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Infant psychotherapy.  It wasn’t that many years ago that I didn’t even know this professional field even existed!  Today I understand that everything about infant psychotherapy for traumatized, neglected and abused infants (and children) applies to me – even though I am now 59 years old!

When I have days when I don’t feel ‘good’ or ‘well’ or ‘right’ it helps me to know why.  On days that seem much more difficult than others I often go searching online for information that I know will mirror back to me WHAT happened to me that created the states I find myself in today.

When I read through the information that follows in this post I KNOW it is describing me.  It could seem strange that I have to go all the way back to my first three years of life in order to locate the information I need to explain to myself that I am FINE – even when I don’t feel one bit FINE!

As I read what follows I can begin to put into perspective how the terrible abuse and trauma I was born into took away from me any possible chance of developing a normal body-brain in any normal way.  The information that follows puts a mirror in front of me that lets me see that NOBODY, absolutely NOBODY could have done any better job at surviving what happened to me than I did.

That same NOBODY could not have helped but end up in a body-brain that was forced to change its course of development in adaptation to severe abuse and trauma just as mine did.  In this information (below) there are big empty spaces along with few actual words in a PowerPoint presentation which gives me and my early abuse and trauma survivor peers plenty of room to add in between the lines any specifics about our actual beginnings that add up, in combination with the scientific facts presented here, to be who and HOW we are today – stunningly successful survivors of what could have easily killed us.

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I know that this is a strange format for a post – but I think this is important information.  It’s just that I found it online in the form of a PowerPoint presentation that Google automatically put into an HTML format for me.  This appears to have come from a presentation done by Dr. Louise Newman, director of the New South Wales Institute of Psychiatry in Scotland.  (I have Americanized the spelling and added a few things in italics between [brackets])

TITLE OF PRESENTATION:

THE FIRST THREE YEARS – promoting infant mental health and development

INFANCY AS A DEVELOPMENTAL PERIOD

• Infancy is a foundational developmental period
• Infancy is a critical period where certain experiences are required for healthy development across the life span
• Infant development occurs in the context of caretaking relationships
• “There is no such thing as an infant” [I have no idea what this means!]

DEVELOPMENT IN INFANCY

• Neuropsychological processes
• Affect regulation
• Representations of self, other
• Attachment Style
• Adaptation  to Stress
• Capacity for intimacy and empathy

INFANT CAPACITIES

• Programmed for social interaction [from before our birth]
• Ability to communicate emotional experience
• Move towards development and self-regulation

EARLY BRAIN DEVELOPMENT

• Promoted by secure attachment
• Sharing of positive affective states
• Caregiver maintains optimal level of arousal [essential for building the entire connection between Central Nervous System and its center set point, brain, stress-calm response system, Autonomic Nervous System, vagus nerve system immune system]
• Mutually attuned synchronized interactions promote affective development

Rapid growth occurs in the first three years of life – connections and networks

• Experience shapes brain development – connections develop as the result of stimulation [neglect has disasterous consequences due to too little stimulation, abuse and trauma = too much stimulation – even TOO happy can be damaging because it also can be too stimulating for a very young developing nervous system-brain]

EXPERIENCE & DEVELOPMENT

• Experience activates specific neuronal connections
• Sharing positive emotional states with a caretaker promotes brain growth and the development of regulatory capacities
• Secure attachment promotes neurobiological functioning, emotional regulation and adaptation to stress

NEUROBIOLOGY OF ATTACHMENT

• Secure attachment promotes brain growth [insecure attachment and its stress creates cortisol reactions that destroy brain cells.  Too little early joy kills brain cells in the left brain happy center]
• Attachment relationship regulates emotional experience and level of arousal
• Attachment figure acts as an external neurobiological regulator

NEUROBIOLOGY OF ATTACHMENT

• SECURE ATTACHMENT – optimal level of arousal
• AVOIDANT ATTACHMENT – downplaying of emotional display
• AMBIVALENT ATTACHMENT – heightened emotional display
• DISORGANIZED ATTACHMENT – high arousal and stress

NEUROCHEMISTRY OF ATTACHMENT

• Resting mutual gaze – endogenous opioids
• Regulation of neurotransmitters – dopamine and serotonin
• Regulation of stress hormones – noradrenalin, cortisol

ATTACHMENT DISORGANIZATION

• Associated with trauma and abuse
• Lack of effective strategy for dealing with caretaker
• High levels of stress and related hormones
• Defensive exclusion of understanding of caretaker
• Excessive use of dissociation and opioid related states

ATTACHMENT DISORGANIZATION

• Poor development of internal state language
• Poor reflective function
• Deficits in empathy
• Contradictory representations of self and other
• Dysregulation of behavior, affect and impulses

TRAUMA IN INFANCY & CHILDHOOD

• Psychic trauma occurs when a sudden unexpected intense external experience overwhelms the individuals’ coping and defensive operations, creating the feeling of utter helplessness [Bold type is mine.  Well, this certainly describes the insane violent mess I was born into, formed within, and endured for the first 18 years of my life — with NO single safe and secure attachment to ANYONE.  There was no possible way for my body-brain to form the circuits, connections, networks and pathways necessary to INTERNALIZE secure attachments.  No wonder I miss my loved ones so much!]
• Lenore Terr (1987)

TRAUMA AND DEVELOPMENT

• Effects of trauma during critical periods of development
• Long-term implications of attachment disruption and maltreatment
• New infant brain research and implications for decision-making, intervention and child protection

CHRONIC TRAUMA AND DEVELOPMENT

• Child adapts to enduring stress according to developmental stage and capacities
• Chronic stress will effect all domains of development and neurobiological functioning [bolding is mine]
• Vulnerability is greatest at stages of rapid neurobiological organization

SPECTRUM OF TRAUMA

• Single overwhelming events
• Chronic enduring stressors
• Indirect exposure
• Transgenerational trauma

MODERATE STRESSORS

• Emotionally unavailable caregiver – depression, anxiety, bereavement
• Parental hostility and anger
• Family conflict and domestic violence
• Unpredictability and inconsistency
• Neglect and stimulus deprivation

EXTEME & CATASTROPHIC STRESSORS –
NCCIP Classification

• Loss of attachment figure
• Continued physical/sexual abuse
• Family overwhelmed – war, displacement, terror
• Abandonment and gross neglect

TRANSGENERATIONAL TRAUMA

• Repetition of disturbed interactions and patterns of relationships
• Repetition of abuse and maltreatment
• Issues for abused parents – anxiety, compensation and reparation, envy
• Re-enactment of unresolved attachment trauma

NEURODEVELOPMENT & TRAUMA

• Dysregulation of HPA axis functioning – stress system
• Altered cortisol pattern – stress hormone
• Reduced volume of hippocampus – memory
• Reduced volume of corpus callosum – information processing
• Potential effects on mood and impulse control, emotional regulation

BRAIN FUNCTION & EXPERIENCE

• STRESS – hyperactive stress response
• CHAOS – poor sensory integration, attentional and processing problems
• NEGLECT – poor emotional regulation, deficits in processing of socioemotional information and attachment
• ABUSE – poor regulation of anger, aggression, impulses, anxiety; deficits in emotional understanding,

IMPACT OF TRAUMA

• Severity of the stressor
• Developmental level of the child
• Availability and capacity of adult support

CHILDRENS’ RESPONSES TO TRAUMA

• Children process and recall acute traumatic events
• Persistent high arousal and anxiety
• Immediate reactions include regression, clinging, muteness
• Traumatic re-enactment in play and behavior

TRAUMA SPECIFIC DIAGNOSES

• Acute stress responses in infants – dissociation
• Post-traumatic stress disorder – traumatic play, fears
• Disruptive Behavior Disorders
• Attachment Disorders

TRAUMA AND THE BRAIN

• Stress hormones and cortisol are neurotoxic
• Sensitized pathways develop in right orbito-frontal brain regions – PTSD
• Long lasting impairment in brain regions involved in regulation of the intensity of feelings
• Persistent dissociation

RESPONSES TO THREAT

• HYPERAROUSAL – fight or flight response; adrenaline/noradrenaline; sympathetic

• DISSOCIATIVE – freeze or play dead response; opioids and dopamine; parasympathetic

CHRONIC TRAUMA

• Persistent orientation to threat and activation of stress response
• Altered opioid, dopaminergic and serotonergic systems
• Hyperarousal and overactivity
• Affective dysregulation and impulsivity

TYPE 2 TRAUMA –

• Adaptation – avoidance, repression, dissociation
• Repetition – re-enactment, play, identification
• Anxiety – arousal, aggression, self-harm
• Self-Concept – depression, guilt, shame

CORE DEFICITS

• Problems with interpersonal relationships
• Problems with affect regulation
• Ongoing vulnerability to stress
• Self and other representations – negative self-concept, mistrust of others
• Deficits in reflective function and empathy

TRAUMA SYNDROME

• Over reaction to trauma associated stimuli
• Poor anxiety tolerance
• Poor modulation of aggression
• Disorganized attachment behaviors, anger towards attachment figures
• Poor affect control
• Self-destructive behaviors

TRAUMA & PERSONALITY DEVELOPMENT

• Dysregulation of affect and impulses
• Disorganized attachment
• Multiple models of self and others
• Poor reflective function
• Negative self-introject

HIGH RISK PARENTING

• Parenting relationships which impact adversely on child development and particularly on  security of attachment
• Spectrum of parenting behaviors, emotional responses, attitudes and conflicts (conscious and unconscious) which are traumatizing for the child and result in disorganization of attachment and impact on emotional and behavioral regulation
• Influenced by parental attachment history, reflective capacity and mental state

PREVENTION IN HIGH RISK DYADS

• Identify maternal history of abuse and trauma
• Identify capacity to think of the infants’ needs and inner world
• Look for patterns of identification of infant with a traumatic figure
• Interventions focus on improving responsivity and emotional attunement
• Aim at improving understanding of infant needs and changing perceptions of the infant
• Infant -led interventions

IMPLICATIONS OF NEW BRAIN RESEARCH

• Importance of protecting children during critical neurodevelopmental periods
• Foundational role of early attachment experiences and psychosocial environment
• Protective role of alternate attachment experiences

PARENT-INFANT CLINICAL INTERVENTION

THEORETICAL MODELS — Part 2

RATIONALE FOR INTERVENTION

• Increasing evidence for the foundational importance of infancy
• Need for prevention and early intervention
• Relationship problems are transgeneratioinal
• New knowledge of early brain development

PARENT-INFANT INTERVENTIONS

• Focus on the infant and the caretaking environment
• Promote infant development and attachment security
• Preventive focus
• Use observable interactions and their meaning
• Model of affective communication

RANGE OF INTERVENTIONS

• Parent-focused psychoeducational Approaches
• Behavioral Management Approaches
• Relationship based Approaches
• Psychodynamic and Psychoanalytic
• Eclectic

INTERVENTIONS

• Dyadic or Triadic
• Infant experience as focus
• Understanding caregiver’s representation of the infant
• Eclectic technique – behavioral, dynamic, systemic

DEVELOPMENT OF PROBLEMS IN INFANCY

• Infant is born with capacities to establish a relationship with a human being
• Born into a network of intergenerational internalized relationships
• Infant has meaning in the mind of the parent

PROBLEMS IN INFANCY

• Problems develop when the mother/caregiver cannot see the infant as separate and communicating
• Unresolved parental attachment trauma permeates the relationship with the infant

WINNICOTT: MATERNAL HOLDING

• Meeting the infants spontaneous gesture
• Allowing the infant to take initiative and communicate internal states
• Non-Intrusive attention
• Allows infant to experience own impulses and promotes authentic self

BION: CONTAINING MOTHER

• Capacity to tolerate infants’ negative affect
• Capacity to interpret infant communication
• Affective regulation and language
• Capacity to tolerate dependency
• Capacity to tolerate individuation of infant

TASKS OF BIRTH

• Adaptation to the particular infant
• Coping with loss of fusion
• Coping with fears of harming the infant
• Tolerance of dependency
• Tolerance of physicality

BABY AT BIRTH

• Imaginary Baby
• Relationship with developing fetus
• Actual Infant

MEANING OF THE INFANT

• Baby as Ghost
• Baby as Self
• Baby as Repetition of Past Relationship

MATERNAL SELF-CONCEPT

• Capacity to Nurture
• Ability to manage frustration and aggressive feelings
• Tolerance of Dependency
• Reworking female identity and relationship with own mother

PROBLEMS OF EARLY ATTACHMENT

• Maternal Anxiety
• Maternal Ambivalence
• Transition to Parenthood
• Partner/Systemic Issues

MATERNAL RISK FACTORS

• Early experiences of neglect and abandonment
• Early abuse and maltreatment
• Unresolved anger and hostility
• Limited access to memories and self-reflection
• Envy and unconscious need to devalue infant experience

EARLY ATTACHMENT PROBLEMS – INFANT FACTORS

• Intrinsic problems of interaction and regulation
• Dysregulated infant – prematurity, neurological, substance exposure, perinatal insult
• Neurodevelopmental Effects of trauma and stress in pregnancy

EARLY MATERNAL DISTURBACES

• Inability to tolerate infant negative states
• Perception of baby as attacking, hostile , rejecting or overwhelming
• Misperception of the infant
• Attribution of negative motives to the infant
• Infant experiences stress, anxiety, depression, anger

PSYCHODYNAMIC PSYCHOTHERAPY

• Double Agenda – listen to mother and observe infant
• Joint Focal Attention – therapist and mother focus on the infant and understand his/her experience and communication
• Parallel Process – relationship between therapist and mother, mother and infant

MISPERCEIVED INFANT

• Lack of sense of authenticity
• Fears of abandonment and annihilation
• Confusion about emotional states and expression
• Neurodevelopmental effects of chronic stress

INFANT-PARENT PSYCHOTHERAPY

• Range of approaches using observable infant-parent emotional interaction
• Model of understanding the infants difficulty as a response to relationship issues and parental impingement
• Relationship disturbances linked to unresolved parental issues

INFANT-PARENT PSYCHOTHERAPY

• Perception of the infant is distorted by parental conflict
• Infant is trapped in a series of reenactments or reworkings of unresolved trauma
• Intervention aims at reconstructing past relationships and freeing infant from network of projections

LEVELS OF INTERVENTION

• Systemic Approach:
• Infant and parent behaviors and communication
• Infant and parent representations

PSYCHODYNAMIC PSYCHOTHERAPY

• Formulation of the core conflict between mother and infant
• Focus on negative affect and its origin
• Use of interpretive interventions
• Focus on infant experience

INFANT-PARENT PSYCHOTHERAPY

• Fraiberg: Ghosts in the Nursery
• Unresolved parental conflict
• Infant presence in the sessions
• Emotional interactions and repetition
• Infant as transference object

INFANT-LED PSYCHOTHERAPY

• Increased focus on the infant as active communication partner
• Aims to help parent see infant as autonomous and communicating
• Techniques to show infant initiating, responding and being meaningful
• Gives infant experience of being validated in the interaction

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