chment and Esomen implications len. Unpublished a Becton reactivity bed iron end [Spmposium 156, E> PP. EDS. & Intell, R. be culty of eatly at Bis preschoolers, and fen. 34, 361-376, ESL (1998, Mari, leperiences on moth Fes atthe bicnnisl Pete Research in I [eisimizstion among [atonsip history le Cid and Adoier be. F (1998) Mater Wino azachment in Besnal mectng of te Patboquerqe, NM Fchoeat represent. fists srcment: A ofthe Adult A Fe Baten 7 Bis de Ruiter, C., FSenic C8 Rien be epeesnttons of bes dmerzan Jour eo Pemcoetincy pechology 24 Contributions of Attachment Theory to Inft ‘ant—Parent Psychotherapy and Other Interventions with Infants and Young Children + ALICIA F. LIEBERMAN CHARLES H. ZEANAH The goal of this chapter is to examine Low at- tachment theory and research have influenced clinical practice, with a particular focus on {nfant-parent psychotherapy and other preven- tive interventions that promote infant mental health by addressing early disturbances in par- ent-child relationships. Only programs and ap- proaches with clearly articulated clinical and preventive goals are described. The chapter is di- vvided into four major sections. The first section describes the shared psychoanalytic origins of at- tachment theory and infant-parent psychothera- y, provides an overview of infant-parent psy- chotherapy and its relation to attachment theory and psychoanalysis, and explores attachment theory's evolving contributions to clinical prac- tice. The second section illustrates the integra- tion of attachment theory and infant-parent psy- chotherapy into several clinical programs for infants and toddlers. The third section describes other programs and approaches influenced by at- tachment theory. The final section reviews the few studies evaluating the efficacy of attach- ment-focused interventions, Some brief conclud- ing remarks highlight the importance of a trust- ing working alliance, empathy, and sensitive re~ sponsiveness to enotional signals as the hall: marks of clinical approaches based on attach- ‘ment theory. ATTACHMENT THEORY AND. INFANT-PARENT PSYCHOTHERAPY: SHARED ORIGINS There is an inhereat affinity between attachment theory and infant-parent psychotherapy because of their common emphasis on the importance of the mother-child relationship in the first 3 years of life as the bedrock for healthy emotional de- velopment, Both attachment theory (Bowlby, 1969/1982) and infant-parent psychotherapy (Fraiberg, Adelsor, & Shapiro, 1975) emerged in the 1970s as seminal influences on the then- emerging field of infant mental health. Although representing different conceptual frameworks, Bowlby and Fraiberg were both psychoanalysts, and their work bears the unmistakable imprint of the object relations approach to psychoanalytic, theory that was the prevailing clinical Zeitgeist. 555556 PARTY, Yet the striking similarities and mutual influ- ences between the approaches have only recently begun to be formally recognized (Lieberman, 1991), Infant-Parent Psychotherapy: Overview Infant-parent psychotherapy was developed as an effort to treat disturbances in the infant-parent re lationship in the first 3 years of life (Fraiberg, 1980), The basic premise of this approach is that such disturbances are the manifestations in the present of unresolved conflicts that one or both of {baby’s parents have with important figures from their own childhood. The current baby is not per- ceived by the parents as a baby in his or her own right, Rather, in Fraiberg’s (1980) highly eloquent ‘words, the baby has become the representative of figures within the parental past, oF a representative ofan aspoct ofthe parental ‘lf that is repudiated or negated. In some cases the baby himself seems engulfed in the parental neuro- sis and is showing the early signs of emotional dis- turbance. In treatment, we examine with the parents the past and the present in order to free them and their baby from old “ghosts” that have invaded the nursery, and then we must make meaningful Hinks between the past andthe presen trough interpreta- tions that will lead to insight. At the same time ‘we maintain the focus onthe baby through the pro- vision of developmental information and discus sion. We move back and forth, between present and Past, parent and baby, but we always return to the baby. (p. 61) ‘The Baby's Presence in the Sessions ‘The presence of the baby during the therapeutic sessions is a central ingredient of this approach to psychotherapy. This was a revolutionary inno- vation when Fraiberg introduced it, and it nas be~ come the sine qua non of most therapeutic ap- proaches to the treatment of infants and toddlers. ‘The widespread acceptance of this often de ‘manding therapeutic format stems from a recog nition that parental reporting is no substitute for direct observation of the baby and of the par- ent-baby interaction. The therapist's observation al skill allows him or her to identify themes, de- tect defensive distortions, capture emotional nuances, and monitor infant development in ways that would not be possible even with the most sincere efforts at parental self-disclosure and description of the infant. Similarly, the baby's presence allows for an emotional immedi- CLINICAL APPLICATIONS acy to therapeutic intervention that could not be replicated if the parents were recollecting a par ticular scene, ‘The Present as a Bridge to the Past Fraiberg’’ metaphor of “ghosts in the nursery (raiberg et al, 1975) has galvanized theoreti cians and clinicians alike, because it evokes the powerful and enduring hoid that a sad and fright- ening childhood can have on adult experience. In individual psychotherapy, it is found again and again that clients can overcome crippling psy chological symptoms and self-defeating patterns of living when they aze able fo reconnect emo- tionally and como to grips with the pain, fear, anger, and helplessness evoked by childhood cir~ cumstances and key childhood events. Similarly, ‘one of the most extraordinary experiences af- forded to the infant-parent psychotherapist is witnessing the amazing transformation in feel ings and behavior toward a baby that can occur When a parent 's able 10 trace ambivalence, anger, and rejecton of the baby to early child: hhood experiences. The parallel transformation of the baby from a fussy, muted, withdrawn, and an- sry creature toa ively, thriving, and engaged hu- ‘man being is the most rewarding aspect of this work. ‘Yer itis also true that retrieving the past is not invariably the ke) to healing in the present, even ‘when it sa key to clinical understanding. This s particularly the case when a parent does not rely on language as the primary form of self-expres- sion, when he or she is not psychologically mind- ed, or when the garent’s psychological function- ing is too fragle or constricted to tolerate delving into pail early memories. Moreover, a parent with severe characterological difficulties ray be quite able to relive past experiences with sgreat emotional intensity and tobe fully aware of the repetition of the past in his or her present feelings toward the baby, and yet may neither find emotional relief in these insights nor devel- ‘op more positive ways of relating tothe chil. In such a case, verbal interpretations of the links between the past and the present do not hold the key to improvernent, andthe most effective inter- ventions are not spoken but rather enacted through the therapist's empathic attitude and be- havior toward the parent and the baby (Lieber- man & Paw, 1993: Paw! & Lieberman, 1997). Another obstacle to the therapeutic value of finding inks between the past and the present is that many distressed and ambivalent parentsBe could not be bllecting a par- Feit evokes the Fad and fright- experience. In fend azain and Fexppling psy- Featine patterns Feconnect emo- Pie pain, fear, Pkildhood cir- fests. Similary, Experiences af- Ppbotherapist is jon in feel- fiat can occur F ambivalence, fm carly child- formation of fad engaged hu- Baspect of this te past is not present, even — Bisdocs not rely Pt sit-expres- Hosically mind- I Fction- to tolerate Fe Moreover, difficulties Ererences with bly aware of or her present may neither nor devel Fro the chil. In Bs of the links Knot hold the effective inter- Irther enacted britade and be- P baby (Lieber. rman, 1997). Peutic value of Ete presen is Fralent parents CHAPTER 24. Attackment’s Contributions fo Infent-1 choose not to speak about their childhoods even ‘when they have been in treatment fora long time; they view therapeutic efforts to discuss their past as factless and intrusive. They prefer to focus in- stead on the difficulties they experience in pre- sent relationships with important figures in their lives—a spouse, a boss a partner, a friend, a sib- ling, a parent, and even the infant-parent psy- chotherapist This may well be a sign that such a parent's defenses against anxicty are uncon- seiously experienced as too fragile, and that the parent is afraid of not being able to withstand the onslaught of recovered affect without emotional collapse. In these circumstances, therapeutic progress can take place not by cajoling the parent to bring up the walled-off past, but by focusing instead on the feeling states involving salient current relationships and by exploring how these feeling states may also be present in relation to the baby (see Silverman, Lieberman, & Pekarsky, 1997, for acinical example). Tnall cases, hypothesized links between a par- ents past and his or her present feelings toward the baby are entertained by the therapist even when not explicitly discussed, and these hypothe- ses may provide the basis for clinical interven- tions. Whether such links become concrete foci for insight-oriented interpretations. depends on clinical need, as well as on the parents interest in pursuing such connections and the parent's emo- tional capacity to withstand the pain of revisiting the past without significant or lasting emotional deterioration Even when the recovery of lost affective con- nections with the past opens new psychological perspectives and brings new emotional freedom, the emerging insights often need to go hand in hhand with conscious, determined, and sometimes very courageous efforts to change behavior in order to achieve lasting positive change in par- enting styles. For this reason, versatility and flex- ibility are hallmarks of infant-parent psychother- apy. In addition to insight-riented interventions, Fraiberg (1980) described three other therapeutic. modalities that are employed in infant-parent psychotherapy: brief eriss intervention, develop- mental guidance, and supportive treatment. The specific therapeutic modality that predominates in the treatment may vary according to the spe- cific circumstances, both across families and with a particular family in the course of treat- ment. In current practice with families facing a mul- tiplicity of socioeconomic as well as emotional streses, the different therapeutic modalities are rent Peychotherapy 557 often used either simultaneously within a session or in rapid succession from one session to anoth- er (Lieberman & Pawl, 1993; Pawl & Lieber ‘man, 1997). A successful crisis intervention may resolve an acute problem and generate enough trust in the therapist to allow treatment to be- come deeper and more insight-oriented. Con- versely, a well-timed interpretation may assua, a parent’s resistance to the point that he or she ‘may accept developmental information that had previously been angrily rejected. Emotional sup- port is always a cemponent of infant-parent psy chotherapy, wheter by itself or in conjunction ‘with psychodynamic interpretations, because the therapist's empathic understanding is considered an essential ingredient in giving parents the ‘courage to explore themselves and to try out new ‘ways of behaving with their babies ‘Across therapeutic modalities, concrete assis- tance with problems of living (in the forms, for example, of providing a ride to the pediatrician, ‘making phone calls to the housing authorities to advocate for better housing, o interceding with public agencies to secure necessary services) can help to create and maintain a valuable therapeu tic alliance when a parent is having difficulty in these areas due to cognitive or emotional prob- lems, depression, or lack of knowledge. The ther- peutic legitimacy and importance given to con- crete actions advocating for the family are reflections of Selma Fraiberg's genius in inte- ‘erating her dual vocation and training as social ‘worker and psychoanalyst. The Baby and the Therapist 1s Transference Objects Fraiberg’s (1980) original concept of the baby rather than the therapist as the object of the par- cent’ transference continues to have much clini cal usefulness. Infant-parent psychotherapists do not see themselves as the center of the therapeu- tic process, in the sense that they do not deli ately cultivate or interpret parental emotional reactions toward themselves. The focus of thera- peutic attention is a parent’ feelings and behav- jots toward the baby, not toward the therapist. In spite of this transferential focus on the baby, parental transfereace to the therapist is ubi tous, Just as a troubled parent perceives the baby through the lens of early emotional experiences, it is only natural taat the perception of the thera- pist asa powerfil figure in the parent's life should be influenced by a similar lens as well. (In attachment theory terms, we would say that the558 PARTY. working models of attachment and caregiving that affect a parent's behavior toward the baby also inform the parent's perception of the thera pist. This point is elaborated in the next section.) Sometimes the therapist is idealized by a needy and grateful parent as the wise, generous, an Knowledgeable provider of help and support. When this happens, the therapist uses the par- cent’s positive emotional investment as a vehicle toward change, while perhaps giving the parent lighthearted permission to detect and complain about the therapist's mistakes whenever these ‘come to the parent’s attention Perhaps more often, a parent may perceive the therapist as a deceptively benign person who might become critical and punitive at any time, and who has the legal power to alert the child protection authorities about situations that might Tead to the child's removal from the home and placement in foster care. When this covert nega- tive transference prevails the first task of the in- fant-parent therapist is to address the parent's anger, mistrust, and fear with tact and under standing, in the knowledge that the negative transference is likely to be an indication of painful experiences of abuse and powerlessness in the parent’s childhood, in his or her immediate past, and/or perhaps also in current circum- stanet In theso situations, the therapist's positive re- gard, attentiveness to the parent's needs, and em- pathic responsiveness are considered to be primary mutative factors in infant-parent psy chotherapy. Through their relationship to the therapist, parents learn, often for the first time, \ways of relating that are characterized by mutual ity and caring rather than by anger and (Lieberman & Pawl, 1993). Because of its power to change negative expectations und create a new and more trusting experience of how to be with another, this aspect of the therapeutic relation- ship can be regarded as a corrective attachment experience (Lieberman, 1991). Through such a corrective experience, an ambivalent and angry parent can begin to experience and practice more protective and nurturing ways of relating to the baby. Contributions of Attachment Theory to Infant-Parent Psychotherapy Readers familiar with attachment theory will ree- ‘ognize the implicit influence of this viewpoint in the description of infant-parent psychotherapy outlined above. This influence is made more ex- CLINICAL APPLICATIONS. plicit in recent writings on infant-parent psy chotherapy (e-g., Lieberman, 1991, 1996, 1997). In particular, clinical practice has been profound- ly influenced by the concept of internal working models of the self and of attachment (Bowlby, 1980; Main, 1991). When viewed from this pe spective, ‘he intergenerational transmission of conflict from one generation to the next can be understood in different (yet complementary) tems from the explanatory mechanisms posited by Fraiberg (1980). The “ghosts in the mursery”” model posits that unresolved parental conflicts are reenacted in relation to the baby—in other words, thet unconscious impulses are displaced or projected from their original objects to the current transference object represented by the in- fant, In the framework of internal working mod- els, this reference to psychoanalytic drive theory need not be invoked. We would say instead that internalized early experiences provide a structur- al framework that serves to sort out, select, and encode current emotional events. For example, the concept of “correetive emotional experience” (Lieberman, 1991), described in the section above, refers fo the changes in the working mod~ el of the self in relation to attachment that can ‘occur when the therapist provides the opportuni ty for sustained exploration of attachment-relat- ed emotional events in the context of empathic support and permission to experience and ex- press a range of positive and negative affects This respect for the mutative power of the thera- pist-parent relationship per se would not be ten= able in a model that emphasizes insight-related psychological change as stemming from a redi- rection of negative affects from current targets to early recipients of them. The contribution of attachment theory to infant-parant psychotherapy is explicitly elabo- rated in recent writings, but this influence was also. quite apparent when infant-parent psy chotherapy was in the process of first being de- veloped, as illustrated in the examples below 1. Fraiterg (1977) chose the term “attach- ment” to refer tothe clinically relevant aspects of the mother-child relationship, including the ex- pressions “lost and broken attachments” and s of attachment.” life events such as separation, loss, abuse, deprivation, and maltreatment were recog- nized as crucial pathogenic factors in a child's development (Fraiberg, 1977, 1980) and were major foci of therapeutic attention, 3, Observable behaviors in both parent andbrarent p3y~ fo96, 1997). Fe profound- Fea working Fat (Bowiby, fs this per fsmission of feext can be boiementery) sms posited be nursery" bel conflict bin other bre displaced Bpects to the fed by the in- pecking mod- Five tory p instead that fede a structur- Be select, and For example, Blexperience” b the section procking mod- Foent that can fee opportu bebenentrlat- B of empathic feoce and ex- — Frof the thera. Bid not be ten- Fesisi-related B trom a redi- Fret targets to Bat theory to Fplicitly elabo- finfluence was Be-parent psy: bfsst being de- Biles below: Perm “attach- Brant aspects of Eparation, loss, feat were rec brs in a child's jBs0) and were B foth parent and CHAPTER 24, Attackment’s Contributions to infent—Parent Psychotherapy child were used in infant-parent psychotherapy as indicators of underlying psychological processes, land these behaviors were used atthe onset and the Conclusion of infant-parent psychotherapy to traluate the effectiveness of treatment (Fraiberg, Lieberman, Pekarsky, & Paw, 1981). . Much emphasis was placed on the impor tance of enhancing maternal empathy and re- sponsiveness to the baby’s signals as the primary Vehicle for fostering the child's mental health Eraiberg et al., 1981). 5. There was a specific focus on infant attach ment behavior and defenses against anxiety (Fraiberg, 1982), including avoidance, which Was first identified as a defensive response by ‘Ainsworth, Blebsar, Waters, and Wall (1978). Remarkably, in light of this unmistakable bor- rowing of attachment theory’s terminology and methods, Fraiberg cited neither Bowlby nor ‘Ainsworth a8 major influences in her writings, although she thought highly of their work (S. Fraiberg, personal communications, 1976, 1979, 1980), This absence of explicit reference to the impact of attachment theory on the genesis of in- fant-parent psychotherapy constitutes an inter- esting historical footnote in the chronicle of the fnfant mental health field. As a psychoanalyst, Fraiberg believed firmly in the usefulness of the economic and dynamic principles of psycho- fmalysis—the very Viewpoints so decisively dis ‘carded in Bowlby's work (see the next section for fn elaboration of this point). For example, ad- dressing the relation among love, sexuality, and aggression, Fraiberg (1977) wrote that “it mat- tets a great deal whether we include drives in our theory or not” (p. 36); she went on {0 use stan- dard psychoanalytic drive terminology in dis cussing what she called “the origins of human fonds,” which she understood, in classical psy- choanalytic fashion, to be the by-products of the Conflicting discharge aims of aggression and Sexuality. Yet unexpectedly, in the midst ofa fair~ ly conventional psychoanalytic account of libidi- nal and drive matters, she stated [Al of this means that inthe process of redirection fi the ritualization of ageression inthe service of Tove, anew pattern emerges which acquires fill ta fus as an instinct and a high degree of autonomy from the aggressive and sexual intints from which it derived. Nor only are the patters of love part of lin autonomous instinct group, but they have a mo- five foree equal to oF greater than that of agares- ‘on under a wide range of conditions. (p. 445 ex phasis added) 559 “These sentences could be mistaken for ones write ten by Bowlby if it were not for the earlier em- phasis on drives, Its clear that withthe ostensi- le purpose of discussing Konrad Lorenz's (1967) views on aggression, Fraiberg was indi- reetly incorporating into her thinking Bowlby's (1969/1982) groundbreaking application of etho- fogical thinking to human bebavios, without cit- ing him or referring to him. Rather than openly incorporating the contributions of ‘attachment theory into her writings, she chose instead (0 translate into classical psychoanalytic drive the ty Bowlby’s (1969/1982) claim that the attach- Trent behavioral system constitutes an autono ‘mous instinct, Fraiberg's failure :o acknowledge Bowlby's in- fluence is pointed example of the prolonged os- tracism of attachment theory in the psychoana- Iptie world, In the following section, we discuss the different factors that coalesced into this state of affairs ‘Attachment Theory, Psychoanalysis, and Clinical Practice “Attachment theory is the theory of socioemo= tional development best supported by empirical research (see Belsky & Cassidy, 1994, for a re- view), Stil it has been remarkably slow in influ- fencing elinical practice with children and adults, Sithough this situation is fortunately changing (Fonagy, 1991; Holmes, 1993; Slade, Chapter 25, this volume). ‘there are several interrelated reasons for the persistent reluctance of clinicians to incorporate Bitachment theory into their understanding of Clinical issues. One major factor is that for many Sears after its appearance, atlachment theory was Hebuked by Bowlby’s fellow psychoanalysts as a ‘adical departure from the core of their discipline (Gee Grosskurth, 1986, and Karen, 1994, for ex- cellent reviews), The reception was so uniformly frosty and even hostile that it ed Bowlby (1988) to complain that “a problem encountered by txery analyst who las proposed new theoretical fdeas is the criticism that the new theory is ‘not psychoanalysis" (p. 58). The preeminence. of Psychoanalysis at the time as the leading influ- nce in clinical training and practice meant that Sttachment theory remained consistently margin- alized within these areas. In addition to these ex- ternal circumstances, several issues related to the development of attachment theory contributed to its slowness in being adopted by clinicians. ‘One intrinsic drawback to its clinical applic560 PARTY. tion was that attachment theory is not a total per sonality theory because it does not include a sys- tematic exploration of other motivational sys- tems (eg, sexuality, dominance, and aggression) and their interrelation with the attachment sys- tem (Lichtenberg, 1989; Lieberman, 1996; Selig man, 1991; Slade & Aber, 1992). For clinicians facing the multiplicity of conflicts and motiva- tions reported by their clients, the unwavering fo- eus on security and protection often seemed overly constricted and constricting. In order to become aware of the clinical usefulness of at- tachment theory, clinicians needed to be shown how to apply it in their everyday practice. Yet this focus on direct clinical application was fora long. time not available within attachment theory. ‘At least at the outset of his career, Bowlby himself seemed less interested in influencing clinical practice than in redressing what he viewed as the unscientific aspects of psycho- ‘analysis and in promoting changes in the cultural mores about child rearing. This dual emphasis on scientific legitimacy and on much-needed social reform regarding attitudes and policies toward children is probably related at least in part to Bowlby's modest self-appraisal as a clinician. In a disarmingly candid interview with Jeremy Holmes (1993), he is quoted as saying: “Iam not strong of intuition... often shudder to think hhow inept I have been as a therapist and how I hhave ignored or misunderstood material a patient hhas presented. Clearly, the best therapy is done by a therapist who is naturally intuitive and also guided by the appropriate theory” (p. 32). Bow! by’s personal preferences as well as his intellec~ tual honesty naturally steered him in the die tion where he believed he could contribute the ‘most: providing clinicians with “the appropriate theory” to guide their work. This was necessarily a slow approach to influ- ceneing clinical practice, because people tend to read writers in their own field of endeavor. The many publications stemming from attachment theory focused on theory and developmental re- search rather than on clinical practice, and seemed off limits to most clinicians in their focus and terminology (e.g., Ainsworth et al, 1978; Bowlby, 1969/1982, 1973, 1980), The first book exploring the clinical applications of attachment theory had a developmental researcher as its se nior editor (Belsky & Nezworski, 1988). Bowlby himself wrote only sparsely on clinical practice, and then quite late in his career (Bowlby, 1988), Mary Ainsworth, although a gifted clinician, did CLINICAL APPLICATIONS not do so at all. The dearth of clinical writings from the seminal figures in attachment theory, combined with th: hostility with which leading psychoanalysts regarded this approach, led to the ‘widespread assumption that attachment theory hhad academic rather than clinical relevance. It is useful to review briefly the connections between attachment theory and psychoanalysis, because of the enduring influence of the psycho- analytic origins of attachment theory, and be- cause of Bowlbys own consistent view of his theory as “the atachment version of psycho- analysis” (J. Bowlby, personal communication, 1989), Bowlby’s continued allegiance to the psycho- analytic perspectve can be explained by his recognition of the explanatory power of three ba- sie viewpoints that form part of the metapsychol- ogy of psychoanalysis. These are the “genetic vicwpoint, which seeks the origins of a psycho- logical phenomenon by investigating antecedent experiences; the “structural” viewpoint, which ‘makes propositions regarding the building blocks ‘or components of the psyche; and the “adaptive” ‘viewpoint, which concerns itself with the ways in which psychologeal functioning represents an accommodation to the specific conditions and demands of an irdividual’s environment (Rapa- port & Gil, 1959). All three of these principles were clearly at work in the original formulation of attachment theory (Bowlby, 1969/1982), as well as in more recent developments in attach- ‘ment theory and research, On the other hand, Bowlby explicitly discard- ed two other basie psychoanalytic principles: the ‘economic” viewpoint, which proposes the exis- tence of a psychic energy (named “libido”) that is distinct from physical energy; and the “dynam- ic” viewpoint, which proposes the existence of psychological’ forces (called “instinctual dri- vves"—ice,, sex and aggression) that strive for ex pression through discharge. Bowlby replaced these notions with a more modern biological ap- proach to the understanding of instinct and a ey~ ‘emetic model of affective life. Such a radical theoretical innovation had a paradoxical effect. Although ensuring the scientific legitimacy of at- tachment theory as a framework open to empiri= cal investigation, these radical innovations also led to the rejection of attachment theory by psy: cchoanalysts, who regarded Bowlby’s innovations as mechanistic, bland, and out of touch with the basie conflicts ofthe human psyche (Grosskurth, 1986; Holmes, 1993).Bical writings Bement theory, pihich leading Beh. led to the fiment theory Hevance. F connections Bychoanalysis Brthe psycho- Bory, and be- B view of his B of psycho- Esmunication, bof a psycho- Be antecedent fpoint, which Blding blocks fee “adaptive” beditions and brent (Rapa: bse principles B formulation W69/1982), as Bis in attach- itl discard- Frinciples: the Bses tho exis- Plibido”) that Bio “dynam- existence of finctual dri- strive for ex- fy replaced frological ap- feet and a beh a radical Brical effect. Flimacy of at- Ex to empiri- Prations also beory by psy- B innovations hoch with the [(Grosskurth, CHAPTER 24, Attachment’s Contributions fo Infant-Parent Peychotherapy 561 ‘Not content with discarding some of the basic principles of psychoanalysis, Bowlby (1969) 1982) also introduced four bold propositions that could not easily be assimilated into the psycho- analytic practice of the time. First, he proposed that certain aspects of human psychological functioning and behavior should be understood from an ethological perspective, with survival and fitness as the explanatory mechanisms for the biological functions of certain behavioral systems, Second, within this context, he intro- duced the concept of attachment as an au- tonomous motivational system on 2 par with hhunger and sexuality in its importance for su vival. This also placed primary emphasis on the importance of real-life events, as apposed to the person's fantasies or subjective perception of such events, for understanding the development of psychopathology in children and for tracing back the origins of psychopathology in adults (Bowlby, 1969/1982, 1973, 1980). Among such pathogenic real-life events are separation from parents, loss, and maltreatment (Bowlby, 1969 1982, 1973, 1980). Finally, Bowlby advocated applying the ethological tradition of behavioral observation to the understanding of psychologi- cal processes in humans, rather than relying pri ‘marily on verbalization, as was the psychoanalyt- ic tradition ‘These conceptual innovations have important clinical implications. They lead the psychothera- pist to understand the patient or client not only as an individual but also as a representative of the hhuman species, endowed with species-specific behavioral propensities that may have their ori- gin in biological imperatives and may not be amenable to change as a result of cultural prac- tices. Attachment theory also turns the clinician's attention to the importance of real-life events in shaping development and in coloring current functioning, emphasizing that actual events have more parsimonious explanatory power for under- standing psychopathology than the drive-related fears and fantasies postulated by classical psy- choanalysis. In keeping with contemporary de- velopmental research, attachment theory consid ers infants to be closely tied to immediate experiences and (at least for most of the first 18, ‘months of life) cognitively incapable of the kinds of fantasies attributed to them by some psycho- analytic theorists (Cassidy, 1990; Slade & Aber, 1992; Stern, 1985). ‘The premises of attachment theory also place ‘great deal of importance on the observation of behavior as an indicator of a person's emotional responses, as opposed to relying mostly on ver bal reports, fantasies, wishes, or dreams. Yet the pioneering spirit ofthese innovations put attach ‘ment theory in a“no man’s land” from a clinical point of view. Fer clinicians influenced by a be- hhaviorist approach, attachment theory seemed too close to its psychoanalytic origins; for psy~ cchoanalysts, it was too iconoclastic. AS a result, attachment theory did not find a ready audience for a clinical exploration of its implications. ‘The current rapprochement between psycho- analysis and attachment theory was set in motion by three simultaneous developments. One was the increasingly sophisticated elaboration within attachment theory of a focus on internal repre- sentation and working models of the self in rela tion to attachment (eg, Bretherton, 1984; Cas- sidy, 1988; Mair, 1991; Main & Cassidy, 1988; Main, Kaplan, & Cassidy, 1989; Zeanah & Bar- ton, 1989; Zeanah & Benoit, 1995). Another and converging trend was the growing openness of psychoanalysis othe importance of real-life events in influencing the course of personality formation (e.g., Wallerstein, 1973), as well as to approaches empiasizing intersubjectivity and a narrative account of the patient’s experience (e 24, Emde, 1988, 1994; Fonagy, 1991; Lichten- berg, 1989; Sterr, 1985, 1995). Finally, the emer ‘gence of clinicians trained both in developmental research and in psychodynamic theory and prac- tice is creating useful bridges between the two disciplines (e-g., Emde, 1988; Lieberman, 1991, 1996; Lyons-Ruth, 1991; Osofsky, 1993; Slade, Chapter 25, this volume; Slade & Aber, 1992; Zeanah & Barton, 1989). These simultaneous ‘and mutually influential developments have led to a new appreciation of the value of attachment theory for clinical practice. Nevertheless, the systematic application of at- tachment theory o clinical issues is still ina rudi- mentary stage of development. As recently as 1992, Erickson, Korfinacher, and Egeland (1992) reported that a computer search of peer-reviewed journals uncovered only “an eclectic assortment of atfachment-related therapy articles,” but no comprehensive conceptualization of the clinical applications of attachment theory (p. 498). They also pointed out that “most practitioners who ‘make use of attachment theory in their clinical ‘work seem to apply it in idiosyncratic ways” (p. 499). These authors singled out infant-parent psychotherapy (Fraiberg et al, 1975) as the most notable exception to this state of affairs362 PARTY ‘THE APPLICATION OF ATTACHMENT THEORY AND. INFANT-PARENT PSYCHOTHERAPY IN INFANCY AND EARLY CHILDHOOD MENTAL HEALTH PROGRAMS: Several mental health programs oriented to in- fants, toddlers, preschoolers, and their families have’ integrated attachment theory and infant— parent psychotherapy in varying degrees into their clinical approaches. This section provides a review of some of these programs. The Infant-Parent Program: ‘The Ann Arbor/San Francisco Model The Infant-Parent Program (IPP) is an iteration of the original Child Development Project at the University of Michigan, Ann Arbor (Fraiberg, 1980), which was a demonstration program de- signed to develop and test infant-parent psy chotherapy as a treatment of choice for relation- ship disorders of infancy. Established in 1979 at the San Francisco General Hospital by Fraiberg and colleagues, the IPP is partially funded by community mental health and other city funds with the goal of offering infant-parent psy- chotherapy to families of infants in the 0-3 age range who experience or are at risk for abuse, ne lect, and relationship disorders (Lieberman & Pawl, 1993; Pawl & Lieberman, 1997), The fam- ilies seen at the program are among the most im- poverished and disenfranchised in the city, 1- flecting the characteristics of the population traditionally served by the San Francisco General Hospital, which isa teaching hospital of the Uni versity of California at San Francisco. More of: ten than not, the family circumstances include poverty, lack of education, joblessness, home- Tessness, inadequate housing, mental iliness, sub- stance abuse, community and domestic violence, or other risk factors. Approximately 30% of the referrals originate in child protective service: with another 15% stemming from juvenile court or family court, The remaining sources of refer ral include public health nurses, pediatricians, psychiatrists, and community agencies serving high-risk families and their children. The theoretical and clinical underpinnings of the program are essentially identical to those out- Tined in the section “Infant-Parent Psychothera- Py: Overview" However, the original emphasis on the links between parents’ carly childhood ex Periences and their current feelings, perceptions, CLINICAL APPLICATIONS attitudes, and behaviors toward their babies (Fraiberg, 1980), though still a core component of the program, has been complemented by an increased appreciation for individual differences in babies and for the very real and immediate contribution that the parents” stressful current circumstances make to maladaptive patterns of caregiving. The hopelessness and suspiciousness often generated by these parents’ difficult life conditions demand a painstaking attunement 10 their immediate subjective experience of the therapist and of the therapeutic process. As a re sult, much attention is given to the parents’ own definition of their problems, their concepts of what they need, their expectations of treatment, and their response to the therapist's interven- tions. The quality of the parent-therapist rela- tionship is often considered the primary mutative factor under these conditions (Pawl & Lieber man, 1997). ‘The children’s emotional and behavioral diffi- culties are the foci of sustained therapeutic atten tion in the context of the parents" perception of these problems, The children’s symptom picture includes failure to thrive, depression, separation anxiety, multiple and seemingly inexplicable fears, severe and prolonged tantrums, dis- tractibility, impulsiveness, lack of age-appropri- ate impulse control, and uncontrolled anger. ‘An important subset of the clinical population troated at the IPP consists of infants and toddlers, diagnosed with reactive attachment disorder as described in the Diagnostic and Statistical Man- ual of Mental Disorders, fourth edition (DSM- IV) and in the Zero to Three diagnostic classifi- cation, These caildren have not been able to form a sustained, focused relationship because of loss of the original attachment figure, followed by in- stitutional care or multiple changes in foster care placement. They shaw the symptom picture typi- cal of this condition, including withdrawal, iri tability, lack of responsiveness to human contact, and lethargy, or their reverse—namely, indis criminate socicbility and shallowness in human relations. Many of these children also show pro- longed and seemingly intractable tantrums and unpredictable touts of aggression, Regardless cf the immediate presenting prab- Jem, IPP intervention invariably begins with an extended assessment process that lasts approxi- mately 6 weeks and is geared to building a reli- able working alliance with each child's parent(s) or caregiver(s), as well as to gathering compre: hensive information about the child, the family, and their circumstances. Except in exceptionaltheir babies fre component fmented by an bal differences bed immediate Essful current fe patterns of bespiciousness F difficult life fattunement to Fience of the Beess. As a re- F parents’ own Fe concepts of bof treatment, fists interven Berapist rela- fmary mutative Bel & Licber- Hiavioral diffi- Espeutic atten- [perception of Beptom picture fon, separation F inexplicable betrums, dis- Faze-appropri- bed anger. Feal population fs and toddlers bet disorder as baxistical Man- Baition (DSM- postic classifi- Fable to form because of loss Followed by in- Bin foster care ba picture typi- Bdrawal, irvi- faman contact, fsamely, indi Bess in human Blo show pro- Prtantrums and Fesenting prob- Bezins with an Flasts approxi Building a reli- fald’s parent(s) bering compre- Bid. the family, fn exceptional CHAPTER 24, Attachment’s Contributions to InfantParent Psychotherapy 563 circumstances, the assessment is carried out by the same clinician who will conduct the treat- ‘ment if infant-parent psychotherapy is consid- cred the treatment of choice at the end of the as- sessment, This is done in order to maximize the continuity of human connection between parent and intervenor, and to avoid a repetition of t history of separation, loss, and short-lived rel tionships with intimate others as well as with ser- vice providers that is the rule in this population ‘The intervenors are master's-level and pre- and postdoctoral therapists representing a variety of disciplines, including social work, psychology, psychiatry, pediatries, and nursing. Whenever clinically appropriate, a developmental neu- ropsychology evaluation involving at least three sessions is conducted in order to obtain a system- atic picture ofthe child’s cognitive, sensorimotor, and emotional functioning, and to provide feet back to the parents, Great care is taken to det mine the timing of this evaluation and to inte grate it with the ongoing clinical assessment and tweatment ofthe child and the family (Lieberman, Van Hom, Grandison, & Pekarsky, 1997). The sessions involve the parent(s) and the child and take place either in the home or in the office playroom, as clinically indicated or as pre~ ferred by the parents, Whenever possible, at least one home visit is conducted during the assess- ment process in order to obtain a more accurate understanding of the family’s living conditions. The format of joint parent-child sessions is dic~ tated by the ongoing need to Team as much as possible about the child’s and parents” function- ing and the quality of their relationship; however variations in this basic format are possible, de~ pending on family composition, the child's age, and other factors. For example, individual ses- sions with one or both parents or meetings with the couple are sometimes called for when private time for the adults is needed in order to discuss emotionally charged issues that affect the child’s welfare but are not appropriate to discuss in the child’s presen Both the assessment and the treatment ses- sions are unstructured, with the themes largely determined by each parent’ free associations and by the unfolding interactions between the parents and the child, The intervenor observes how the parents and the child relate to each other and how each of them responds to the emotions that emerge during the sessions. Child observations are used to determine the child’s level and quality of functioning in the sensorimotor, social, and emotional domains, and these observations are used to supplement and enrich the formal devel- ‘opmental neuropsychology evaluation. Ques- tions, probings, joint play, developmental guid- ance, expressions of emotional support, and insight-oriented interpretations are used as clini cally indicated to help the parents modify their rigid, and distorted perceptions of the child and to construct a more developmental- ly appropriate, empathic, and nuanced behavioral repertoire in their interactions with the child. ‘These interventions have the goal of helping the child become more securely reliant on the par- In every aspect of treatment, the therapist is aware of the pervasiveness of a parallel process between what trenspires between the parents and the therapist and what transpires between the parents and the child. In keeping with this aware ness, the therapist is careful at all times to be em- pathically responsive to the emotional needs of both the patents and the child, and not to force the disclosure or expression of negative feelings or psychological conflicts in either the parents or the child, Many of the recent writings involving the ‘work of the IPP emphasize the compatibility of infant-parent psychotherapy with assessment procedures and therapeutic techniques influ- enced by attachment theory. In particular, a randomized treaiment outcome study of the eF- fectiveness of infant-parent psychotherapy, con- ducted with a Latino subsample, utilized the strange situation procedure and other assessment, instruments derived from attachment theory re- search fo assess the intervention and control ‘groups before and after treatment (Lieberman, Weston, & Pawl, 1991). This study demonstrated significant differences between the intervention and control groups in maternal empathy, dyadic ‘goal-corrected partnership, and children’s avoid ‘ance, resistance, and anger toward their mother with the scores in all of these measures signif cantly favoring the treatment group. The results support the theoretical and clinical compatibility ‘of concepts central to both attachment theory and infant-parent psychotherapy, and point the way toward a fruitful collaboration of research and clinical intervention within an integrated para digm, The Child Trauma Research Project: A San Francisco Innovation ‘The Child Trauma Research Project (CTRP) is a treatment outcorie research program that utilizes564 PARTY ‘age-modified infant-parent psychotherapy in or: der to assess and treat children in the first 5 years of life who have been traumatized by domestic vviolence—specifically, by the experience of wit. essing their mothers being battered and/or Taped by partners. This program seeks to inte- ‘rate the assessment and intervention strategies Of attachment theory and infant-parent psy- chotherapy into a researchable model of child: ‘mother psychotherapy that addresses the disrup. tion in attachment pattern resulting. from vio~ Tence-related trauma to both a mother and a child (Lieberman et al, 1997). The goal of the pro- gram is to investigate the effectiveness of dyadic Dsychotherapy in helping to address and alleviate the traumatic effects of violence on the child mother relationship. The clinical objectives are to enable the mother to enter into and to appreci- ate the child's inner world; to help the child and the mother to jointly construct a narrative of experiences, including the impact of violence: and to offer mother and child a safe space that al- lows them to enact their conflicts in order to find more adaptive ways of resolving them. In order to reduce the chances of retraumatization in the course of treatment, only families where the mothers no longer have active relationships with the perpetrators are included. Exclusion ary criteria involve homelessness and maternal Psychosis, mental retardation, and substance abuse, in order to increase sample homogeneity and reduce the need for multiple treatment ap- proaches. The treatment outcome research component of the CTRP informs the assessment process, dic~ tating the need for standardized instruments and assessment procedures. At the same time, the fundamental clinical principles of infant mental health assessment are integral parts of the assess- ‘ment. These principles involve the importance of a collaborative relationship between the mother and the therapist; the assessment of the child's functioning in the context of his or her primary relationships; the need to assess the child in fa miliar settings, including the home and the child care setting; and the need for an assessment peri- od lasting several weeks, in order to gain a de- tailed understanding of the prevailing emotional themes, range of functioning in both the child ‘and the mother, degree of variation in the quality of the attachment relationship, and the influence of situational factors as compared to stable fami- ly cireumstances and chronic stressors. With these prineiples firmly in place, the use of stan- dardized instruments for the mother and for the CLINICAL APPLICATIONS Child does not detract from the working alliance that must be established during the assessment process. The instruments include measures of de- pression, anxicty, ard posttraumatic stress disor- der to assess the mother's condition; other me sures to assess the mother’s perceptions of her child: and a final set of measures to ascertain the childs cognitive furctioning and dimensions of attachment The clinical premise underlying the intervei tion is directly derived from an integration of at- tachment theory and psychoanalytic insights into children’s inner lives, The assumption is. that Watching the mother being battered by a partner is traumatizing because it shatters the child's confidence in the mother as a source of protec tion, and because it makes real the very young child's age-appropricte fantasies about the de- structiveness of feclings of anger and aggression. As a result, the child ean no longer rely on the ‘mother as a secure base because, from the child’ Perspective, she was damaged and unable to help when the child most needed her. The child’ predicament can be expressed in the following questions: “If Mommy can't protect herself, how can she protect me? If something happens to Mommy, what will be2ome of me? Who will take care of me?" When the perpetrator is also the father of the child and he is out of the home, the child's long ings for the loving aspects ofthe father get mixed. up with the fear of the destructive parts of the fa- ther and the fear of being like him. We hear many and 4-year-olds, both boys and girls, say to their mothers: “I will kill you. I will beat you up will call Daddy and ésk him to Kill you because ‘you are bad.” In making these statements, a child is asking: “Am I dangerous like Daddy? Will you, Mommy, let me do to you the things that Daddy did to you? What will happen to you if | am like Daddy? Will [hurt you and kill you? And will you make me go awiy the way you made Daddy go away?" All these questions are far from rhetorical: they have a powerful existential immediacy. They are real because the events to which they refer actually happened and can happen again at any time. The simultaneous framing of the clinical challenges in terms of attachment theory and in terms of the fantasies engendered by reallife events allow for forms of intervention in which the actual interactions between mother and child are addressed, contained, and redirected in ways. that restore a feeling of security and protection for both mother and child.be alliance Bssessment pares of Bress disor- bther mea- fons of her feertain the bensions of B interven- Bion of at- Bsights into fon is that by 8 partner fie child's fof protec fery young fat the de- beeression. Fely on the bie child's Hie to help Fie child's Pifollowing Erself, how Bappens to bo will take ; fiber of the bild’s ong. Fectmixed bs of the fa- Pear many feiss say to fet you up. fou because bas. a child bay? Will fhings that bao you if | Biyou? And you made bshetorical Hiacy. They Pthey refer pain at ary fie clinical Bory and in by real-life pein which frand child bed in ways b protection CHAPTER 24. Atfachment’s Contributions to Infant-Parent ‘An evaluation of the effectiveness of this pro- gram is currently underway. Steps Towards Effective, Enjoyable Parenting: The Minnesota Program Steps Towards Effective, Enjoyable Parenting (STEEP) emerged as a community-oriented ap- plication of research findings from the Minneso- {a Parent-Child Project (Erickson et al, 1992). A program involving multiple services, STEEP has the underlying goal of influencing a mother’s in- ternal working model of attachment by focusing ‘on her feclings, attitudes, and representations of the mother-child relationship. The original pro- gram focused on first-time mothers, although subsequent community applications have ex- panded to mothers with more than one child as well. The initial focus on primiparous women ‘was prompted by the desire to develop a proac- tive preventive approach that could be imple- mented before a mother felt she had failed at be~ ing a parent, The participants are selected on the basis of being at risk for parenting problems due to stressful life circumstances, poverty, youth, lack of education, and social isolation, ‘The STEEP program begins with home visits that start to take place during the second trimester of pregnancy. These visits focus on helping a mother to prepare for the birth of her baby, both by anticipating the baby's needs and by discussing the mother’ feelings and expecta- tions about parenthood. These home visits take place every other week and continue until the ba~ bies’ first birthdays. In order to build cohesive- ness and continuity, the same intervenor con- Farms peyehoanaljis Journal of he marcan Poychoan- lye Assocation 41(Sapp), 193-208, Pasi Jy & Lihorman, A, F(1997), fn parest psy ‘htrap. In. 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