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]..,A. Freud, 1926 [Melanie Klein],Klein, 1932 and Hermine Hug von Hellmuth.MacLean & Rappen, 1991 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,Winnicott, 1971 but he did not work with PTIP.
Definitions PTIP was introduced by Selma Fraiberg and Françoise Dolto after World War II.Selma Fraiberg, 1980Dolto, 1982; Dolto, 1985 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 Bick, 1964 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",Winnicott, 1960 p. 588 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"Winnicott, 1960 or "containing"Bion, 1962 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,Lojkasek, Cohen, & Muir, 1994 infant massage,Field, 2000 interaction guidance,McDonough, 2004 and Marte Meo.Aarts, 2000 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.Barrows, 1999Fivaz-Depeursinge & Corboz-Warnery, 1999von Klitzing, Simoni, Amsler, & Bürgin, 1999
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".Watillon, 1993, p. 1045 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".Olinick, 1985, p. 500 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.Stern, 1985 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 Gavin et al., 2006 and infant emotional disturbances,Skovgaard et al., 2007Zeanah, 2009 was demonstrated only recently. Many "baby worries" emerge at Child Health Centers without the mother feeling that she needs psychotherapy herself.Stern, 1995 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".Fraiberg, 1989, p. 60 The second aimed at guiding parents with a more limited psychological-mindedness and was more of an "educational technique".Sherick, 2009, p. 231 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",Fraiberg, 1989, p. 60 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" Fraiberg, 1980, p. 111 could be withdrawn and the mother-baby relationship improve. In randomized controlled trials (RCT),Cohen et al., 1999Lieberman, Weston, & Pawl, 1991Robert-Tissot et al., 1996 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,Cramer & Palacio Espasa, 1993Manzano, Palacio Espasa, & Zilkha, 1999 work with less disadvantaged families than Fraiberg. Some publications were published in English.Cramer, 1997Espasa & Alcorn, 2004Zlot, 2007 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",Cramer & Palacio Espasa, 1993, p. 85 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 Winnicott, 1971 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 Dolto, 2013/1971 but they do not cover her work with infants (see, however,Paglia, 2009). She thought a baby may understand some literal meaning of the therapist's words. This is refuted by research.Karmiloff & Karmiloff-Smith, 2001 On the other hand, babies seem to grasp that words indicate something special though they do not understand their literal sense.Gervain, Macagno, Cogoi, Peña, & Mehler, 2008 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".Dolto, 1994
Other Parisian therapists focus on psychosomatic disorders, which they link theoretically to infantile distress.Aisenstein, 2006
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".Norman, 2001, p. 85 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.Salomonsson, 2007 A similar perspective is used by infant researchers who micro-analyze the interactive mismatches of certain mother-infant interactions.Beebe & Lachmann, 2014Tronick, 2007
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".Salo, 2007, p. 965 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;Lojkasek et al., 1994 from the Hincks-Dellcrest Center in Toronto) has been compared with Fraiberg's mother-infant psychotherapy in an RCT.Cohen et al., 1999Cohen, Lojkasek, Muir, Muir, & Parker, 2002 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".Cohen et al., 1999, p. 433 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…".Cohen et al., 1999, p. 434 See also.Tuters, Doulis, & Yabsley, 2011
The PIP team at the Anna Freud Centre Parent-Infant Psychotherapy (PIP) at the Anna Freud Centre in London Baradon et al., 2005 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