Observing and interpreting clinical process: Methods and findings from 'Layered analysis' of parent-infant psychotherapy.

This paper describes a method for investigating clinical process, Layered Analysis, which combines therapist countertransference reports and multi-faceted microanalytic research approaches. Findings from the application of Layered Analysis to video-recorded micro-events of rupture and repair in four psychoanalytic parent-infant psychotherapy sessions are presented. Layered analysis showed that countertransference and observation are complementary perspectives, which enable concomitant study of interactive events, conscious internal experiences, as well as nonconscious and unconscious elements of therapeutic interaction. Interactional rupture and repair were found to constitute co-constructed micro-events that occurred fleetingly and often implicitly, and differed in the structure, coherence and flow of interactions and in the relationship between verbal and nonverbal communication. Furthermore, interactional ruptures were found to sometimes 'get into' the therapist and transiently disrupt their self-organization, such that the therapist became a locus of disruption for the patient(s), actively contributing to the rupture, which thus became embedded in the therapeutic system. Interactive repair was found to be most often initiated by the therapist and to be underpinned by the therapist re-establishing self-regulation, through metabolizing embodied and verbal aspects of the rupture. Studying such processes can enhance our understanding of clinical process, inform therapist training and clinical supervision, and contribute to clinical outcomes.

Este ensayo describe un método para investigar un proceso clínico, Análisis en Capas, el cual combina los reportes de contratransferencia del terapeuta y los acercamientos investigativos micro analíticos multifacéticos. Se presentan los resultados de aplicar Análisis en Capas a micro eventos, grabados en video, de ruptura y reparación en cuatro sesiones de sicoterapia sicoanalítica de progenitor e infante. Los Análisis en capas mostraron que la contratransferencia y la observación son perspectivas complementarias que, en combinación, permiten el estudio concomitante de eventos interactivos, experiencias internas conscientes, así como elementos no conscientes de la interacción terapéutica. Adicionalmente, los resultados mostraron que la ruptura y la reparación constituyen micro eventos co-construidos que ocurren muy fugazmente y a menudo implícitamente, y que difieren en la estructura, coherencia, flujo de interacciones y en la relación entre la comunicación verbal y no verbal. Es más, rupturas interaccionales pueden 'meterse en' el terapeuta y transitoriamente interrumpir su autoorganización, de manera que el terapeuta se convierte en un punto de interrupción para el paciente y la ruptura pasa a ser parte del sistema terapéutico. La reparación interactiva está sostenida por, y depende de, la metabolización del terapeuta de los aspectos incorporados y verbales de la ruptura. Estudiar tales procesos puede mejorar nuestra comprensión del proceso clínico y ser usado en entrenamiento y supervisión de terapeutas.

Cet article décrit une méthode d'investigation du processus clinique d'Analyse Multidimensionnelle en Couches, qui combine des rapports de contre-transfert du thérapeute et des approches de recherche micro-analytique à facettes multiples. Les résultats de l'application de l'analyse multidimensionnelle en couches à des micro-événements enregistrés à la vidéo de rupture et de réparation dans quatre séances de psychothérapie psychanalytiques parent bébé sont présentés. L'analyse multidimensionnelle en couches a montré que le contre-transfert et l'observation sont des perspectives complémentaires qui, combinés l'un avec l'autre, permettent une étude concomitante d'événements interactifs, d'expériences internes conscientes et d'éléments non-conscients de l'interaction thérapeutique. De plus, les résultats ont montré que la rupture et la réparation constituent des micro-événements co-construits, qui se passent très fugacement et souvent implicitement et diffèrent en structure, cohérence et flux des interactions et dans la relation entre la communication verbale et non verbale. Enfin les ruptures interactionnelles peuvent 'entrer' dans le thérapeute et perturber de façon transitoire leur auto-organisation, de telle manière que le thérapeute devient le locus de la perturbation pour le/la/les patient(e/s) et la rupture s'encastre dans le système thérapeutique. La réparation interactive est étayée par, et elle en dépend également, la métabolisation d'aspects verbaux et incarnés de la rupture du thérapeute. L'étude de tels processus peut améliorer notre compréhension du processus clinique et être utilisée dans la formation et la supervision des thérapeutes.

Trust me! Parental embodied mentalizing predicts infant cognitive and language development in longitudinal follow-up.

Children's cognitive and language development is a central aspect of human development and has wide and long-standing impact. The parent-infant relationship is the chief arena for the infant to learn about the world. Studies reveal associations between quality of parental care and children's cognitive and language development when the former is measured as maternal sensitivity. Nonetheless, the extent to which parental mentalizing - a parent's understanding of the thoughts, feelings, and attitudes of a child, and presumed to underlie sensitivity - contributes to children's cognitive development and functioning, has yet to be thoroughly investigated. According to the epistemic trust theory, high mentalizing parents often use ostensive cues, which signal to the infant that they are perceived and treated as unique subjective beings. By doing so, parents foster epistemic trust in their infants, allowing the infant to use the parents a reliable source of knowledge to learn from. Until recently, parental mentalizing has been limited to verbal approaches and measurement. This is a substantial limitation of the construct as we know that understanding of intentionality is both non-verbal and verbal. In this investigation we employed both verbal and non-verbal, body-based, approaches to parental mentalizing, to examine whether parental mentalizing in a clinical sample predicts children's cognitive and language development 12 months later. Findings from a longitudinal intervention study of 39 mothers and their infants revealed that parental embodied mentalizing in infancy significantly predicted language development 12 months later and marginally predicted child cognitive development. Importantly, PEM explained unique variance in the child's cognitive and linguistic capacities over and above maternal emotional availability, child interactive behavior, parental reflective functioning, depression, ethnicity, education, marital status, and number of other children. The theoretical, empirical, and clinical implications of these findings are discussed.

Studying the process of psychoanalytic parent-infant psychotherapy: Embodied and discursive aspects.

This paper presents findings from an intensive, mixed methods case study of one session of psychoanalytic parent-infant psychotherapy (PPIP) addressing early relational trauma, and aims to shed light on the multimodal interactive processes that take place in the moment-to-moment exchanges comprising the therapeutic encounter. Different research methods were used on video material from PPIP sessions, including microanalysis of adult-infant interactions, discourse analysis of talk, and coding systems developed to study parent-infant interaction. These different perspectives were brought together with the clinical narrative to illuminate the complex, dynamic processes of parent-infant-therapist interaction. More specifically, the detailed analysis of one interactive episode revealed brief behavioral manifestations of fearful and disoriented states of mind, reflecting dysregulated interaction between mother and infant, which also powerfully affected the therapist. The processes through which the therapist gradually resolves this rupture are also described in detail. Through this pilot study, we were able to show that it is possible to systematically study the process of PPIP. The study contributes to the growing psychotherapy research literature that takes into account both the verbal domain and implicit, interactional processes in therapeutic practice, and underscores the therapist's comprehensive engagement in the therapeutic process.

Este ensayo presenta resultados de un intensivo estudio de caso, con métodos mixtos, de una sesión de sicoterapia sicoanalítica de progenitor e infante (PPIP) dirigida al temprano trauma en la relación, y se propone arrojar luz sobre los procesos interactivos multimodales que se llevan a cabo en los intercambios de momento a momento que componen el encuentro terapéutico. Se usaron diferentes métodos de investigación en el material de video de las sesiones de PPIP, incluyendo el micro-análisis de las interacciones adulto-infante, análisis discursivos del habla y sistemas de codificación desarrollados para estudiar la interacción progenitor-infante. Estas diferentes perspectivas se pusieron juntas con la narrativa clínica para dar luz a los complejos, dinámicos procesos de interacción progenitor-infante-terapeuta. Más específicamente, los análisis detallados de un episodio interactivo revelaron breves manifestaciones de conducta de estados mentales de miedo y desorientación, lo cual refleja la interacción desregulada entre la madre y el bebé, lo que también afecta poderosamente al terapeuta. También se describen en detalle los procesos a través de los cuales el terapeuta gradualmente resuelve esta ruptura. Por medio de este estudio piloto, pudimos mostrar que es posible estudiar sistemáticamente el proceso de sicoterapia sicoanalítica de progenitor e infante. El estudio contribuye al creciente cuerpo investigativo sobre sicoterapia que toma en cuenta tanto el dominio verbal como los implícitos procesos interactivos en la práctica terapéutica y subraya la participación comprensiva del terapeuta en el proceso terapéutico. Palabras claves: sicoterapia progenitor-infante, comunicación multimodal, dominio implícito, investigación de procesos, trauma en la relación.

Studying the process of psychoanalytic parent-infant psychotherapy: Embodied and discursive aspects Cet article présente les résultats d'une étude de cas intensive par méthodes mixtes d'une session de psychothérapie psychanalytique parent-bébé adressant un trauma relationnel précoce. Il se donne pour but de mettre en lumière les processus interactifs multimodaux qui prennent place dans les échanges de moment-à-moment que comprend la rencontre thérapeutique. Différentes méthodes de recherches ont utilisé du matériel vidéo de séances PPIP, y compris des micro-analyses des interactions adulte-bébé, une analyse textuelle du dialogue et des systèmes de codage développés afin d'étudier l'interaction parent-bébé. Ces différentes perspectives ont été rassemblées avec la narration clinique afin d'illuminer les processus complexes et dynamiques de l'interaction parent-bébé-thérapeute. Plus particulièrement l'analyse détaillée d'un épisode interactif a révélé de brèves manifestations comportementales d'états d'esprit craintifs et désorientés, reflétant une interaction dys-régulée entre la mère et le bébé, qui ont aussi profondément affecté le thérapeute. Les processus au travers desquels le thérapeute a graduellement résolu cette rupture sont également décrits en détail. A travers cette étude pilote nous avons pu montrer qu'il est possible d'étudier systématiquement le processus de psychothérapie psychanalytique parent-bébé. L'étude contribue aux recherches en psychothérapie qui tiennent en compte à la fois le domaine verbal et implicite et les processus interactionnels dans la pratique thérapeutique, et souligne l'engagement total du thérapeute dans le processus thérapeutique. Mots clés: Psychothérapie parent-bébé, communication multimodale, domaine implicite, recherches processus, trauma relationn.

Lay counselors: Thoughts on the crossing of ecological frameworks and the use of lay counselors in the scale up of early infant mental health interventions.

The recent call for the scale-up of evidence-based early childhood development interventions, in lower and middle-income countries and for minority groups in high-income countries, has seen numerous suggestions to train greater numbers of lay mental health workers to fulfill these functions. While studies have found that concepts from developed country settings, such as attachment, parental sensitivity, and containment, find purchase and relevance within developing settings, the management of contextual and cultural factors and the tensions of cultural interfacing in the rollout of these programs in developing country settings require consideration. Drawing on the experiences of two successful South African mother-infant home-visiting programs as examples, this article discusses some of the challenges in provision of attachment-based infant mental health programs and highlights the need for careful consideration of a number of factors pertaining to the recruitment, supervision, and management of lay mental health workers before large-scale rollout is conducted.

La reciente llamada para aumentar proporcionalmente las intervenciones sobre el desarrollo en la niñez con base en la evidencia, en países de ingresos más bajos e ingresos medios, y en el caso de grupos minoritarios en países de ingresos altos, ha visto numerosas sugerencias para entrenar un mayor número de trabajadores laicos de la salud mental que puedan realizar estas funciones. Mientras que los estudios han concluido con que conceptos provenientes de ambientes de países desarrollados, tales como afectividad, sensibilidad de los padres y contención, venden y encuentran relevancia dentro de escenarios de países en desarrollo, el tratamiento de factores contextuales y culturales y las tensiones de interconexiones culturales en la introducción de estos programas en escenarios de países en desarrollo requiere consideración. Utilizando las experiencias de dos exitosos programas madre-infante de visitas a casa en Sudáfrica como ejemplos, este artículo discute algunos de los retos en cuanto a la provisión de programas de salud mental infantil basados en la afectividad y subraya la necesidad de la cuidadosa consideración de un número de factores referentes al reclutamiento, supervisión y dirección de trabajadores laicos de la salud mental antes de que se lleve a cabo la introducción a gran escala.

L'injonction récente à intensifier les programmes d'intervention de développement de la petite enfance fondés sur des données probantes, dans des pays en voie de développement, et pour des groupes minoritaires dans les pays riches, a déclenché de nombreuses suggestions de formation d'un plus grand nombre de travailleurs laïcs de la santé mentale afin de remplir ces fonctions. Alors que des études ont établi que des concepts issus de contextes de pays développés, tels que l'attachement, la sensibilité parentale et la discipline trouvent acquisition et raison d'être au sein de contextes développés, la gestion de facteurs contextuels et culturels et les tensions d'interfaçage culturel dans le lancement de ces programmes dans des contextes de pays en voie de développement exigent d'être considérées et tenues en compte. A partir des expériences de deux programmes de Visite à Domicile Mère-Nourrisson Sud- Africains comme exemples, cet article discute certains des défis dans la prestation de programmes de Santé Mentale du Nourrisson basés sur l'attachement et met en lumière le besoin de considération attentionnée à un nombre de facteurs ayant trait au recrutement, à la supervision et à la gestion de travailleurs laïcs de santé avant que soit lancée une version à grande échelle du programme.

"What support would you find helpful?" The relationship between treatment expectations, therapeutic engagement, and clinical outcomes in parent-infant psychotherapy.

The aim of this study was to investigate the impact of pretreatment expectations on clinical outcomes and engagement in Parent-Infant Psychotherapy (PIP). Sixty-one mothers who were experiencing mental health difficulties and who were receiving PIP with their young infants participated in the study. A mixed-methodology was used to examine participants' expectations through transformation content analysis of pretreatment interviews; recurring themes were classified and quantified. Further statistical analyses explored relationships between the quantified themes of parental expectations and clinical outcomes and engagement in treatment. No significant correlation was found between expectations and engagement. One of the six clinical outcomes significantly correlated with parental expectations. Improved reflective functioning (RF) was predicted by participants describing expectations of wanting to improve their parent-infant relationship through the treatment, and expressing concerns about discussing their past experiences. These two expectations predicted improvements in RF independently and when combined. These results indicate that PIP may be more effective for some mothers than others and that assessing future clients' expectations before beginning PIP may be beneficial.

El propósito de este estudio fue investigar el impacto de las expectativas anteriores al tratamiento acerca de los resultados clínicos y la participación en la Sicoterapia Progenitor-Infante (PIP). Sesenta y una madres que experimentaban dificultades de salud mental y que estaban recibiendo PIP con sus pequeños infantes participaron en el estudio. Se utilizó una metodología mixta para examinar las expectativas de las participantes a través de análisis de contenido de transformación de las entrevistas anteriores al tratamiento; los temas recurrentes fueron clasificados y cuantificados. Análisis estadísticos adicionales exploraron las relaciones entre los temas cuantificados de expectativas de las madres y los resultados clínicos y participación en el tratamiento. No se encontró una correlación significativa entre las expectativas y la participación. Uno de los seis resultados clínicos se correlacionó significativamente con las expectativas de las madres. Las participantes predijeron el funcionamiento reflexivo mejorado (RF) al describir sus expectativas de querer mejorar su relación progenitor-infante por medio del tratamiento, así como al expresar preocupación sobre discutir sus experiencias pasadas. Estas dos expectativas predijeron las mejoras en RF independientemente y cuando estaban combinadas. Estos resultados indican que PIP pudiera ser más eficaz para ciertas madres que para otras y que evaluar las expectativas de futuros clientes antes de comenzar PIP pudiera ser beneficioso.

Le but de cette étude était de se pencher sur l'impact des attentes pré-traitement sur les résultats cliniques et l'engagement clinique dans une Psychothérapie Parent-Nourrisson (abrégée ici PPN)/ Soixante et une mères qui faisaient l'expérience de difficultés de santé mentale et qui recevaient une PPN avec leur jeune bébé ont participé à cette étude. Une méthodologie mixte a été utilisée afin d'examiner les attentes des participantes à travers une analyse de contenu de transformation des entretiens pré-traitement. Les thèmes qui revenaient ont été ont été classifiés et quantifiés. Des analyses statistiques supplémentaires ont exploré les relations entre les thèmes quantifiés des attentes des parents et les résultats cliniques ainsi que l'engagement clinique dans le traitement. Aucune corrélation n'a été trouvée avec les attentes parentales. Un fonctionnement réfléchi (abrégé RF en français) amélioré a été prédit par les participantes, décrivant des attentes, attentes selon lesquelles elles voulaient améliorer leur relation parent-nourrisson à travers le traitement, et exprimant leurs soucis concernant la discussion de leurs expériences passées. Ces deux attentes ont prédit des améliorations dans le RF indépendamment et lors combinées. Ces résultats indiquent que la PPN peut être plus efficaces pour certaines mères que d'autre et que le fait d'évaluer les attentes des clients avant de commencer la PPN peut s'avérer être une bénéfice.

INTERFACING INFANT MENTAL HEALTH KNOWLEDGE: PERSPECTIVES OF SOUTH AFRICAN SUPERVISORS SUPPORTING LAY MOTHER-INFANT HOME VISITORS.

This article is part of a project investigating the interfacing of clinically and research-generated knowledge in the field of infant mental health (IMH) with local cultural models of child care and development. The article explores the experiences and challenges reported by psychology-trained supervisors in supervision with local, lay, trained home visitors. Supervisors and supervisees were drawn from two early intervention programs which apply relational IMH mental health models in socioeconomically deprived townships in South Africa. Literature that considers supervisors' experiences of conducting supervision with lay counselors has been limited, and even more so in settings where there are marked cultural and contextual differences between supervisors and supervisees. These differences pose particular challenges regarding the finding of a shared theoretical understanding of the work as well as to the establishment of a secure working alliance. While it was found that psychoanalytic and attachment-informed theories of infant development are applicable in these South African settings, differences in race, language, education, socioeconomic status, and culture between supervisors and supervisees challenge the supervisor-supervisee relationship and require psychological processing and creative solutions to ensure integrity in the application of the model.

INTERFACING INFANT MENTAL HEALTH KNOWLEDGE SYSTEMS: REFLECTIONS ON THE NARRATIVES OF LAY HOME VISITORS' EXPERIENCES OF LEARNING AND APPLYING RELATIONAL CONCEPTS OF DEVELOPMENT IN A SOUTH AFRICAN INTERVENTION PROGRAM.

The question of interfacing research and clinically generated knowledge in the field of infant mental health (IMH) with local cultural knowledge and belief systems has provoked extended discussion in recent years. This article explores convergences and divergences between current research-based, relational IMH mental health models and "community" knowledge held by a group of South African lay home visitors from a socioeconomically deprived township. These women were trained in a psychoanalytic and attachment-informed infant mental health program that promotes a relational model of infant development. They provide an intervention that supports high risk mother-infant relationships in the same locality. A two-tiered approach was taken to the analysis of the home visitor interviews and focused on the home visitors' constructed narratives of infant development posttraining as well as the personal impact of the training and work on the home visitors themselves. The study found that psychoanalytic and attachment-informed thinking about development makes sense to those operating within the local South African cultural context, but that the accommodation of this knowledge is a complex and challenging process.

RANDOMIZED CONTROLLED TRIAL OF PARENT-INFANT PSYCHOTHERAPY FOR PARENTS WITH MENTAL HEALTH PROBLEMS AND YOUNG INFANTS.

There is a dearth of good-quality research investigating the outcomes of psychoanalytic parent-infant psychotherapy (PIP). This randomized controlled trial investigated the outcomes of PIP for parents with mental health problems who also were experiencing high levels of social adversity and their young infants (<12 months). Dyads were clinically referred and randomly allocated to PIP or a control condition of standard secondary and specialist primary care treatment (n = 38 in each group). Outcomes were assessed at baseline and at 6-month and 12-month follow-ups. The primary outcome was infant development. Secondary outcomes included parent-infant interaction, maternal psychopathology, maternal representations, maternal reflective functioning, and infant attachment. There were no differential effects over time between the groups on measures of infant development, parent-infant interaction, or maternal reflective functioning. Infant attachment classifications, measured only at the 12-month follow-up, did not differ between the groups. There were favorable outcomes over time for the PIP-treated dyads relative to the control group on several measures of maternal mental health, parenting stress, and parental representations of the baby and their relationship. The findings indicate potential benefits of parent-infant psychotherapy for improving mothers' psychological well-being and their representations of their baby and the parent-infant relationship.

New Beginnings for mothers and babies in prison: a cluster randomized controlled trial.

Mothers in prison represent a high-risk parenting population. New Beginnings is an attachment-based group intervention designed specifically for mothers and babies in prison. This cluster randomized trial examined the outcomes for 88 mothers and babies participating in the New Beginnings program and 75 dyads residing in prisons where the intervention did not take place. Outcomes were measured in terms of parental reflective functioning, the quality of parent-infant interaction, maternal depression, and maternal representations. Mothers in the control group deteriorated in their level of reflective functioning and behavioral interaction with their babies over time, whereas the mothers in the intervention group did not. There were no significant group effects on levels of maternal depression or mothers' self-reported representations of their babies over time. An attachment-based intervention may mitigate some of the risks to the quality of the parent-infant relationship for these dyads.

A psychotherapeutic baby clinic in a hostel for homeless families: practice and evaluation.

OBJECTIVES: A pilot baby clinic in a hostel for homeless families has been established to address the specific attachment and developmental needs of infants living in temporary accommodation. The aim of this study was to assess whether this clinic model was associated with more positive outcomes than mainstream community services in terms of infant development and parent-infant interactions. DESIGN: Parent-infant psychotherapy and health visiting services collaborated to develop a new model of baby clinic, which reconfigured the traditional clinic to give priority to infants' affective experiences in a therapeutic group setting. Outcomes for parent-infant dyads in a homeless hostel where this service model was applied were compared with outcomes for parents and infants in hostels, which did not have such a service. METHODS: Fifty-nine mother-baby dyads participated in evaluation, 30 in the intervention hostel group and 29 living in comparison hostels. Infant mental and motor development was assessed using the Bayley Scales of Infant Development. Interactions between the parents and infants were video-recorded and coded on the Coding Interactive Behaviour Scales. RESULTS: The indices of mental and motor development of infants in the intervention hostel were significantly improved over time in relation to infants in the comparison hostels. No significant differences were found in the quality of parent-infant interaction between the two groups over time. CONCLUSIONS: The findings indicate that the service model may have positive benefits for infant development. The findings, study limitations, and clinical implications are discussed. PRACTITIONER POINTS: Parents and infants living in temporary accommodation represent a high-risk and hard-to-reach population. A new model of intervention, which combines universal infant health services with a therapeutic parent-infant group may be an effective means of supporting the emotional needs of hard-to-reach parents and infants.

"What is genuine maternal love"? Clinical considerations and technique n psychoanalytic parent-infant psychotherapy.

The question of what is genuine maternal love was posed by a mother struggling to understand and value the nature of her bond with her small baby. The question surfaced time and again in the context of this dyad's long-term parent-infant psychotherapy and has challenged me to examine my thinking and, indeed, has produced impassioned discussions within the Parent Infant Project team at The Anna Freud Centre. In this paper I will address this question through sessional material of this mother and baby and discuss issues of technique in response to it, including my countertransference and conceptualization.

Psychotherapeutic work with parents and infants -- psychoanalytic and attachment perspectives.

Psychodynamic psychotherapy with parents and infants addresses the relationship between them where there has been a disruption or distortion in the process of bonding. Often this is characterized by a repudiation of the state of infancy by the parent, and a negation of infantile needs in the baby and in herself. The infant joins the mother in co-constructing defensive measures against their infantile attachment needs, thereby actualizing intergenerational repetitions. The therapist is a clinical observer of the relationship between parent and infant and an emotional participant in it. From the behavioural and affective interactions, she deduces their emerging mental models and procedures of being with each other. Her role is to represent symbolically, for both parent and infant, their experience of being with the other. Through this the affective dialogue is elaborated, to include feeling and thought constellations that were previously enacted procedurally. The paper illustrates these ideas about the therapeutic process through transcripts of case material.