# Parent-infant psychotherapy

Psychodynamic Therapy with Infants and Parents (abbr. PTIP) aims to relieve emotional disturbances within the parent(s), the baby, and/or their interaction, for example, postnatal depression and anxiety, infant distress with breastfeeding and sleep, and attachment disorders. It rests on attachment theory and psychoanalysis. Sigmund Freud suggested that a modification of his method could be applied to children, and child analysis was introduced in the 1920s by [Anna Freud].., [Melanie Klein], and Hermine Hug von Hellmuth. Klein speculated on infantile experiences to understand her patients' disorders but she did not practice PTIP. Donald Winnicott, a pediatrician and analyst, focused on the mother-baby interplay in his theorizing and his brief parent-child consultations, but he did not work with PTIP.

## Definitions

PTIP was introduced by Selma Fraiberg and Françoise Dolto after World War II. Fraiberg was trained in the ego-psychological tradition, while Dolto was a contemporary and colleague of Jacques Lacan. Another section Attachment-based therapy (children) complements the present one. A related method was developed by Esther Bick at the Tavistock Clinic in London, psychoanalytic infant observation, aiming to enhance therapy students' skills and to train clinicians who work with babies. This article focuses on "the phase prior to word presentation and the use of word symbols", that is, up to 18 months of age.
A psychodynamic perspective sees humans as struggling with unconscious urges that impact on their character, relationships, interests, passions, conscious attitudes, and cognitive capacities. PTIP focuses both on patients' behaviors and feelings as well as their unconscious motives for developing and maintaining them. Supportive elements are limited, though the therapist's "holding" or "containing" the patient's distress does have such ingredients. Other methods are more supportive and encourage the mother to change her behavior with the baby; developmental guidance, infant massage, interaction guidance, and Marte Meo. They are not covered here.
Parents strive consciously to bond with the child and provide a fertile ground for attachment. Simultaneously, their unconscious impulses may run in opposite directions. Psychoanalytic theory often regards the mother as the baby's primary object, especially, her body parts or functions that stimulate the infant's fantasy life. Her bodily closeness with the foetus and the child will add unique qualities to their relationship. Yet, modern fathers are involved with their babies and some therapists argue that they should be invited more often in PTIP.

## A late development

Sigmund Freud viewed the baby as involved in passionate relationships with his parents. He also uncovered infant-like remnants in every adult's personality. This affects the countertransference, the therapist's emotional reactions to the patient, even more so if the patient is a baby. The PTIP therapist is prone to a "massive identification with the child… it is not always easy to control one's reactions to [the baby's] positive or negative provocations". This may explain why PTIP took a long time to develop. Also, the notion of psychoanalysis as a "talking cure" led to the idea that the primary therapy data are words, rather than all the "representations or signifiers of process". This, too, may have prevented analysts from treating babies. Those from the tradition of ego psychology advise against attributing mental capacities beyond the baby's developmental time-table. This may make them reluctant to view the baby as an active participant in therapy. A final reason for the late development of PTIP might be that the high prevalence of postnatal depression and infant emotional disturbances, was demonstrated only recently. Many "baby worries" emerge at Child Health Centers without the mother feeling that she needs psychotherapy herself. It is the baby who functions, through various symptoms, as the alarm-clock.

## PTIP methods: A survey
### Infant-parent psychotherapy

Selma Fraiberg formulated brief crisis interventions, interaction guidance-supportive treatments, and infant-parent psychotherapy. The first focused on problems arising from a "circumscribed set of external events". The second aimed at guiding parents with a more limited psychological-mindedness and was more of an "educational technique". Infant-parent psychotherapy, in contrast, was a PTIP method used when a baby reminded the parents of "an aspect of the parental self that is repudiated or negated", for example a painful childhood memory. This "ghost in the nursery" marred the parent's interactions with the baby, who got engulfed in the parental neurosis and developed an emotional disturbance himself. The treatment goal was that "the pathology which had spread to embrace the baby" could be withdrawn and the mother-baby relationship improve. In randomized controlled trials (RCT), Fraiberg's method was about as efficacious as Interaction Guidance (Robert-Tissot et al.) and Watch, Wait and Wonder (Cohen et al.), though the effects were slower in coming. Compared with a non-intervention group, its results were superior (Lieberman et al.). Lieberman and Van Horn also wrote a comprehensive monograph, see under "Further reading".
Therapists in Geneva, work with less disadvantaged families than Fraiberg. Some publications were published in English. Their thinking resembles Fraiberg's but they focus more on the mother's psychopathology, for example, her self-preoccupation. The infant's symptoms might express "a repressed tendency in the parent", which enters into a "core conflictual relationship" with the baby and will be enacted in therapy. These clinicians seem to regard the child as less of an active therapy participant than did Fraiberg.

### Therapeutic consultations

The interventions of Serge Lebovici at the Centre Alfred Binet in Paris resembled Winnicott's therapeutic consultations and Fraiberg's crisis interventions. Whereas Fraiberg suggested the mother's trauma might build up to forming the "ghost", Lebovici focused more on how her unconscious infantile sexuality colored her relationship with the baby. The baby's presence in sessions stimulated the therapist's metaphoric function, which he used to understand the roots of the dilemmas of mother and child.
Some books by Françoise Dolto, another Parisian psychoanalyst, were translated into English but they do not cover her work with infants (see, however,). She thought a baby may understand some literal meaning of the therapist's words. This is refuted by research. On the other hand, babies seem to grasp that words indicate something special though they do not understand their literal sense. Dolto claimed that when parents conceal painful or embarrassing facts it may stunt the baby's development, as when a mother wishes to protect her baby and conceal her personal worries. This creates a paradoxical situation for the baby who might sense mother's painful affects beneath her care-taking. Dolto thought words impacted on the baby via the parent's courage in pronouncing embarrassing emotional truths: "Before the age of words, the presence of a mother speaking to her infant is a nourishment more valuable than the milk she offers at the breast".
Other Parisian therapists focus on psychosomatic disorders, which they link theoretically to infantile distress.

### Mother-infant psychoanalytic treatment

Like Dolto, the Swedish psychoanalyst Johan Norman sought to establish a relationship with the infant, who he thought possessed a primordial subjectivity and an intersubjectivity. He also thought the baby sought for containment from the therapist, and that she had a "unique flexibility in changing representations of itself and others that comes to an end as the ego develops". Early therapy was thus recommended. He addressed the baby about emotional processes but disagreed that she can understand the lexical meaning of words.
Questions about the baby's role in PTIP become less puzzling once we clarify that human communication takes place at various levels, among which the verbal is only one. Many analysts today use concepts by the American philosopher of Semiotics, Charles Sanders Peirce to describe the therapeutic process. They can help us understand the communicative levels in PTIP treatments. A similar perspective is used by infant researchers who micro-analyze the interactive mismatches of certain mother-infant interactions.

### The infant as subject

Therapists in Melbourne work with babies to "enter treatment through the infant's world rather than primarily through the parents' representations". They develop a relationship with the baby in presence of the parents, believing that "the infant as subject" needs engagement in his own right. They, too, are convinced that a baby may direct emotions towards a therapist but in some contrast to Norman, they do not privilege promoting the baby's negative affects towards him/her.

### Watch, Wait and Wonder

This technique (WWW; from the Hincks-Dellcrest Center in Toronto) has been compared with Fraiberg's mother-infant psychotherapy in an RCT. Its proponents argue that if a mother does not perceive and respond to her baby's signals, a secure attachment will not develop. The therapist asks her to get on the floor, observe the baby, and interact at the baby's initiative. Mother becomes an "observer of her infant's activity, potentially gaining insight into the infant's inner world and relational needs". The therapist is "watching, waiting, and wondering about the interactions between mother and infant" (p. 437). The method also contains supportive elements in providing "a safe, supportive environment…". See also.

### The PIP team at the Anna Freud Centre

Parent-Infant Psychotherapy (PIP) at the Anna Freud Centre in London integrates Freudian metapsychology with infant research, attachment theory and developmental psychology. The authors use a psychoanalytic framework and wish to promote "the parent-infant relationship in order to facilitate infant development" (p. 25), support the baby's "attachment needs" towards his caregivers (p. 8), and scaffold him to help in his "emotional regulation" (p. 26). The baby is seen as a "partner in the therapeutic process" (p. 79). The overall goal is to support his "beginning mentalization and emotional regulation" (p. 75).

## The impact of the setting and the clinical sample

Most authors worked in public health clinics, whereas Norman's cases were drawn mainly from his private practice and were long, high-frequency treatments with what seemed well-motivated parents. Fraiberg often treated mothers with a low educational and economic status, which also applies to the London PIP team. The Melbourne therapists treat severely sick children and their parents. Such factors will influence the parents' trust in the clinician, motivation for therapeutic work, and economic and practical means of taking part in treatment.

## Outcome research

PTIP therapists have published clinical studies in various scientific journals. Randomized controlled trials (RCT) are increasing: Most used follow-up periods of up to six months, except two with a follow-up of four years.
Many problems pertain to evaluating PTIP. Mother and baby are at different developmental levels and during infancy, emotional experiences may change swiftly. The baby's health is inferred through questionnaires or mother-baby recordings. Another validity problem is that most studies were made at the clinical center where the investigated method was developed. Thus, we do not know if it is equally effective in other circumstances. This may explain why a recent Cochrane review only found some evidence of improved infant attachment but none concerning parental mental health. This is in contrast to several RCTs, which did find effects on maternal depression. Plausibly, the Cochrane study comprised several samples of different socio-economic and psychiatric characteristics. Some methods may be efficacious if the clinician takes such pre-treatment factors into consideration and recommends "the right treatment for the right family". Another meta-analysis found, in contrast, minor treatment effects on infant development and mental health, and significant effects on parent-infant relationship and parenting ability. To sum up, research methods need further development and we need studies from more centers.

## Training and organization

There are courses, for example, at the [Columbia University Center for Psychoanalytic Training and Research] and the Anni Bergman Parent Infant Training Program in New York, the Anna Freud Centre and the Tavistock and Portman NHS Foundation Trust and the School of Infant Mental Health in London, [International Psychoanalytic University Berlin], the University Sackler School of Medicine in Tel Aviv, the "Säuglings-Kleinkind-Eltern-Psychotherapie" or SKEPT in München, Centro Studi Martha Harris in Italy, the Eriksson Infant Mental Health Certificate Program in Chicago, the Infant-Parent Program at the University of California, San Francisco, training programs in Barcelona organized by the Spanish Psychoanalytical Society, and in Buenos Aires at the Hospital Italiano. The members of the World Association of Infant Mental Health (WAIMH) are therapists and researchers. Its congresses contain presentations of detailed PTIP case material and outcome studies. The WAIMH consists of local associations, which also host regular conferences.