1 Infant-Parent Psychotherapy in the Clinical World
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Infant-parent psychotherapy in the clinical world: An overview of principles and the range of evidence-based practices and practice-based evidence. Introduction. The practice of infant-parent psychotherapy within a team setting, serving a local high risk population, was probably one of the main starting points for the now world-wide infant mental health movement; although a psychoanalytic approach to the early development, emotional needs and treatment of infants was already widely established (e.g. Furman, 1951; Cramer, 1974; Lebovici, 1983; Mahler, Pine and Bergman, 1975; Spitz, 1951; Winnicott, 1965), building on a long history of psychoanalytic thought about infancy going back to before the second world war (see Willheim, 2013 for an overview). This form of service provision began with the pioneering work of Selma Fraiberg and her colleagues in the Child Development Project at the University of Michigan (1963-1979), where she was the professor of child psychoanalysis, having come from a long interest in applying psychodynamic thought to the development of young children (Fraiberg, 1959). In 1972 they created a psychoanalytically based service for struggling low income mothers, working in the family home rather than a clinic setting, calling it ‘kitchen sink therapy’ since from the beginning there was a hands-on element to their approach, engaging with what was happening in the moment and addressing as far as possible any negative issues in the physical as well as psychological world affecting the family. This initiative, and the clinicians trained within it, went on to form the nucleus of the Michigan Association for Infant Mental Health, which in turn led to the establishment of the international Infant Mental Health Journal and the creation of the World Association for Infant Mental Health with all its in-country subsidiaries across the world. Fraiberg moved to the University of California with colleagues Jeree Pawl and Alicia Lieberman in 1979 but tragically died of a brain tumour in 1982. Her work, though, lived on as it provided a dynamic template for the relationship-based training in infant-parent (and later child-parent) psychotherapy as developed by Liebermann and Van Horn (2008) in San Francisco. 1 The aim of Fraiberg’s service was to address both the multiple difficulties in the current living situation and the unconscious conflicts and core beliefs stemming from the mother’s early childhood experiences within her family of origin that might be distorting her perceptions of and interactions with her baby. At the original heart of infant-parent psychotherapy was the idea freeing the ‘baby in peril’ (Fraiberg, Adeleson and Shapiro, 1975: 403) by addressing the parent’s unconscious ‘ghosts in the nursery’, a graphic metaphor for unresolved conflicts from their own early childhood that are unconsciously being played out both in their relationship with their child and in what may be fixed beliefs about significant others and themselves – states of mind recapitulated within significant relationships. A more European tradition might speak of ‘fantasmatic interactions’ (Kreisler and Cramer, 1981) which are ‘unconscious ways of seeing, perceiving, and reacting to the baby that are rooted in the parents’ own early experiences as a child reawakened or reactivated by the baby’ (Lebovici, Barriguete and Salinas, 2002: 164). But whatever the terminology, it is the unconscious determinants of the parent-baby relationship that concern infant- parent psychotherapy, since ‘an infant has a profound and almost uncanny ability to evoke primitive, nonverbal, and deeply internalized relationships in his parents. The infant is an almost perfect transference object’ (Wright, 1985: 253). A mismatch between perception and reality is common and has happened to everyone, but when this might become a threat to a child’s development swift help is necessary. ‘In every nursery there are ghosts. They are visitors from the unremembered pasts of the parents; the uninvited guests at the christening’ (Fraiberg, Adeleson and Shapiro, 1975: 387). She and her team tied this into their philosophy of intervention, writing: ‘The key to our ghost story appears to lie in the fate of affects in childhood. Our hypothesis is that access to childhood pain becomes a powerful deterrent against repetition in parenting, while repression and isolation of painful affect provide the psychological requirements for identification with the betrayers and the aggressors’ (ibid: 420). Thus this was an approach that from the beginning set out to break the generational continuity of trauma. 2 However, although the focus on unresolved conflicts leading to misperceptions remains a central concept it is also over simplistic if this is the only factor worked with in treatment (it was not in Fraiberg’s team), since in a family struggling with multiple stressors there will always be many other equally important issues that disrupt the infant-parent relationship that should be addressed as well. The idea of a ‘multimodal’ provision is more productive and better suited to the clinical situation. ‘The therapist changes roles and techniques depending on the initial problem and how the situation evolves’ (Maldonado- Durán and Lartigue, 2002: 129). A multidisciplinary infant mental health team (obviously not using such a title for parents) with a choice of theoretical lenses leads to better understanding, more flexibility and access to a variety of techniques; one size will never fit all. ‘When therapists are trained to use different interventions, they can apply various strategies to specific clinical challenges, taking into account factors such as the family’s motivation to change, the infant’s particular problems, and realistic constraints of the situation …’ (ibid: 131). The multimodal team should, ideally, have the resources to address the infant’s current or prospective difficulties within the Russian Doll pattern of stepped relationships that applies to their unique situation. As below: 3 The metaphor of ghosts from the unremembered past continues to be a feature of descriptions of therapeutic work with parent and their very young children that fall under the all-embracing American term of Child-Parent Psychotherapy, which expands the work into the phase of toddlerhood and beyond when the balance of attention has to shift slightly. ‘The lasting imprint of the “ghosts in the nursery” model is manifested in CPP’s attention to the parent’s and child’s ongoing efforts to adapt to the characteristics of (1) their environment, (2) the psychological and relational origins of current mental health problems, and (3) the parent’s and child’s deployment of coping strategies and unconscious defence mechanisms for the purpose of self-protection against intolerable internal emotional states and external dangers’ (Lieberman, Dimmler and Ghosh Ippen, 2019: 490). The core task within this tradition is to unpack how the parent’s ongoing and past experiences and their implicit assumptions about parenting are influencing the feelings, behaviours, ideas and perceptions that are affecting their baby. An effect of past experience that may be invisible to the parent, manifest in the present will, without remediation, likely flow into the future. A parent’s selective interpretation, or perceptual biases, in tuning into and understanding her or his infant’s cues will shape the child’s burgeoning sense of self and their expectations of others. This is an insight-oriented approach, not invariably the best for every parent, and it should always be tempered with here and now support. Past the period of infancy proper, once the child inhabits a verbal world, this methodology also addresses the child’s internalised responses to trauma where what was once a defensive adaptation has become an interpersonal drawback. But there is a balance. These days infant-parent psychotherapists also look for strengths, especially the angels in the nursery - ‘messages of intrinsic goodness and unconditional love’ from the parent’s own childhood (Lieberman, Padron, Van Horn and Harris, 2005: 506) that once re- connected with will then have the potential to become a powerful emotional resource in the form of ‘benevolent influences that affirm and guard the course of development’ (ibid) that can continue to be internally accessed after the 4 therapy has ended. Hope comes from an identification with a protector or nurturer rather than with the aggressor. The same applies to self-esteem. Therapeutic focus. Infant-parent psychotherapy exists to enable the best possible relationship between caregiver and infant so that, in attachment terms, the former becomes a secure base and safe haven for the child and ceases to be the potential scaregiver of disorganized attachment. (The work is not limited to biological parents.) ‘While the infant’s mental health is the ultimate goal, the primary therapeutic focus of infant-parent psychotherapy involves the uncovering of unconscious links between the parent’s psychological conflicts and parenting practices that are gravely misatuned to the baby’s needs and derail the infant’s normative development’ (Lieberman, 2004: 98). However, much care has to be taken here that technique does not get in the way of always keeping the parent’s feelings and willingness to work within a therapeutic relationship in mind. If a parent finds it hard to engage with their baby then engaging with a therapist may well be difficult, possibly deeply threatening, and take time. If a parent feels defensive then they