The function of language in parent‐infant psychotherapy

Parent‐infant psychotherapy, a rather new field in psychoanalysis, raises questions of how to conceptualize the clinical process. Previous publications have used semiotic concepts to account for the therapist's non‐verbal communication and investigated the countertransference, including what the baby might grasp of its variations. The present paper focuses on another argument for using verbal interventions to a baby in therapy; they present him with a symbolic order that differs from that of the parent. The qualitative difference between the parent's and the analyst's address is conceptualized by Dolto's term parler vrai. The therapeutic leverage is not the analytic interventions' lexical content but their message that words can be used to expose conflicts. Thereby, one can transform warded‐off desires into demands that can be negotiated with one's objects. The reasons why this address catches the baby's attention are discussed. A prerequisite for such attention is that the infant brain is prewired for perceiving words as a special communicative mode. Relevant neuroscientific research is reviewed in regard to this question. The presentation relies on concepts by Dolto, Lacan and Winnicott and findings from neuroscience and developmental psychology. It also briefly discusses Chomsky's linguistic concepts in relation to these therapies.     

Transferences in parent–infant psychoanalytic treatments

In parent–infant treatments, babies sometimes exhibit symptoms such as screaming, clinging, and fearful gaze avoidance of the analyst. The paper investigates if such phenomena may be regarded as transference manifestations, and if so, if they appear both in younger and older infants. Based on three case presentations, it is concluded that some babies are capable of forming both brief and enduring transferences. The term “indirect infant transference” refers to when a baby reacts emotionally to the analyst as long as the parent's transference remains unresolved. “Direct transference” refers to when a baby reacts in a non‐mediated way to the analyst. The necessary tool of investigation for discovering these phenomena is a psychoanalytic method with an explicit, though not exclusive, focus on the baby. Discerning them in the clinical encounter may help us understand the baby's predicament and when and how to address the baby or the parent. These treatments constitute an empirical field awaiting more extensive clinical and theoretical investigation. Already now, they suggest that transference may be rooted in, and may appear during, very early developmental stages. The paper's positions are compared with those put forward by other parent‐infant clinicians.     

Parent‐infant‐psychotherapy and psychoanalytic treatment: contradiction or mutual inspiration?

Psychoanalysis and parent‐infant‐psychotherapy are compared. Although parent‐infant‐psychotherapy developed from psychoanalysis, it appears at first glance not to be “analytic” with its aim of dealing quickly with the symptoms presented and also with its different setting. The author shows that an analytic approach in understanding the multi‐facetted net of relationships between family members and the infant in its “phantasmic interaction” and a consideration of the implication for analysis of the empirical research carried out in conjunction with parent‐infant‐therapy can lead to a fruitful exchange of ideas. One example of this is research into the correlation between attachment patterns and the processing of conflicts. Furthermore a dialogue between these two disciplines can remind psychoanalysts that a critical discussion of the external circumstances of their methods does not immediately call into question their fundamental approach to therapy: the work in transference on relationship fantasies.     

Infant gaze following depends on communicative signals: An eye‐tracking study of 5‐ to 7‐month‐olds in Vanuatu

Gaze is considered a crucial component of early communication between an infant and her caregiver. When communicatively addressed, infants respond aptly to others’ gaze by following its direction. However, experience with face‐to‐face contact varies across cultures, begging the question whether infants’ competencies in receiving others’ communicative gaze signals are universal or culturally specific . We used eye‐tracking to assess gaze‐following responses of 5‐ to 7‐month olds in Vanuatu, where face‐to‐face parent–infant interactions are less prevalent than in Western populations. We found that—just like Western 6‐month‐olds studied previously—5‐ to ‐7‐month‐olds living in Vanuatu followed gaze only, when communicatively addressed. That is, if presented gaze shifts were preceded by infant‐directed speech, but not if they were preceded by adult‐directed speech. These results are consistent with the notion that early infant gaze following is tied to infants’ early emerging communicative competencies and rooted in universal mechanisms rather than being dependent on cultural specificities of early socialization.     

Therapeutic action in psychoanalytic therapy with toddlers and parents

Psychotherapy with toddlers and parents can focus on promoting attachment, facilitating development and improving interactions. Some techniques provide guidance to the parents, whereas others interpret to them their unconscious fantasies or ‘ghosts’ contributing to the child’s disorder. A recent paper introduced a psychoanalytically oriented technique, which emphasised the therapist’s interaction with the child in the presence of the parent(s). The child was addressed about his/her unconscious motivations in the session and the feelings towards the therapist. Also, the parent’s transference onto the therapist was seen as a vehicle that might further the therapeutic process and was accordingly addressed. The present paper analyses the therapeutic action in such treatments. Whereas work with the parents resembles that of ordinary psychodynamic therapy, therapeutic action is more difficult to conceptualise regarding the toddler, whose understanding of verbal interpretations and the therapist’s dialogues with the parent is more limited than that of an adult. However, a clinical vignette demonstrates a toddler’s precise and swift reactions to communications from mother or therapist. The paper investigates evidence from neuroscience and psychological research as to which communicative channels – beyond words – toddlers might perceive and comprehend. In addition, it is claimed that the countertransference is key to explaining how the therapist understands such communication.     

Children in psychodynamic psychotherapy: changes in global functioning

This study was part of the Erica Process and Outcome Study. The aim was to investigate if children's global functioning improves after psychodynamic psychotherapy. Variables that may predict changes in global functioning were examined both statistically and qualitatively, for example, the child's age and gender; diagnosis and comorbidity; treatment variables. The sample consisted of 33 children (five to 10 years of age) who participated in psychodynamic psychotherapy with parallel work with parents. Twenty-nine children had at least one DSM-IV diagnosis, and 15 children had comorbid conditions. At the start of psychotherapy, the most frequent diagnoses were attention disorder and disruptive behaviour. Child psychotherapists rated the children's global functioning using CGAS and HCAM. Large effect sizes were obtained (d = 1.80 and d = 1.98). However, no statistical correlations were found between global functioning and the selected variables. In order to illuminate the complex connection between process and outcome the study was complemented with in-depth case studies where data were taken from questionnaires, completed by the child therapists every third month. Two child therapies were selected: one in which the therapist rated a large change and one in which a small change was rated (CGAS). The analysis showed that important individual change, for example, attainment of formulated goals, was not always reflected in the change rated using the CGAS. Findings suggest that psychodynamic child psychotherapy can be beneficial. However, further research is needed to identify factors that contribute to change in children's global functioning.     

Nostalgia in response to group‐based exclusion: The role of attachment‐related avoidance

We proposed that nostalgia, by virtue of its sociality, can be an indirect strategy to counteract relational deficiencies stemming from group‐based exclusion. We instructed Greek participants to recall an event in which they experienced exclusion on the basis of their nationality versus a control event. We anticipated that participants would react to group‐based exclusion with increased nostalgia. Specifically, because low attachment‐related avoidance facilitates proximity‐seeking in response to distress, we hypothesized that group‐based exclusion would increase nostalgia (a form of proximity‐seeking) more strongly when avoidance is low. Results supported this moderation hypothesis. In turn, increased nostalgia in response to group‐based exclusion predicted stronger ingroup identification. For low‐avoidants, then, group‐based exclusion fortified ingroup identification via increased nostalgia (moderated mediation).     

The little puppet: working with autistic defences in mother-infant psychotherapy

This paper outlines a constellation around birth in our society that is related to advanced western medicine and the way that families move around the globe. It describes a brief therapy with a three-year-old child who was diagnosed as autistic, and a mother who resorted to 'heroic' defences against the anxiety of being unsupported in a strange country. The therapist undertook to process the catastrophic experiences of the birth as expressed in the child's play and transform the accompanying monstrous fantasies into human experiences and thoughts. By providing a maternal container for both mother and child, the therapist was able to dissolve the couple's negative enmeshment and help create a space in the mother's mind in which she could process her own feelings, and thereby process and understand the child's feelings and communications.     

The elephant tied up with string: a clinical case study showing the importance of NHS provision of intensive,time-limited psychoanalytic psychotherapy treatments

Prof. Richard Layard's influential advocacy for greater provision of ‘evidence-based’ psychological therapies, based in part on an economic rationale, has lead to greatly increased provision of cognitive behavioural therapy (CBT) and short-term therapies for depression, through the Increasing Access to Psychological Therapies (IAPT) initiative, whilst longer-term psychodynamic treatments are under threat, criticised as lacking an evidence base. This paper argues for the continuing provision of intensive thrice-weekly psychoanalytic psychotherapy treatments, time-limited to two years. It does so by describing such a treatment within an NHS psychotherapy department with a patient with a long history of severe personality pathology, including significant levels of perversity. The paper describes the patient's difficulties and his movement through the treatment, focussing on his difficulties making genuine emotional contact, his destructiveness of such contact, his acting out in the treatment, his perversity and the vital working through of the ending. The shifts the patient made are described, and follow-up information on the patient is given. The paper discusses the unique benefits of time-limited treatment and intensive psychoanalytic treatments for this ‘hard-to-help’ group of patients, and the economic rationale that can be made for such treatments.     

Mind the baby: The role of the nanny in infant observation

The influence of nannies and other significant caregivers on a child's psychological and emotional development may be profound and if unrecognized may contribute to psychopathology in adulthood. However, the significance of the nanny has been relatively neglected within the psychoanalytic literature. In this paper I will discuss the impact of early caregivers other than the biological mother on the psychic development of the child, and the role of the nanny within the family dynamics as a figure attracting powerful unconscious phantasies and unwanted projections. These ideas will be illustrated by a detailed account of a year‐long observation of an infant who had a succession of several different nannies in her first three months before her parents employed a more permanent nanny. It is proposed that the baby's emerging attachments to her two primary caregivers, mother and nanny, developed in parallel and influenced each other, with observable impact on her behaviour and developing personality. The paper concludes with a review of the place of infant observation within psychoanalytic training and how the experience of witnessing the earliest infant‐caregiver relationships in an extra‐analytic setting both refines understanding of developmental theory and builds a foundation for psychoanalytic practice.     

The analytic process in psychoanalysis and psychotherapy: from the interpersonal to the intrapsychic level

The current debate over the conflicting interpersonal and intrapsychic views of the analytic process may or may not help us to distinguish between psychoanalysis and analytic psychotherapy. A comparison of psychoanalysis in the English-speaking world--especially in the United States--with French psychoanalysis reveals the features that unite and at the same time divide these different psychoanalytical tendencies, both of which are the heirs to Freud's thought, in terms, in particular, of the setting (couch and chair) and of technique (interpretation, transference analysis and technical neutrality). Whereas all psychoanalytic work belongs within the framework of an interpersonal relationship, that relationship becomes meaningful only when linked to the intrapsychic dimension, which alone can open the way to the unconscious and to infantile sexuality.     

Research in counselling and psychotherapy Post‐COVID‐19

The COVID‐19 pandemic brings to light many areas the field of counselling and psychotherapy may need to address in future research. We outline several issues stemming from or exacerbated by the pandemic and offer suggestions for future research to address the mental health needs of those impacted. Our suggestions focus on five domains: (a) the health and well‐being of helping professionals, (b) the infodemic, (c) discrimination and minority stress, (d) spiritual and existential dynamics in mental health and (e) couple and family stress and resilience. We aim to provide a multi‐systemic perspective of mental health and well‐being in the time of COVID‐19, as well as encourage current and future studies to incorporate these suggestions to advance the health and well‐being of our communities through evidence‐based treatment approaches.     

States of identity: a perspective drawing upon Fordham's model and infant studies

This paper examines the Jungian concept of identity and distinguishes it from projective identification and participation mystique which also refer to non-differentiation between self and object but involve projective mechanisms. Clinical work by Fordham and a psychoanalytic infant observation are used to illustrate early perceptual operations defined by experimental researches. These operations are understood to be expressions of the primary self which manifest themselves before the structuring necessary for normal projective identification. This paper attempts to describe an intersubjective experience between mother and baby that allows for their separate ways of relating, but does not depend on projective mechanisms that can exist only after there has been adequate development.     

Adding “Circle of Security – Parenting” to treatment as usual in three Swedish infant mental health clinics. Effects on parents’ internal representations and quality of parent‐infant interaction

This study presents effects of adding Circle of Security‐Parenting (COS ‐P) to an already established comprehensive therapeutic model for early parent‐child intervention in three Swedish infant mental health (IMH ) clinics. Parents’ internal representations and quality of parent‐infant interaction were studied in a clinical sample comprised of 52 parent‐infant dyads randomly allocated to two comparable groups. One group consisted of 28 dyads receiving treatment as usual (TAU ) supplemented with COS ‐P in a small group format, and another group of 24 dyads receiving TAU only. Assessments were made at baseline (T1), 6 months after inclusion (T2) and 12 months after inclusion (T3). Changes over time were explored in 42 dyads. In the COS ‐P group, the proportion of balanced representations, as assessed with Working Model of the Child Interview (WMCI ), significantly increased between T1 and T3. Further, the proportion of emotionally available interactions, as assessed with Emotional Availability scales (EA ), significantly increased over time in the COS ‐P group. Improvements in the TAU ‐group were close to significant. Limitations of the study are mainly related to the small sample size. Strength is the real world character of the study, where COS ‐P was implemented in a clinical context not otherwise adapted to research. We conclude by discussing the value of supplementing TAU with COS ‐P in IMH treatment.     

The role of self‐image as a predictor of psychotherapy outcome

The present study examined the relationship between self‐image and outcome in psychotherapy. Patients (n = 170) received treatment‐as‐usual at a university clinic, and met diagnostic criteria for mostly anxiety and depression related disorders. Self‐image was measured with the Structural Analysis of Social Behavior (SASB‐I) introject pre and post‐treatment. Using multiple regression analyses, higher levels of Self‐ignore and Self‐blame pre‐treatment predicted a poorer treatment outcome in terms of symptoms (SCL‐90‐R) and interpersonal problems (IIP‐64), respectively. Increase in Self‐love and decrease in Self‐blame (pre to post) predicted reduced symptoms at post‐treatment, whereas decrease in Self‐attack and Self‐control, as well as increase in Self‐affirm, predicted reduced interpersonal problems. The results suggest that self‐image improvement may be important in order to achieve a good outcome in psychotherapy.     

Exploring the factors affecting child and adolescent psychotherapists' and counsellors' decision‐making in clinical work with parents

This study examined interventions with parents/carers in child and adolescent counselling and psychotherapy (CAP). The aim was to investigate clinicians' rationale behind their decision to work with parents and what types of interventions they use. Furthermore, the nature of clinicians' core training with regard to interventions with parents was investigated. The study used both quantitative data and qualitative textual data from an online survey of 110 CAP clinicians. There was significant agreement, regardless of previous training or level of experience, that clinical work with parents in CAP is beneficial, but little consensus for a rationale or model for best practice. There was a relationship between training, theoretical orientation and whether CAPs felt competent to work with parents. Unexpectedly, a significant number (83%) of integrative practitioners said that there had been ‘little’ to ‘none at all’ focus on working with parents on their core training course. Other unforeseen findings were in the domain of working outside generally accepted boundaries for CAP, with a notable number of clinicians making home visits—24.1% with parents alone and 38.9% with parent and child together—along with 47.2% using phone calls and/or email for coaching and support with parents. Many clinicians were candid about their sense of a lack of competence in working with parents, even though at least half were senior, experienced clinicians. A number of these practitioners made specific reference to the wish for further specialist training, with many asking for signposting to where further training could be obtained.