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 physical 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

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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 parent 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

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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) depression and of the parents’ and child’s life-affirming goals PTSD symptoms. and conveying a message of hope and possibil- • Session 5: Feedback. ity are the core goals of the foundational phase and guide every aspect of treatment. For these The foundational phase culminates in an in- reasons, therapist comfort and skill in address- dividual session with the parent(s) to co-create ing traumatic events is a core CPP competency. Clinical considerations are primary in guid- a treatment formulation and treatment plan. The ing how the foundational phase is conducted. clinician elicits the parents’ experience of the The therapist consciously cultivates an empath- assessment, focusing on how they felt and what ic stance and active expressions of emotional they learned about themselves and their child, support in response to parental disclosures and and building on the parents’ description to ex- engages the parent in thinking how the emerg- plain the clinician’s own perceptions and rec- ing understanding might inform the co-creation ommendations. Although the therapist provided of a treatment plan. The therapist consistently preliminary therapeutic interventions—includ- weaves into the sessions the rationale for joint ing psychoeducation and trial insight-oriented parent–child sessions and explores the role of interpretations—throughout the foundational parental individual and cultural childrearing phase, the feedback session offers the oppor- values and practices, including attitudes regard- tunity to present a coherent formulation of the ing trauma disclosure. Although there are many clinician’s understanding of the child’s mental individual variations, the basic structure of the health needs in the context of the parents’ own foundational phase includes the suggested top- individual needs and family circumstances. The ics described below. feedback culminates in the creation of “the formulation triangle,” in which the therapist suc- • Session 1: Obtaining informed consent; ex- cinctly links the proposed core etiological fac- plaining confidentiality; describing the legal tors to the child’s symptoms and explains how requirements to report maltreatment and how treatment will address these key causal con- the agency handles these requirements; learn- nections (see Figure 29.1). If the parents’ own ing about the reasons for seeking treatment, trauma history and mental health disturbances including whenever relevant, an exploration are an important etiological factor in the child’s of different perceptions and motivations in functioning, the therapist proposes a “parents’ the parent(s) and other involved parties, such formulation triangle,” in which the parents’ as the child welfare system; demographic pathogenic experiences are linked to their cur- information; child developmental history; child symptoms; and parental understanding rent individual functioning, perception of the of child symptoms and efforts to address the child, and parenting practices. The parents’ symptoms. experience is then linked to the child’s experi- • Session 2: Observation of the parent and child ence. When the parents agree with the proposed during structured and/or free-play situations; formulations, the next step involves a conversa- observation of the child in interaction with tion with the parents about how the child will be the therapist or another assessor during struc- introduced to treatment, taking into account the tured and/or free-play situation; assessment child’s developmental stage, individual differ- of the child’s developmental functioning ences, and capabilities. When the parents do not using structured tools or clinical observation; agree with the proposed formulation, the therapist engages the parents in a conversation that

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. assessment of the child’s functioning in alter- native settings or with other caregivers (e.g., leads to a consensus about next steps.

Core CPP Treatment observations are used during treatment to align therapeutic objectives to the child’s changing The feedback session marks the formal end of developmental needs. The safety and emotional the foundational phase and the beginning of the quality of the child–parent relationship is the core treatment, which is based on an agreed-up- unifying clinical theme across the birth–5 years on explanation between parent(s) and therapist age range encompassed by CPP. For this reason, about how to understand the child’s difficulties, the term “child–parent psychotherapy” rep- what presenting problems to focus on, how to resents an overarching construct that encom- introduce treatment to the child, and how the passes the age-specific labels of “infant–parent parent(s) will participate in the joint sessions. psychotherapy” (Fraiberg, 1980; Lieberman, Silverman, & Pawl, 2000), “toddler–parent psychotherapy” (Cicchetti, Toth, & Rogosch, 1999; The First Treatment Session: Introducing Lieberman, 1992), and “preschooler–parent psy- the Child to CPP chotherapy” (Toth, Maughan, Manly, Spagnola, The first session builds on the feedback session & Cicchetti, 2002). With preverbal, prelocomo- by introducing the formulation triangle to the tive infants and their parents, CPP relies more child using words and actions that are geared extensively than treatment at later ages on the to the child’s developmental stage. The parent therapeutic techniques first described by Frai- is asked to explain treatment to the child when- berg (1980) to elucidate how real-life circum- ever possible, but many parents find themselves stances and the parents’ psychological difficul- at a loss for words even after agreeing to do so ties affect their capacity to cherish, nurture, during the feedback session. In those situations, and protect the infant. As the growing child be- the therapist takes the initiative in describing comes an increasingly more active participant the triangle of explanations to the child, asking in the sessions, the therapeutic focus moves for the parent’s participation as clinically indi- from an exploration of the parents’ subjective cated (see Figure 29.1). experiences to addressing the mutual parent– child perceptions, attributions, and emotional demands of the present moment. When the Treatment Considerations child is able to use language and symbolic play Child’s Developmental Stage to articulate feelings, the child’s understanding of external circumstances and his or her own The child’s developmental stage is incorporated inner world moves to center stage during the into the clinical case formulation, and ongoing sessions, and the parents’ individual subjective

Treatment

FIGURE 29.1. The formulation triangle: introducing the child to CPP. From Lieberman and Ghosh Ippen (2014). 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.

experiences are incorporated as an adjunct to 4. Young children are afraid of being hurt and the intervention rather than as a discrete focus of losing parts of their bodies. of attention. 5. Young children imitate their parents’ be- The CPP developmental framework incor- havior because they want to be like them porates the normative developmental anxieties and assume that the parent’s behavior is a first identified by Freud (1959) and repeatedly model to emulate. elaborated in subsequent decades (see, e.g., 6. Young children feel responsible and blame Brenner, 1976; Marans, 2005; Pynoos, Stein- themselves when the parent is angry or berg, & Wraith, 1995)—namely, fear of separa- upset for whatever reason. tion and loss, fear of losing the parents’ love, 7. Young children harbor a conviction that fear of body damage, and fear of not living up parents know everything and are always to the expectations of one’s social group. Trau- right. ma and environmental adversities consistently 8. Young children need clear and consistent exacerbate the intensity and pervasiveness limits to their dangerous or culturally inap- of these normative anxieties and give them a propriate behaviors in order to feel safe and firm basis in external reality. The persistence protected. of these early anxieties in the parents’ emo- 9. Young children used the word “no” to es- tional responses as adults is often overlooked tablish and practice their autonomy. by clinicians who are not attuned to the nature 10. Memory starts at birth. Babies and young and adaptive function of the normative fears of children remember experiences before they early childhood. Children manifest these fears can speak about them. through behaviors that often befuddle parents 11. Young children need their parents’ help and and evoke rejecting or punitive responses, in- support in learning to express strong emo- cluding inconsolable bouts of crying, prolonged tions without hurting themselves or others. tantrums, adamant refusals to comply, self- 12. Child–parent conflicts are inevitable due endangering behavior, hitting, biting, and other to their different developmental needs, but forms of aggression. Many of the seemingly in- they can be resolved in ways that promote comprehensible behaviors of infants and young trust and support development. children become not only understandable but also compellingly eloquent when understood in These developmental guidelines are the the context of specific situations or larger life backdrop for CPP interventions. CPP therapists circumstances that trigger or exacerbate these use them to guide their choice of interventions fears. Reciprocally, many parental responses and may describe a guideline to the parent as that are frightening to their children and evoke a way of expanding parental understanding of critical judgment on the therapist’s part are child development. The guidelines can also be rooted in the parent’s often unconscious fear of translated into language that is understandable loss, rejection, body damage, and self-loathing. to young children and used to facilitate the cre- CPP therapists endeavor to reach a simultane- ation of a shared emotional agenda between par- ous understanding of the child’s and the parent’s ent and child. This is done, for example, when emotional experiences as adaptations to these the therapist speaks for the child in the child’s universal fears. presence, in order to help the parent understand The following guidelines are used to expand the child’s experience. parents’ understanding and empathy for their children’s experience and to guide their search Parents’ Developmental Stage for an emotionally contingent and developmentally appropriate response (Lieberman & Van Development is a lifelong process, and the par- Horn, 2008). ents’ developmental stage is also incorporated into the treatment formulation. Parents’ ability 1. Young children cry and cling in order to to integrate the parenting role into their sense of communicate an immediate need for pa- themselves is influenced by the extent to which rental proximity and care. they have attained the normative developmen- 2. Separation distress is an expression of the tal milestones that precede parenthood, includ- child’s fear of losing the parent. ing a cohesive sense of self, mature intimacy in 3. Young children want to please their parents adult relationships, and satisfying engagement

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guidelines described earlier are weaved into the rehearse a range of outcomes in an effort to intervention as ways of promoting not only the achieve mastery over their reality (Erikson, parent’s understanding of the child but also the 1964). Children’s use of play to enact anxiety- parent’s increasing self-understanding, both as provoking experiences, to express wishful an adult and in the past, while growing up. fantasies, to symbolize and even to avoid emo- The ability to function adequately in adult tionally charged themes makes playing a natu- roles is an important component of the par- ral vehicle for therapeutic intervention. Like ent’s ability to nurture, protect, and socialize other child psychotherapies, CPP encourages the child. Adverse life circumstances, trau- play. CPP differs from other approaches in matic stressors, and mental health problems viewing play as not only as an individual child are recurrent obstacles to adaptive parenting endeavor but also an opportunity to help the because these factors have a direct impact on child and the parent to play together because the child’s moment-to-moment experience, and joint play can become the vehicle to co-create because they distort the parent’s ability to no- trauma narratives and protective narratives tice, interpret, and respond to the child’s needs. that address the relevant emotional issues con- The focus of treatment may expand or shift as fronting them. In addition to this therapeutic needed in response to urgent material need or function, play is also used in CPP as an oppor- family crises in order to bolster the parents’ tunity for the child and parent to be together functioning in their roles as providers and part- and enjoy the pleasures of mutuality and dis- ners in adult relationships. When the parents’ covery, as illustrated in Slade’s (1994) concept emotional needs are urgent and immediate, the of “simply playing.” CPP therapist resorts to a range of interventions to maintain or restore their capacity to attend to the child’s experience. These interventions in- Theoretical Influences clude dividing the therapist’s focus of attention between the child’s and the parents’ individual CPP carries the imprint of its psychoanalytic needs, adding parallel individual sessions with origins in infant–parent psychotherapy, which the parents, telephone conversations focused on became identified with the well known meta- the parents’ experience, and referral for indi- phor “ghosts in the nursery” (Fraiberg, Adel- vidual or group psychotherapy when clinically son, & Shapiro, 1975). This expression is used indicated. to describe the intergenerational transmission of psychopathology through the parents’ re- Child-Centered Focus enactment with their baby of unresolved conflicts from their own childhood. The lasting A hallmark of CPP is the child’s presence in imprint of the “ghosts in the nursery” model the session. Nevertheless, even when not physi- is manifested in CPP’s attention to the par- cally present, the child is maintained as the or- ent’s and child’s ongoing efforts to adapt to the ganizing focus of the intervention in the mind characteristics of (1) their environment, (2) the of the CPP therapist. Individual sessions with psychological and relational origins of current the parent aim at helping the parents function mental health problems, and (3) the parent’s and more effectively as adults for the sake of the child’s deployment of coping strategies and un- child, which includes becoming increasingly conscious defense mechanisms for the purpose attuned to responses and feelings mobilized by of self-protection against intolerable internal their parenting role, and to the impact of their emotional states and external dangers. These behavior and psychological states on the child premises, defined by Rapaport and Gil (1959) (Lieberman & Van Horn, 2005). as the adaptive, genetic, and structural assumptions in the metapsychology of psychoanalysis, The Role of Play were also adopted by Bowlby (1969) as integral components of attachment theory. Play is the form of communication that most In addition, CPP incorporates the points of richly conveys young children’s efforts to make view advanced in attachment theory that (1) meaning from their experiences. Through the human infant is biologically predisposed to play, children express their understanding of form an affective bond with the mother figure; their external circumstances, enact their fears (2) frightening experiences with attachment

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attachment figures, are pathogenic events with Intervention Modalities long-term repercussions on personality structure; (3) maternal and paternal sensitivity to the CPP makes use of a variety of intervention mo- infant’s signals promote healthy adaptation; (4) dalities in response to different clinical needs observation of child behavior in ecologically (Lieberman & Van Horn, 2005). The unifying representative environments is the bedrock for threads across modalities are the goal of pro- the understanding the etiology of early psycho- moting healthy development in the child and pathology; and (5) a prospective approach is the parent, and the simultaneous attention to essential to understanding the relationship be- the child’s and the parent’s experiences for the tween risk factors and their manifestations in purpose of supporting their relationship. The the course of development (Ainsworth, Blehar, cross-disciplinary nature of CPP is reflected in Waters, & Wall, 1979; Bowlby, 1969). the use of modalities informed by social work, In addition to psychoanalytic and attach- along with modalities based on developmental ment theory, CPP encompasses other theoretical psychology, psychoanalytic/attachment theory, perspectives as well. Developmental psychopa- trauma, social learning theory, and CBT. Sev- thology contributes an understanding of devel- eral of these modalities were first described by opmental outcomes that is informed by the in- Fraiberg (1980) as components of infant–parent clusion of biological, psychological, social, and psychotherapy. cultural levels of analysis and attention to the transactional processes among risk and protec- Translating Behavioral Meanings Using Play, tive factors within and between these domains Physical Contact, and Language (Cicchetti & Sroufe, 2000). Theory and clinical strategies from the field of adult and child Many problems in the child–parent relationship trauma are incorporated when the child and/or involve misunderstandings or distortions in the parents have experienced traumatic events the meaning that parent and child give to each (Pynoos, Steinberg, & Piacentini, 1999; van der other’s behavior. This is a particularly salient Kolk, 1987). The influence of a cross-disciplin- problem when trauma exposure has a nega- ary, integrative perspective is also manifested in tive impact on the developmentally appropriate CPP’s use of principles from cognitive-behav- perceptions that parent and child have of each ioral therapy (CBT) that aim at guiding cogni- other. In response to trauma, children might de- tive change as a port of entry to effect affective velop a conviction—which may be accurate or and behavioral change (Cohen, Mannarino, & distorted by their cognitive immaturity—that Deblinger, 2006), and principles from social the parent is the agent of the traumatic event, learning theory about the transmission of co- the parent willfully failed to protect, or the child ercive family patterns through imitation and precipitated the traumatic behavior through bad learning of family roles (Patterson, 1982). behavior. CPP aims to clarify and correct inac- The philosophical outlook encompassing curate or maladaptive attributions by describ- these different perspectives is the conviction ing the motives and function of specific child that hope and positive engagement with the behaviors to highlight how the behavior is an activities of living are the primary ingredients effort to cope with the normative anxieties of of any successful therapeutic endeavor. A new infancy and early childhood. As the child be- model of “angels in the nursery” has been in- comes increasingly attuned to parental motives corporated into CPP as a necessary counter- in the course of development, the intervention balance to the “ghosts in the nursery” focus on also involves age-appropriate explanations of unresolved conflict and psychopathology (Li- the parent’s point of view. Putting feelings into eberman, Padrón, Van Horn, & Harris, 2005). words, play, and physical contact are used as The pain, anger, and despair generated by ad- vehicles to build up trust and expand empathic verse relationships and life circumstances in understanding. the past and the present need to be countered To set the stage for the intervention, the with an affirmation that change for the better is therapist provides toys that are chosen accord- possible, and that benevolent old memories can ing to the child’s developmental stage and the be retrieved from the past or new supportive goals of treatment, including toys that evoke re- memories can be created in the present to stand lationship themes (a family of dolls that match as “angels in the nursery” that will guard over the child’s and family’s ethnicity; farm animals;

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and self-care (kitchen and eating utensils, toy developmental guidance that is tailored to their food); materials that promote artistic expression cognitive and emotional resources because they (paper and crayons); toys that reflect the spe- are reassured by learning that other children cific stressors endured by the child (police cars, also feel the way they do. Developmental guid- ambulance); and toys that promote the theme ance is not restricted to information about nor- of healing (medical kit). The selection of toys mal development. In the aftermath of stressful may change in the course of treatment as some or traumatic events, providing psychoeducation themes are outgrown and new themes emerge. about expectable responses can be extremely CPP encourages play between the parent and helpful both to the parent and, to the extent that the child, with the clinician taking the role of it is age-appropriate, to the child because it nor- encouraging play, participating as requested malizes their reactions and makes them feel un- by the child, and serving as a translator of the derstood and accepted. play to clarify its meaning in ways that enlarge understanding and provide support for the child Modeling Appropriate Protective Behavior and the parent. Putting feelings into words is systematically In this modality, the therapist takes action to pursued as an avenue to help children under- stop dangerous or self-destructive behavior. stand and manage intense emotion. Strong feel- Modeling protective action is particularly rel- ings are always felt, first and foremost, through evant to parents and children whose percep- bodily sensations, and young children’s need to tions of danger and safety are unrealistic or translate these body sensations into words is an distorted as the result of repeated exposure to important building block in the ability to regu- family or community violence, or other trau- late affect. Describing in words what the child matic experiences. Young children’s ability is experiencing helps to correct mutual misper- to appraise danger is undermined when their ceptions and misattributions. The parents’ own own attachment figures become the agents of emotional regulation improves when they par- fear. When this happens, the therapist’s pro- ticipate in a therapeutic process in which put- tective actions are not only important in pro- ting feelings into words is an explicit focus of viding safety but also represent a commitment the intervention. to help the parents learn or relearn how to pro- The role of touch and affection is woven into tect their child. the intervention because physical contact is an important vehicle for building trust and con- Insight-Oriented Interpretation veying love between parent and child. When the child is frightened or upset and the parent This modality is used to clarify the unconscious does not intervene, for example, the clinician or symbolic meaning of behavior in ways that may first describe what the child is feeling, then increase self-understanding. Interpretation can speak about the reassuring power of picking be used with parents and with children capable up and holding a frightened child or letting the of receptive language. Well-timed interpreta- child sit on the parent’s lap. tions can help parents become aware of motives, negative attributions, and behaviors that Unstructured Reflective Developmental Guidance interfere with their ability to nurture and protect their children. However, the therapist must exer- The developmental guidelines listed earlier are cise good clinical judgment in deciding whether an example of the kinds of intervention em- offering an interpretation in the presence of the ployed in this modality. CPP developmental child may violate the parent’s privacy. Interpre- guidance is unstructured because it responds to tations can also help young children who blame the needs of the moment rather than following themselves for the traumatic event(s) or for their a prescribed curriculum, and it is reflective be- parents’ problems, by promoting a more accu- cause it encourages the parent to integrate think- rate understanding of causality and of their own ing and feeling into a new a more empathic un- role in the family. derstanding of development (Fonagy & Target, 2002). Developmental guidance also may in- Addressing Traumatic Reminders corporate reframing, empathy, and appropriate limit setting in response to the child’s behavior. When the child is referred for treatment follow-

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. Toddlers and preschoolers also can profit from ing a traumatic event, series of traumatic events,

or dangerous current circumstances, treatment sense of themselves is under assault by due to the must address traumatic play and other manifes- hardships of poverty and discrimination. In these tations of traumatic stress by enabling the child situations, emotional support becomes an end in to narrate the traumatic event through play, itself, as well as a therapeutic tool because it af- drawings, or verbal description, and by provid- firms the parents’ and the child’s right to dignity ing relaxation and reassurance experiences to and respect, and aims at increasing their self- address somatic reexperiencing and behavioral worth as members of society. reenactments. Many events traumatize the child and the parent simultaneously, such as car ac- Crisis Intervention, Case Management, cidents, community violence, and domestic vio- and Concrete Assistance lence. The parent also may experience vicarious trauma from witnessing what happened to the Parents facing acute problems of living can child, for example, when the child is abused by become more receptive to mental health treat- the other parent or attacked by a dog. Treatment ment when the therapist is actively involved in in these cases needs to address the impact of the alleviating their negative life circumstances. trauma on the parents as well, including appro- These activities may include advocacy with priate referrals when necessary. different agencies, consultation with the child care provider to prevent expulsion of the child Retrieving Benevolent Memories for inappropriate behavior, mediation between the parent and Child Protective Services if Just as it is important to identify and address questions of abuse or neglect arise, or referral traumatic cues, it is also therapeutic to bring to to other needed services. Crisis intervention conscious awareness what William Harris (per- is often the first intervention offered when the sonal communication, February 2004) called child is referred following a traumatic situation, “beneficial cues”—moments of well-being that such as maltreatment, community violence, or bolster self-worth because they serve as re- an accident. Ensuring safety is the first order of minders of experiences of being supported and business in these circumstances, and concrete cherished. Linking the past and the present is interventions can give the beleaguered parents a as important with benevolent experiences as sense that change for the better may be possible with conflict-laden memories. Remembering as the result of treatment. episodes of loving care can give parents the im- petus to provide such experiences to the child. When these benevolent memories are not avail- Selecting Ports of Entry for able, the treatment must provide a setting for the Therapeutic Interventions creation of new memories that offer a sense of trust, pleasure, and self-worth. Choosing what to address during a session can be daunting in joint child–parent sessions be- Emotional Support cause the therapist may often be confused by the multiple stimuli that demand his or her The therapist’s emotional availability is a core attention. In CPP, the concept of “ports of component of all psychotherapies. It takes the entry”—developed by Stern (1995)—is adapted forms of conveying, through words and action, to refer to the variety of elements in the par- a realistic hope that (1) the treatment goals can ent–child relationship system that may be used be achieved, (2) there may be sharing in the as the starting point for an intervention (Lieber- satisfaction of achieving personal goals and de- man & Van Horn, 2005). Because CPP targets velopmental milestones, (3) there may be help negative attributions and maladaptive parent in maintaining effective coping strategies, (4) and child behaviors, the therapist must choose progress will be pointed out, (5) self-expression ports of entry on the basis of clinical judgment will be encouraged, (6) and reality testing will be of what needs attention in the moment. One port supported (Luborsky, 1984; Wallerstein, 1986). might be chosen because the moment is charged In CPP, this stance on the part of the therapist with emotional meaning; another might be se- has the additional goal of modeling for the parent lected because it has important long-term im- and for the child ways of being with one anoth- plications for the child’s or the parent’s mental er. Emotional support is particularly important health. Once an initial port of entry is chosen,

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. in the treatment of parents and children whose other points of entry can open up in quick suc-

cession (although sometimes efforts to pursue a tried and tried, but you couldn’t do it.” The port of entry may seem to lead nowhere). Exam- mother’s face softened and she looked very ples of different ports of entry as opportunities sad. She said in a whisper, “The doctor told me for intervention are provided below. that my contractions were not strong enough.” The therapist said gently, “Both of you tried so Child and/or Parent Individual Behavior hard.” The mother cried again, and the therapist asked what she was feeling. The mother re- During a home visit that took place in the kitch- plied, “I feel like a failure.” The therapist said, en, a 3-week-old baby was crying loudly as his “I know you are very sad and upset right now. mother, still hurting from a C-section and ex- But you are not a failure. You gave birth to a hausted by sleepless nights, was describing her healthy and beautiful baby.” The mother said anger at her obstetrician, who insisted on the C- in a surprised tone, as if the thought had not section in spite of the mother’s entreaty to wait. occurred to her, “I did, didn’t I?” The thera- The therapist made a sympathetic comment pist smiled at her and said, “You sure did!” She about the fear and pain that the mother went then nuzzled the baby’s head and added, “And through, then said, using the child’s behavior he smells so good.” as an initial portal of entry: “He is crying so The conversation shifted to baby shampoo hard! He seems to be saying that he also had and the pleasure of the baby’s father in giving a hard time.” The mother replied angrily: “He him a bath. The therapist talked about the hor- thinks he had a hard time! He didn’t even push monal changes that the mother was undergoing, well enough to be born normally!” Taken aback and the impact of these changes on her mood, by the mother’s blaming of the baby, the thera- and said lightly that the body takes a while to pist turned her attention to the mother’s expe- adjust. By the end of the session, the mother’s rience and said, “You sound so disappointed mood was considerably brighter. with him!” The mother burst into tears, and for In this example, the therapist used the child’s a while mother and baby cried simultaneously. and the mother’s individual behavior as ports The therapist felt torn between her impulse to of entry into the meaning of their respective pick up the baby, her anger at the mother for experiences. By speaking to the baby’s ear- having a distorted perception of the child, and nest but unsuccessful efforts to be born vagi- pity for the mother’s despair. nally, the therapist facilitated a reframe of the After a silence, during which she struggled mother’s negative attributions to the baby and to sort out what would be the most helpful in- enabled her to acknowledge her own sense of tervention, the therapist allied herself with the failure at not having sufficiently strong con- mother’s experience as a bridge to build empa- tractions to prevent the C-section. The thera- thy for the baby, and said softly, “These first pist also normalized the mother’s feelings by weeks can be so exhausting, and you are still providing developmental guidance about the hurting from the incision. Can I do something hormonal changes she was going through. The to help you right now?” The mother and the combination of these interventions with con- baby continued crying. The therapist went to crete helpfulness in offering water and sooth- the kitchen sink, poured a glass of water, and ing the baby led to a more positive frame of brought it to the mother. The mother drank the mind on the mother’s part by the end of the water and thanked the therapist with a weak session. voice. The therapist asked, “Would you like me to Interactive Exchanges between Parent and Child see if I can soothe the baby? You look so tired right now.” The mother nodded wordlessly. Three-year-old Sam pushed his 18-month-old The therapist picked up and rocked the baby, brother when the toddler swiped at the tower of humming softly. As the baby’s crying subsid- the blocks Sam was building and made it fall. ed, she said to the baby, “Your mom did not The little boy fell on the floor and started cry- want to have a C-section. She wanted you to ing frantically. His mother picked him up while be born naturally.” The mother looked coldly screaming at Sam: “You are a murderer! You at the baby. The therapist continued talking to will kill him!” Sam started crying loudly, but the baby: “She was hoping that you would be his mother ignored him while consoling the stronger and would push more, but you were younger son. The therapist turned to Sam and

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. too little and did not know how to do it. You said, “Your mommy got mad when you hit

Manny, but you were mad because Manny hit to start exploring the themes of aggression and your tower and made it fall down.” She started victimization that were prevalent in this fam- rebuilding the tower, and invited the crying ily. The therapist was careful not to address Sam: “Let’s put it back together again.” Sam’s the mother’s perception of Sam as a murderer crying subsided and he joined the therapist in directly because the mother was still unsure rebuilding the tower. about the value of treatment and became easily While engaged in this activity, the therapist defensive when she felt criticized. The thera- turned to the mother and asked, “What did you pist affirmed instead the mother’s appropriate mean when you told Sam that he is a murderer?” desire to teach Sam not to hit, using this shared The mother, still angry, answered that Sam was goal as a platform to explore the larger themes aggressive toward Manny and she feared that of danger and of appropriate and hurtful re- he would seriously hurt his brother someday. sponses to danger. The therapist also dared to The therapist suppressed her wish to contradict name the lingering fear of the father’s aggres- the mother directly by telling her that this was sion as a possible model for Sam’s behavior—a an unrealistic fear. Instead, she made herself theme that had been described in the formula- remember that this was a mother with a long tion triangle both during the feedback session history of childhood abuse and domestic vio- and during Sam’s first treatment session with lence with the children’s father. She answered, his mother. “I agree with you that Sam needs to learn not to hit Manny. What have you tried to teach him Child Mental Representations of the Self not to hit?” The mother shrugged her shoulders and the Parent: Mobilizing Protection and said, “I tell him ‘no,’ but he doesn’t listen.” Turning to Sam, the therapist said, “Your mom A 2½-year-old boy was trying unsuccessfully doesn’t like it when you hit Manny. She wants to put a block into a shape container. He sud- to teach you not to hit because hitting hurts.” denly banged his head against the wall. His Sam continued building the tower and did not mother laughed and said, “Don’t do that.” The respond. The mother screamed, “Listen to what boy hit his head again. The mother said to the she is saying!” The therapist said, speaking to therapist, “He is so weird.” The therapist ad- both mother and child, “Learning not to hit is dressed both mother and child by speaking to very hard and takes a long time. Even grown- the child: “Your mommy doesn’t want you to hit ups are still learning.” The mother’s body re- yourself, but I think you are punishing yourself laxed, and sensing that she was less angry and because you couldn’t put the shape in the box.” more receptive, the therapist said to her, “I think The child looked fixedly at the therapist and anytime you see any kind of hitting you get hit his head again, but this time more slowly. scared that it will get out of control because of The therapist turned to the mother and said, “I everything that you went through.” This state- think he needs help to know that it’s okay if he ment opened the door for a discussion of the can’t put the shape in.” The mother said, “He’s mother’s fear of Sam’s anger. weird,” but then she turned to the child and said, Relieved that the mother could identify the “Come here, baby.” The child went to her and fear underlying her anger at the child, the thera- the mother sat him on her lap and put her arms pist moved to make the mother more aware of around him. The therapist commented, “All her attribution to Sam of adult-like destructive better now.” She then brought the shape sorter aggression. She said, “Maybe you see Sam as to mother and child and said, “Now you can try bigger and stronger than he actually is, and for- again.” This time the mother directed the child get that he is also a scared little boy trying to on how to put the shape into the container, and protect himself. I think Sam also thinks that the child succeeded in doing so. Manny is bigger and stronger than he actually The beginning of this scene revealed the in- is.” The mother listened attentively. The thera- tricate connection between this child’s mental pist then turned to Sam and said, “Hitting is too representation of himself and his perception of scary. Your mom remembers how scary it was how his mother saw him. The mother’s dismiss- when your daddy hit. She wants to keep you and al of the child’s distress at not succeeding rein- Manny safe.” forced his sense that he deserved punishment. In this session, which occurred 2 months into Instead of treating the mother’s use of the word treatment, the therapist used the mother’s per- weird as an entrenched negative attribution that

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. ception of Sam as a murderer as a port of entry called for direct intervention, the therapist en-

couraged instead a concrete maternal response Empirical Evidence that reassured the child, both by providing reassuring physical contact and by moving on to CPP has been accredited as an evidence-based successful problem solving as a way of dispel- treatment since 2011 by the Substance Abuse ling the child’s self-perception of having failed and Mental Health Services Administration and showing him that he could achieve his goal (SAMHSA) National Registry of Evidence- with his mother’s help. Based and Promising Practices. CPP efficacy Each of the previous examples illustrates a has been empirically documented in five ran- particular way in which the parents and/or the domized trials with high-risk groups of toddlers child were conveying a view of themselves or and preschoolers. The samples include anx- the other that detracted from nurturing, pro- iously attached toddlers of impoverished, unac- tection, and age-appropriate socialization. The culturated Latina mothers with trauma histories therapists’ interventions began with efforts to (Lieberman, Weston, & Pawl, 1991); toddlers of understand the motives underlying the child depressed mothers (Cicchetti, Rogosch, & Toth, and parent perceptions and behavior, framing 2000; Cicchetti et al., 1999); maltreated infants them in a supportive developmental context. and maltreated preschoolers in the child protec- As they unfolded, the interventions moved back tion system (Toth et al., 2002; Toth, Rogosch, and forth between child and parent individual Manly, & Cicchetti, 2006); toddlers of mothers behaviors, feelings, and mental representa- with clinical depression (Cicchetti et al., 1999); tions of themselves and each other. The choice and preschoolers exposed to domestic violence of ports of entry is extensive because relation- (Lieberman et al., 2005, 2015). ships affect relationships, and these influences Findings from these randomized controlled are expressed in a multiplicity of ways that open trials (RCTs) have demonstrated that this ap- up many possibilities for intervention (Emde, proach results in improvements in a variety of Everhart, & Wise, 2004; Lieberman & Van domains, including reduced child and maternal Horn, 2005; Sameroff & Emde, 1989). The spe- symptoms, more positive child attributions (of cific port of entry may be determined by factors parents, themselves, and relationships), im- such as the psychotherapist’s theoretical prefer- provements in the mother–child relationship ences; the parent’s cultural mores, educational and the child’s attachment security, and im- level, and temperamental style; the child’s tem- provements in child cognitive functioning. The peramental style and ability to symbolize; the five RCTs include more than 500 racially/eth- quality of the working relationship between the nically diverse children in households ranging parent and the therapist; and the urgency of the from poverty to middle-class backgrounds and clinical issues involved. populations of maltreated infants, toddlers, and Some parents are willing to reflect on the preschoolers in the child welfare system and child’s thoughts and feelings but become guard- preschoolers exposed to an average of five trau- ed or angry when the therapist addresses their matic events. Across studies, CPP groups had parenting practices. Other parents want to focus significantly better outcomes than comparison on their own situation and fend off efforts to groups posttreatment and at follow-up 6 months, include the child’s experience in the treatment. 1 year, and 9 years later in measures of child For these reasons, there are no “typical” CPP cortisol patterns, security of attachment, be- cases, and therapeutic strategies are tailored havior problems, aggression, PTSD symptoms, to the specific characteristics of the child and comorbid conditions, cognitive performance, the parents. In general, the match between the maternal avoidance, psychiatric symptoms, and therapist’s therapeutic strategies and the par- marital satisfaction (e.g., Cicchetti et al., 1999, ent’s and the child’s receptiveness is the best 2000, 2006; Ghosh Ippen, Harris, Van Horn, & predictor of treatment outcome. The timing of Lieberman, 2011; Lieberman, Ghosh Ippen, & questions, suggestions, and interpretations is a Van Horn, 2006; Lieberman, Weston, & Pawl, crucial element in fostering treatment motiva- 1991; Lieberman, Van Horn, & Ghosh Ippen, tion. The therapist needs to cultivate a careful 2005; Pickreign Stronach, Toth, Rogosch, & balance between addressing the relevant clini- Cicchetti., 2013; Toth et al., 2002). cal issues and remaining tactfully alert to the CPP also has evidence of cost-effectiveness. parent’s and child’s ability to tolerate and make In one follow-up study with children who had use of these interventions. open cases in the child welfare system, pre- 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.

schoolers in the CPP group had a 2% place- knowledge of early childhood development; (2) ment in foster care 1 year posttreatment com- specialized trauma knowledge; (3) knowledge pared with 21% in the comparison group (J. T. and competencies specific to the learners’ roles; Manly, personal communication, 2016). In an (4) ongoing practice; (5) evaluation of profes- effectiveness study with preschoolers in foster sional practice; (6) engaging supervisors and care who received CPP and matched controls key administrators to develop leadership; (7) who received treatment as usual at the Illinois interdisciplinary training to address intersys- Department of Child and Family Services, the tem fragmentation; and (8) consultation and CPP group had 50% fewer placement changes support to promote sustainability. In addition to than the comparison group (Habib et al., 2008). learning collaboratives, CPP is taught through A second effectiveness study at the University internships and fellowships for master’s, doc- of California, San Francisco (UCSF) found toral, and postdoctoral students. CPP currently that after 20 weeks of CPP, preschoolers and has 55 CPP trainers in 30 states, who maintain mothers had statistically significant declines in peer consultation through listserv exchanges PTSD symptoms, with large effect sizes (0.88– and twice-monthly conference calls for fidel- 1.20). These findings indicate that significant ity and cultural and system adaptations. Since improvements in children and in mothers are 2011, 96 implementation-level CPP trainings evident with a briefer dosage of CPP than the were conducted in more than 30 states. Interna- dosage of approximately 35 sessions used in tional outreach includes implementation-level the RCTs of CPP efficacy. The CPP treatment trainings in Australia, Colombia, Israel, and the manual is now in its second edition, with up- Scandinavian countries. dated fidelity forms (Lieberman et al., 2015). Community outreach is conducted to reach Training materials also include two books with infants and young children in need of mental clinical case studies (Lieberman, Compton, health services, whose families are unlikely to Van Horn, & Ippen, 2003; Lieberman & Van bring them to a mental health clinic. Horn, 2008) and the CPP Train the Trainers Through a model developed at the UCSF Manual (Ghosh Ippen, Van Horn, & Lieber- Child Trauma Research Program called the man, 2015). CPP therapists receive fidelity Tipping Point Mental Health Initiative, post- measures to input, which are scored using a doctoral students are placed in community- REDCap database or PDF data entry forms. based agencies to provide onsite CPP and integrate this approach with other services provided in the community agency. CPP super- Training and Community Dissemination visors provide clinical supervision to the postdoctoral fellows, as well as technical assistance CPP is disseminated nationally through the to the community agency staff, in order to in- Early Trauma Treatment Network, a center of crease efficiency in service delivery. Commu- the SAMHSA National Child Traumatic Stress nity agencies participating in the Tipping Point Network (NCTSN) that involves the collabora- Mental Health Initiative include a primary care tion of four university-based programs: UCSF clinic, a child care center, and family resource Child Trauma Research Program as lead pro- centers. gram; Child Witness to Violence at Boston In summary, CPP is a trauma-informed treat- Medical Center (Boston site); Child Violence ment for young children from birth to age 5 and Exposure Program at Louisiana State Univer- their families that endeavors to address the in- sity Health Sciences Center; and the Infant ternalization of pathogenic life circumstances Team at Tulane University School of Medi- into maladaptive psychological patterns start- cine. The training of clinicians in CPP is con- ing in infancy, with potential lifelong conse- ducted within the NCTSN learning collabora- quences for adult mental health and parenting tive model, which combines didactic teaching practices. Through direct service, training, and with competence training through case-focused dissemination activities, CPP practitioners are consultation for 18 months. Trainings incor- committed as a group to enhancing the mental porate the areas recommended by the Institute health of children and families, with special of Medicine and the National Research Coun- attention to the needs of underserved minor- cil (2015) Transforming the Workforce report ity groups with histories of marginalization (www.iom.edu/birthtoeight): (1) foundational and historical trauma as a vehicle to enhance 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.

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