Over the past three decades, the development of early childhood psychiatry and the many studies of early mother-baby relationships have led to the development of joint parent-infant psychotherapeutic treatments with a multitude of approaches Of diverse theoretical inspiration.We will first present the models that are best known today, with their respective originality, and then we will try to highlight the general characteristics that make the specificity of these treatments.
By definition, joint psychotherapies between parents and very young children are aimed at children between 0 and 3 years of age, but most often less than 2 years of age, and have a specific indication of a linkage disorder, which distinguishes them from therapeutic consultations and The individual assistance to the baby or the parents.
Three main types of indications can be individualized according to the existing problem:
– the existence of early interactive disorders between parents and the baby; They may be expressed in the form of a complaint expressed by the parents or of interactive disorders in the baby in the relationship with them; Functional disturbances (sleep, diet), behavioral disturbances (opposition, anger) or attachment disorders;
– the presence of great difficulties for parents to perform their parental tasks; This may be related to their socio-environmental living conditions (and particularly the problem of multiple-risk families), or to their personal problems (eg pre-existing serious psychological disorders, borderline personality disorders, or depressive or anxious disorders ), Or the existence of a psychiatric pathology linked to the puerperium (postpartum depressions);
– finally the difficulties specific to the baby which can disorganize the parental capacities; It can be disorders existing in the baby (difficulties of regulation, organic pathologies) or related to the context of birth (great prematurity, neonatal hospitalizations); These babies are all the more at risk because the personal history of the parents makes them vulnerable to their ability to care for a very young child.
Two types of situation can therefore be individualized according to the nature of what weighs at the level of the link.The interactive link is already disturbed and causes disorders in the baby, and the goal is then essentially curative.Parents are both partners and patients as protagonists of the relationship. Sometimes the link is at risk and the goal is preventive: parents are active partners and the purpose of psychotherapy is partly to prevent the disruptive action of risk factors on the vital components of the relationship (for example, The establishment of the bond of attachment).
On the other hand, the existence of chronic psychotic disorders (eg, schizophrenia) is not an indication of “classical” joint psychotherapy, as described in this article. Indeed, for these parents, a more comprehensive approach taking into account different domains of dysfunction (psychiatric, educational aid, child protection) is necessary. In general, when the intensity of psychopathological disorders (eg, addictive disorders, manic-depressive psychoses) invades the subject’s functioning, heavily undermines his or her parental abilities or jeopardizes the safety of young children, Can not be limited to psychotherapeutic work alone.
Some great models:
MODEL PIONEER OF FRAIBERG (1975, 1980):
Most early childhood clinicians were inspired by the founding model of Fraiberg, one of the first to propose and conceptualize joint mother-baby treatments. One of the strengths of her work is to consider parents as allies and to support their hopes for their baby. The presence of it is essential; It is central to the treatment and concerns of the psychotherapist. Very soon, Fraiberg assumed that he was an object of transfer, awakening in his parents old experiences and emotions against which they had hitherto generally defended themselves. Thus, he may be subconsciously attributed the image of a rejecting parent, his mother feeling rejected or helpless in front of him. The objective of the treatment is not to explore in itself the fantasy life of this one,
But to spot and hunt “the ghosts in the nursery”, that is to say the ghosts of the past that put the weight of traumatisms or painful experiments suffered by the baby on the baby and hindering the link Attachment to the child. For this it is essential to allow the mother to remember and relive the painful affects associated with these painful events of her own childhood.
Fraiberg, who had a double training as a social worker and psychoanalyst, was also one of the first to propose a psychotherapeutic approach at home in the face of high-risk early childhood situations where there is no demand for Consultation with the family. According to Fraiberg, this is an unconventional psychoanalytic approach, especially aimed at younger mothers with a great lack of confidence in care institutions. The emphasis is on the active involvement of the psychotherapist and on his concern to establish and maintain a true therapeutic alliance with the parents.
The concept of developmental counseling is another important aspect of this approach, especially in the face of parents showing a major difficulty in meeting their baby’s needs and sometimes even giving them the most basic care.It is based on the idea that the psychotherapist is also responsible for the baby’s health and that the baby can not wait for the resolution of pathology or parental conflicts. These guidance interventions centered on the needs of the child are based on a Solid therapeutic alliance and on the emotional support provided by the therapist.
SUBSEQUENT OR INSPIRED MODELS FROM FRAIBERG:
Õ Models inspired by classical psychoanalysis The models inspired by classical psychoanalysis refer to the key concepts of unconscious psychic transfer and functioning, Oedipal conflict, fantasy and compulsion of repetition. They are based on a fundamental idea: to understand and treat the disorders of the interaction, one has to reach the underlying unconscious parental problem. The psychotherapist will therefore be interested in the mother’s intrapsychic world as well as with certain aspects of his fantasy life and unconscious conflicts that weigh in his relationship with the baby and are put into action in the interactions.
The French school is particularly marked by the model of therapeutic consultations developed by Lebovici. In the course of these consultations, the latter focused on a transgenerational investigation aimed at identifying the place of the imaginary child in the mother’s psychic life and the place of the baby in the “tree of life” of the family. The latter, in effect, “expires a transgenerational mandate”. In this perspective, the emphasis is on infantile sexuality and on the vicissitudes of the oedipal conflict in the parents. Lebovici highlighted the active role of the baby in these consultations, in which he tried to “create the conditions for the baby to parentalise his parents” or the parents to be “parentified” by him. He worked on observable interaction sequences and on the unconscious fantasmatic interactions that they translated. Taking up the perspective developed by Winnicott, he also emphasized the value of empathy and the emotional atmosphere that is displayed during these consultations.
The program of mother-infant psychotherapies carried out in Seine-Saint-Denis by Stoléru and Morales-Huet in the homes of families with multiple problems, inaccessible to a traditional therapeutic approach, was inspired by Lebovici’s conceptualizations, but also by work Greenspan et al., And especially those of Fraiberg.
Finally, we need to evoke the Debray model, which is in the perspective of psychosomatic theory and for which it is not only in these early treatments to solve the symptoms presented by the baby, but to put everything in Work to finally engage the mother in an individual psychoanalytic approach.
The model of the Geneva school (Cramer and Palacio-Espasa) generally offers brief therapies. For the latter, the originality of these joint treatments is linked to the fact that they are part of a period, the postpartum, characterized by a “projective effusion” on the baby, itself inseparable from the maternal preoccupation primary. So Cramer talks about area therapy, focused on the parental conflict that is projected on the baby. The concepts of phantasmatic interaction and projective identification describe how the mother’s fantasy, reactivated by the baby’s presence, will be replayed and “dramatized” by the baby.
The therapist will work on these “interactive symptomatic sequences” in which the baby stages internal scenarios belonging to the maternal psyche. From a central and repetitive theme, he will thus endeavor to “decontaminate” the young child of the parental projections more or less massively operated on him.
This Geneva model of short-term therapies is aimed at parents with sufficient insight and elaboration skills. It aims at the rapid resolution of the symptom at the origin of the consultation.
In a recent book on the fate of early pathologies (other than pervasive developmental disorders and autism), Cramer questions the fate of 53 children seen in early and re-evaluated early joint therapies Age of 11 years. At the end of this study, the authors note a great diversity of futures, the predictions made in the early childhood being finally quite random. They conclude that the clinician must be extremely careful when he gives his prognostic advice to the parents.
In addition to the positive therapeutic effects of these early treatments (effects maintained 1 month after termination), another effect was also observed in this study: the authors note that during the 10-year interval preceding the Pre-adolescence, almost half of the mothers have used various treatments for themselves or for their child, which reflects a positive awareness of this type of approach, of preventive or therapeutic value.
Models inspired by the developmentalist currents of thought and intended for families with multiple risks:
Early treatment models for families with multiple problems and inaccessible to traditional treatments were developed in the United States in the 1980s. In addition to the pioneering Fraiberg model, which has a psychoanalytic inspiration, Behavioralist and developmentalist inspiration.
Greenspan takes up some Fraiberg principles, but with an emphasis on immediate interactive exchanges and care techniques focused on the sensorimotor, cognitive and socio-emotional development of the baby. It also proposes an original approach at home, with teenage mothers and isolated, from very deficient backgrounds. It stresses the need to help these families concretely in their basic “vital” needs and to establish a trusting and secure relationship.
Mac Donough’s Interactive Guidance is another early intervention model that was also initially intended for families with multiple problems who refused any traditional therapeutic approach or for which these treatment attempts had been experienced as failures and marked by therapeutic breakdowns.
The establishment of a therapeutic alliance with parents appears to be fundamental, with basic principles giving them a decisive place in the treatment process and in assessing its effectiveness: these objectives are defined in a consensual way as The criteria of what will be considered a therapeutic success. The therapist must answer all the questions asked and the parents are invited to invite all the other family members in connection with the baby to the treatment. This approach also takes into account the cultural context in which the family lives. Acts (home visits, educational guidance, practical aids, networking) provide the tangible proof of this therapeutic alliance considered as the engine of treatment.
In this type of intervention where parents, considered as active partners, are invited to “monitor” the treatment; It is also a question of developing an approach sensitive to the strengths and resources of each individual, rather than to their points of vulnerability.
The mother-father-baby observable interactions are the target of intervention, these interactions being considered on the one hand as a reflection of family structure and parental care and on the other hand as that of the internal representational world of parents and the baby . The analysis of these interactions is more in a systemic and developmental perspective than that of Fraiberg, and one wonders whether these interactions facilitate or not the development of the young child, rather than questioning the resurgence of “ghosts” Of the past that can underlie them.
Another specificity of this work is the use of autovidoscopy.
At each session, a short sequence of parent-child play is filmed, then viewed and discussed with parents. This technique allows the therapist to identify interactive sequences that highlight the mother’s sensitivity to the child’s signals and needs and also to show parents the subtle or more obvious positive changes in parenting interactions or attitudes. All criticism is proscribed there.
Models inspired by the theory of attachment:
Over the past two decades, the theory of attachment has greatly influenced the clinical practice of parent-baby psychotherapies in Anglo-Saxon environments. Its founder, Bowlby, published a key book A secure base in 1988, where he develops his ideas concerning the clinical applications of attachment theory. In particular, he points out how the attachment experiences of early childhood affect the transference relationship to the therapist, and he stresses the need, all the more compelling because we are dealing with patients who once developed an insecure relationship with their therapists. Figures of attachment, to give psychotherapy a climate of security.
It is through this secure base that the patient, here the mother, will be able to explore the painful contents of her past and present life, just as the young child with a secure relationship with her mother will be able to explore the world around her.
In the United States, attachment research has resulted in many early intervention programs of diverse inspiration. A number of authors who have summarized the characteristics of these attachementist programs have shown that many of them are offered to multiple-risk families previously inaccessible to conventional psychotherapeutic treatments.Whatever their theoretical and technical framework, they have as therapeutic target the disorders of the attachment of which the baby suffers and aim to improve the security of the bond with its mother, conducive to a good development.
According to their theoretical references, some of them, inspired more “educational” and behavioral, aim to modify the quality of the parental answers, especially of maternal sensitivity to the needs of the baby. Others, inspired by Fraiberg’s psychodynamic model, seek to modify certain maternal representations rooted in painful early attachment experiences and thus to break the risk of transgenerational transmission. These include Lieberman and Pawl’s team, who continued the work of Fraiberg in San Francisco and the Weatherston model of care in Lansing, Michigan. For the hard-to-reach families that these programs are often targeted to, the construction of the alliance and the cadre often involves the treatment process at home.
In Europe, psychoanalysis has only recently recognized the importance of attachment theory, and while psychoanalysis has given rise to reflections and even technical changes in child psychiatric practice, Resulted in the development of new clinical models.
Finally, whatever the theoretical differences underlying the various models discussed above, joint parent-baby psychotherapies have the common goal of breaking through transgenerational transmission, based on relationship work, when it is a source of Dysfunction, to reconcile parents with their baby, to allow them to perceive their own reality and to give more freedom to the development of the child. We will now present the main general characteristics of these treatments.
Common Characteristics of Joint Parent-Baby Therapies:
These are so-called “non-specific” factors found in the different types of treatment.
THE PARTICULAR PSYCHIC FUNCTIONING OF EACH OF THE PROTAGONISTS MAY POSSIBLE THE INTERVENTION:
On the part of the parents: all the authors agree that the pregnancy and the birth of a child lead to important psychological changes in the parents, even if they do not theorize them in the same way: these changes will allow l Psychotherapeutic intervention, which would not necessarily have been possible before. In fact, most parents have a desire for their child to have better than what they themselves have, which makes them more apt than they would have been before to accept a therapeutic or preventive intervention For that one.
But not all authors formulate things in the same way.
Thus, from a classical psychoanalytic perspective, Winnicott first made the hypothesis of a new state in the postpartum mother, with the notion of primary maternal solicitude; Bydlowski introduced the concept of a psychic transparency existing in the mother, from the time of pregnancy, which involves a certain regression and the lifting of repressions facilitating the psychotherapeutic work.
According to a recent psychodynamic conception, Stern developed the notion of maternal constellation: it is a special temporary psychic organization in the mother that determines new behaviors and new anxious concerns about the baby. She then felt a great need to be surrounded and supported by women (her mother or other maternal substitutes) and by her husband as the father of her (future) baby rather than as a loving partner.
In both parents, caring for a baby awakens and involves new abilities that have begun to build up throughout their lives, but especially during pregnancy, birth and postpartum. The notion of parentification has been developed on the basis of Anglo-Saxon studies, such as the maturation of the “caregiving system” in both parents, which allows them to promote closeness with the child and to provide him with Comfort when he feels distressed.
A sensitive caregiving promotes the development of secure attachment relationships in children.
For the baby: its rapid development, in stages, offers numerous opportunities for therapeutic and preventive intervention. Brazelton has described touchpoints as strengths in the development of the baby, which provide parents with opportunities to change their child’s relational modalities and are “gateways” to psychotherapies. Stern gives the example of such a reflection by proposing open sequential treatments.
TECHNICAL ASPECTS OF JOINT PSYCHOTHERAPIES:
Actual presence of the baby:
The presence of the baby in the sessions has many implications. There are at least two people to treat: the mother, the baby and sometimes the father. This configuration imposes technical adjustments: the lengthening of the sessions; A bifocal vision of the therapist, who must both listen to the parents and watch the baby with them. This presence of the baby during the sessions gives access to many observations and immediate experiences, which individual sessions would not allow.
The interactions between his parents, observed in parallel with their stories of their family history, also give access to different types of memories and memories (procedural, event, semantic), which allow a reflection on the modalities of Attachment and transgenerational transmission.
The baby can thus be considered as a catalyst for therapeutic work: its presence awakens and promotes in parents the expression of buried emotions, which gives these early treatments a particular emotional climate. The intensity of this climate implies even more the need for the therapist to analyze finely his identificatory and countertransferential movements.
Finally, the essential developmental stakes for the baby introduce a double temporality in the therapy: the baby can not wait for the resolution of the parental problem which hinders his development and pushes a rapid intervention adapted to his needs.
Target of joint therapies:
It is above all interpersonal: it is on the relationship mother-fatherbébé that the therapist intervenes, taking into account the specific characteristics of each partner. This target requires a change from the conventional instruction to what could be a new fundamental rule: “Tell me what is going on for you and your baby.” The therapist must be able to identify with each partner, which is sometimes problematic, and implies the need for double training.
Each of the protagonists is also a target, but as a member of the mother-father-baby relationship, each parent is considered in his or her particular contribution to the baby; For example, it has been shown that safety with the father is more associated with gambling and problem solving than with the sensitivity as described for the mother. Each parent is also taken into account in his or her ability to play a corrective role on the influence of the other. When it has autonomous functioning in terms of attachment, each can serve as a safe base to the other, which can thus provide better care to the baby.
The functioning of the parents’ couple is also taken into account, as it influences the ability of parents to provide good quality care to their child. Significant conflicts within the couple may hamper this ability.
The baby is now known as having triadic skills from the very beginning of his life, that is, he can very early connect with more than one person at a time: the father- Mother-baby is the crucible of the child’s socio-emotional development, particularly in the first year of life. The degree of coordination achieved by the partners corresponds to the family alliance, which is more or less coordinated.
THE QUESTION OF THE ALLIANCE:
Psychotherapy solicits the parents, partners and objects of care, in their system of representation of the help. The current theories on the therapeutic alliance or more generally on the “helping relationship” are particularly useful.
Asking for help (treatment or guidance) at a time of upheaval arises from a universal need to feel protected and comforted, and from that belief that one can be helped by someone who is necessarily “stronger and more Wise. “
Parents with attachment problems pose different challenges for training and maintaining the therapeutic alliance.
Seligman defines the very specific therapeutic alliance of joint psychotherapies as bringing together the following basic conditions of cooperation:
– parents have confidence in our concern and concern for them and our ability to help;
– that they have the will to consider our advice, information or therapeutic projects;
– there is minimal adherence to appointments with them;
– finally, when a psychological exploration is attempted, the parents are able and willing to endure what is represented as a source of suffering, effort and discomfort the activity of self-reflection on painful phenomena.
This representation of the helping relationship arising from the early internalization of interactive experiments is a striking illustration of Fraiberg’s theories. The “ghosts of the child’s room” rarely refer to Oedipal problems or intrapsychic love / hate conflicts, but always to a situation of non-response to the vital needs of comfort and support that these parents experienced when they Were children. The search for more or less recent experiences in which they have made a request for assistance, and the systematic exploration of the answers they have received and the meaning they have given them, is a way of accessing the quality of Experiences experienced once with their own parent figures. This technique aims to avoid the repetition of what Seligman described as bureaucratic transfer. It is a level of interpersonal interpretation (transferential / countertransferential), based on the assumption that this is the first level of intervention used systematically as soon as necessary to facilitate the alliance. Which will play in the initial encounter with the therapist will ultimately translate the model of relationship that the parent has built with his own attachment figures from early childhood, more or less redesigned model according to his later experiences.
All authors emphasize the importance of the immediate analysis of any negative (eg verbal or behavioral) manifestation (eg, expression of anger, doubt, distrust) between the parents and the therapist. Person, the technique, the framework or the objectives of the treatment. This new experience, experienced by the family, thus being able to have an exchange on this subject, safely and without retaliation, limited initially to what happened hic et nunc during the interview, gives access to His current representations of the aid relationship. Secondly, it will enable us to approach, with varying length of time and at a more or less deep and painful level, the transgenerational representations of this aid relationship. This technique contributes to the development of a strong therapeutic alliance, helping to overcome the transferential hazards of the clinical relationship.
A possible change in these representations in parents will in turn contribute to modifying their own responses to their child’s distress signals.
Treatment of choice:
A detailed evaluation of the needs of each triad is necessary, it is done on several interviews and includes observations carried out in several settings (in the office, at home, at the crèche …), so that the therapist can establish the necessary alliance And define with the parents what type of treatment this will involve. Thus, the “treatment of choice” for the family can be proposed, depending on the probable duration of treatment (short or long, global or sequential psychotherapy), depending on the location (at home or in the therapist’s office) What the family can bear and what is best for it.
The “gateway” in the treatment can be done either by the baby or by the parent-baby link, depending on what is brought to us, the complaint, our observations and the tolerance of the parents to different Modalities of intervention.
Child psychiatry research is increasingly emphasizing the importance of developmental processes on the one hand, and the multidimensional and “ecological” nature of childhood disorders on the other. At the same time, the evolution of therapeutic programs shows a growing tendency to consider the whole system in which the child lives, rather than focusing solely on his symptomatology, and also an increasing tendency to combine different modalities of Treatment (psychodynamic, behavioral, cognitivist, systemic). We thus witness the emergence of an “implicit systemic developmental model”, which also applies to early intervention programs, where, beyond the mother-baby dyad, environmental and contextual factors Is absolutely fundamental. While the different approaches often retain their framework and theoretical specificity, they increasingly meet clinical priorities and see a number of their techniques converge. Emphasis is placed on the involvement of the family in treatment, contextual and environmental approach to the disorder, equal emphasis and emotions, and cognitive and developmental processes, and the growing recognition of interest Not to focus exclusively on the past of the mother (and the child) or on the only current situation hic et nunc.
Clinical approaches based on attachment theory have highlighted the importance of the therapist’s confident therapeutic alliance, empathy and sensitivity, as well as the emotional atmosphere of these psychotherapies .
Comparative studies seeking to evaluate the effectiveness of different approaches highlight the determining role of these so-called “non-specific” factors, common to these, and show that whatever the “gateway” in the system Dyadic or familial, the results are quite similar. It is clear from this research that it is precisely the therapeutic alliance established with the parents and the quality of the clinical relationship that are the most predictive factors for the successful outcome of the treatment.