The Anna Freud Centre's approach to evidence based practice

The Anna Freud Centre is proud of its contributions to the evidence base of child psychotherapy under the leadership of several Directors. In the view of the current Directorial Team, the progressive improvement of treatment for children and adolescents with mental health difficulties (emotional, relationship, developmental, behavioural and family problems) is a vital part of the task of leading the AFC.

The child psychoanalytic tradition, and the perspective on developmental psychopathology, founded and elaborated by Anna Freud and her colleagues at the Centre, continues fundamentally to shape our work. Click here to read more about the Centre's history. In the 25 years since Anna Freud's death, we and many others have worked hard to keep that tradition and perspective growing, relevant to the contemporary child mental health world, and responsive to new knowledge and methods in the worlds of clinical practice and developmental research (click here for one among many examples: Fonagy, P., Target, M. (2002). The History and Current Status of Outcome Research at the Anna Freud Centre).

One area of research which child psychotherapy and psychoanalysis has very much needed to engage with is the 'evidence-based medicine' approach to the evaluation of treatment outcomes and cost-effectiveness. This area of scientific work has become extremely important to healthcare policy and planning, and we have for two decades accepted the challenge to test our belief that a psychoanalytic approach, just like other clinical approaches, can be shown to be effective in the treatment of a variety of children's emotional and developmental problems.

Carrying out such research on an intensive, long-term treatment, which aims to achieve change across personality and development, not just in particular symptoms, is particularly difficult and expensive, and was in the past unwelcome to many psychoanalytic practitioners. We are very proud that members of the directorial team and others at the Centre have led the way in attempts to demonstrate the effectiveness of intensive psychoanalytic psychotherapy, using a variety of methodologies from qualitative and narrative approaches, through single-case experimental designs to full-scale randomised controlled trials (RCTs).

We have also been very active over a long period in training, supervising and consulting to many groups trying to do this work in other centres nationally and internationally. There is still a large gap between the evidence-base for psychoanalytic psychotherapy with children and that for briefer and more symptom-focussed therapies. Click here for information on our 2002 review of the evidence base for treatments for children and adolescents.

The Directorial Team's approach has been:

Accepting that the demand for evidence of effectiveness is legitimate and potentially facilitates improved practice, and better targeting of scarce resources, hence:
Being very active in outcome research for which we now have a well-established reputation as researchers and systematic reviewers
Making the case that outcome studies, especially the RCT design, do not deliver all the answers about the usefulness of a form of therapy, and that the current evidence-base across treatments has serious limitations, including its uneven coverage of different therapeutic approaches
Arguing that the relative lack of evidence to support the practice of psychoanalytic psychotherapy with children does not mean that it is less effective than other approaches, and that there are good reasons for believing that (particularly for certain groups of children) it is vital to have this treatment available
Encouraging and helping psychoanalysts and child psychotherapists to undertake outcome research despite its methodological challenges and the traditional antagonism towards empirical research in our field
Developing and demonstrating the usefulness of research designs in addition to the RCT (see the Thematic Review commissioned by NHS London, which includes some of our studies using other systematic methods)
Arguing, in major interdisciplinary scientific conferences on child mental health, that the 'gold standard' evidence-base of RCTs must be rooted in and complemented by clinical observation, case studies and single-case designs. Click here to view a recent presentation by Peter Fonagy on this topic at the 2007 ESCAP Congress.
Based on the credibility and balance of the above work, being invited to take leadership roles in policy development and academic reviewing (e.g. in the development of the NICE Clinical Guideline for treatment of depression in children), across the child mental health field
Working with our expert clinical colleagues to develop new protocols for treatment (e.g. parent-infant psychotherapy, mentalization based treatment for borderline personality disorder) applying a psychodynamic developmental model, including attachment theory and our understanding of social cognition, and collaborating with leading colleagues with other models such as systemic therapy, to meet the need for more widely-available and specific approaches which are nevertheless informed by our theoretical perspective

We think that there is an ethical obligation to try to collect systematic and transparent evidence to inform children, young people and families as well as professionals (who often have an unquestioned allegiance to one approach), given the large number of therapies available for emotional and behavioural problems. We do not think that we can assume we already know best, and our research has from early on turned up findings which have initially surprised our own profession but which have since become accepted and even enrich theory-building (e.g. Fonagy, P. & Target, M. (1996). Predictors of outcome in child psychoanalysis: a retrospective study of 763 cases at the Anna Freud Centre. Journal of the American Psychoanalytic Association, 44, 27-77.).

There seems to be a greater acceptance now in our field that an absence of evidence is not acceptable and the Centre, under its current leadership, continues to engage with and wherever possible expand the debate to ensure that decisions concerning treatment provision are always guided by all relevant information, in a rigorous but also open-minded way. We recognize that child mental health professionals committed to serve children and families do not agree about how different forms of evidence should be regarded, and that there has been a serious gap between academic research and practice 'on the ground' so that generalizing from research findings requires care and caution, and future research needs to be informed as fully as possible by clinical experience, in choosing questions to test and appropriate methods for doing so.

We believe that in time broad-based scientific research from both laboratory and clinic will yield increasingly effective methods for identifying and integrating best evidence with everyday practice. The Centre's leadership is convinced that empirical research is valuable for practice but equally that practice is also vitally necessary for grounding science and clinical research in everyday clinical observation and therapeutic work.