and neural biomarkers’ through the establishment of mathematical models, the most promising approach to the treatment of adolescent depression. He concludes that this will enable practitioners to create a regime of ‘personalised medicine’ or a ‘bespoke treatment package’ for each adolescent that is bound to improve the way in which practitioners manage adolescent depression.
The question here appears to be that of incompatibility of discourses within this large research project. The fact that groups of practitioners come to the inquiry about adolescent depression from different theoretical and clinical positions is not in itself the problem. A problem emerges when there is no reflective dialogue between the proponents of these different approaches. Rather than being forced to react against each other, one would hope that this multi-centred focus could be used to constitute an inter-subjective search and inquiry into the problem of adolescent depression.
It is salutary in this respect to return to the opening paragraph of the IMPACT Study Protocol which states, ‘First depressive episodes tend to arise in vulnerable individuals exposed to current chronic psychosocial adversities and acute adverse life events’. The complexity and interpersonal and systemic elements of this problem would be unlikely to come to the fore if the parameters used to measure the effectiveness of outcome of therapy are indeed set within exclusive biomedical criteria. For example, assessing the brain scans of the adolescents will trump the changes ascribed to therapeutic intervention, since these findings cannot be so easily reduced to these measurable parameters. The complexity and meaning of the life events for the adolescents and their families further tends to recede in the light of the linear focus on outcome, negatively constructed as in ‘time to recovery’ and ‘risk for relapse’.
It is interesting to note that Shedler (2010) makes the point that outcome studies generally fail to show differences between treatments even if significant differences do exist. Shedler’s explanation for this is that there is a ‘mismatch between what psychodynamic therapy aims to accomplish and what outcome studies typically measure’ (Shedler, 2010, p.105). Shedler goes on to say that the primary reason for this, is that psychological health cannot be considered as the mere absence of symptoms, and that our research attention would be better focused on the ‘positive presence of inner capacities and resources that allow people to live life with a greater sense of freedom and possibility’ (Shedler, 2010, p.105).