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Child–Parent Psychotherapy a Trauma-Informed Treatment for Young Children and Their Caregivers

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Child–Parent Psychotherapy a Trauma-Informed Treatment for Young Children and Their Caregivers CHAPTER 29 Child–Parent Psychotherapy A Trauma-Informed Treatment for Young Children and Their Caregivers Alicia F. Lieberman Miriam Hernandez Dimmler Chandra Michiko Ghosh Ippen Child–parent psychotherapy (CPP) is a rela- tions that impair the parent–child relationship, tionship-based treatment for infants, toddlers, such as depression, anxiety, and posttraumatic and preschoolers who are experiencing mental stress; and frightening or maladaptive parent health problems or are at risk for such distur- and child behaviors, including externalizing bances due to exposure to traumatic events, problems (e.g., excessive controllingness, pu- environmental adversities, parental mental ill- nitiveness, self-endangerment and aggression) ness, maladaptive parenting practices, and/or and internalizing problems, such as emotional discordant parent–child temperamental styles. constriction and social withdrawal (Lieberman, The overarching goal of treatment is to help Ghosh Ippen, & Van Horn, 2015). parents create physical and emotional safety for the child and the family. This goal of physi- cal and psychological safety is pursued through Reality and Internalization in the therapeutic strategies designed to promote an Child–Parent Relationship age-appropriate, goal-corrected partnership between parent and child (Bowlby, 1969), in The cornerstone of CPP is Bowlby’s premise which parents become the child’s protectors and that reality matters, and that the parents’ avail- guides in striving toward three components of ability and competence as protectors from early mental health: developmentally expectable danger are key ingredients in fostering young emotional regulation, safe and rewarding rela- children’s secure attachments (Bowlby, 1969). tionships, and joyful engagement in exploration Attachment theory placed the function of chil- and learning. In situations of danger to physical dren’s attachment and parents’ caregiving be- well-being as a result of domestic violence, mal- haviors in the evolutionary context of protection treatment, or community violence, CPP endeav- from predators and emphasized the role of en- ors to create a safe caregiving context by foster- vironmental threats not ameliorated by access ing the parents’ and child’s realistic appraisal of to a safe caregiver as an etiological factor in danger and promoting safe caregiving practices children’s mental health disturbances (Bowlby, as vehicles to increase the child’s trust in the 1988). Since the influential move of attach- parents’ availability and competence as protec- ment research from the level of behavioral ob- tors. More concretely, CPP targets for change servation to the level of internal representation dangerous environmental and family circum- starting in the 1980s (Main, Kaplan, & Cas- Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. stances; symptoms of mental health condi- sidy, 1985), there has been a growing interest 485 EBSCO : eBook Collection (EBSCOhost) - printed on 7/2/2019 3:16 PM via TUFTS UNIV AN: 1843598 ; Zeanah, Charles H..; Handbook of Infant Mental Health, Fourth Edition Account: s3579704.main.ehost 486 V. Intervention in the intergenerational transmission of anxious phatic about the pathogenic consequences of and disorganized patterns of attachment and a “knowing what you are not supposed to know concomitant decrease in attention to the child’s and feeling what you are not supposed to feel” exposure to real-life dangers as an etiological as children’s defensive strategies against the factor in attachment disturbances and mental dangers of knowing and showing how they feel health disorders in infancy and early childhood about frightening family events take the form of (Lieberman, 2004). dissociation, aggression, depression, and other CPP is based on the premise that given the maladaptive responses (Bowlby, 1988, p. 99). well-documented high level of young children’s CPP emphasizes the importance of an open and exposure to traumatic events such as accidental supportive attitude toward knowing and explor- injury and interpersonal and community vio- ing the impact of trauma as a core therapeutic lence (Lieberman, Chu, Van Horn, & Harris, strategy shared by most trauma-informed treat- 2011), it is essential to incorporate the identifi- ment approaches to help traumatized individu- cation of exposure to frightening and dangerous als put their trauma experience in context, nor- events and its impact on the child’s emotional malize their experience, differentiate between life as an integral component of therapeutic remembering and reliving the traumatic event, interventions in infancy and early childhood and restore healthy engagement with develop- (Lieberman et al., 2015). CPP helps parent and mental goals (Marmar, Foy, Kagan, & Pynoos, child discover and address sources of danger 1993). and fear, practice safe and enjoyable ways of CPP starts with a four- to six-session assess- acting and relating, and internalize perceptions ment and engagement period. This introduc- of themselves and each other as worthy and ca- tory stage constitutes the foundational phase pable of love and protection. These goals are of treatment and includes individual sessions pursued through joint child–parent sessions, in with the parent, with the goal of co-creating a which the CPP therapist uses spontaneous be- treatment plan based on a shared understanding haviors, interactions, and free play as ports of of the child’s needs. All effective treatment de- entry to translate the meaning of the child’s be- pends on the client’s motivation to collaborate in havior for the parent and to facilitate the child’s treatment, and the goal of the CPP foundational age-appropriate understanding of the parent’s phase is gathering and framing information to motives. create a collaborative relationship with the par- ent on behalf of the child. Information gathering includes the presenting problem, background of Assessing Real-Life Circumstances the referral to treatment, demographic infor- and Their Impact mation, child’s developmental timetable and The Assessment and Engagement Phase individual differences, and risk and protective factors in the family constellation. The parent It is widely known that young children are is asked about specific traumatic and stressful profoundly affected by their environmental events in the child’s life, and in the life of each circumstances and most specifically by what of the child’s primary caregivers. happened to them and to their parents. Expo- Throughout the foundational phase, the ther- sure to trauma and adversity may affect chil- apist balances information gathering with re- dren, parents, and their relationship through spect for the caregivers’ sense of timing in self- different transactional processes that have disclosure, but conveys a consistent message been comprehensively elucidated in the rela- that the questions are geared toward creating a tional perspective on posttraumatic stress dis- treatment plan by understanding how the real- order (PTSD) proposed by Scheeringa, Zeanah, life circumstances of the family may influence Myers, and Putnam (2003). Nevertheless, this the child’s emotional states and behavior, as understanding is not regularly translated into well as the parents’ self-perception, emotional systematic screening and assessment of risk well-being, and parenting practices. A recurrent factors, trauma exposure, and protective factors concern raised by clinicians who are first learn- when a young child is referred for mental health ing about CPP is that speaking with the parent treatment, with far-reaching consequences for and the child about traumatic events early in inaccurate diagnosis and inappropriate treat- treatment may be detrimental to the formation ment when trauma is not uncovered as a pos- of a therapeutic alliance. This concern has been Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. sible etiological factor in the child’s symptom disconfirmed by many years of practice. CPP picture (Crusto et al., 2010). Bowlby was em- outcome research has found that therapeutic EBSCO : eBook Collection (EBSCOhost) - printed on 7/2/2019 3:16 PM via TUFTS UNIV AN: 1843598 ; Zeanah, Charles H..; Handbook of Infant Mental Health, Fourth Edition Account: s3579704.main.ehost 29. Child–Parent Psychotherapy 487 engagement and progress are facilitated when child care), either through direct observation, treatment incorporates open acknowledgment interview, or structured questionnaire. of real-life conditions that affect children’s and •• Session 3: Assessment of child exposure to parents’ emotional states. Parents and children traumatic events, preferably using a struc- consistently respond with relief to the clini- tured instrument such as the Traumatic cian’s message that the frightening events that Events Screening Interview—Parent Report happened to them are influencing how they feel Revised (TESI-PRR; Ghosh Ippen et al., and behave, and that treatment can help change 2002). the behaviors that are interfering with their •• Session 4: Assessment of the parent(s) trauma sense of well-being and trust in relationships. history, preferably using a structured instru- Putting traumatic events in the larger context ment; assessment of parent(s)
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