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Ludovica Grassi, MD: Infant-parent psychotherapy: relevance of psychoanalytic theorizing on the therapeutic process

Child Psychiatrist and Psychoanalyst
In 1969 Winnicott pointed out that, after psychoanalysis had been fighting its battle on behalf of the individual against the disturbances arising from environmental influences, the unavoidable happened: psychoanalysts were finally obliged to take into consideration the early stages of human development when dependence is so strong that the behavior of those who embody the environment can not be overlooked.
The whole development of psychoanalysis, though, is characterized by a complex dialectic between individual and environment, external reality and fantasy. This was firstly brought to light with deep intensity and pain by Freud's clinical and auto-analytical experience, when in 1897 he wrote to Fliess: I do not believe to my neurotic any more. This statement, apparently so clear and concise, opened the way in Freud's research to a paradox which would generate theoretic fluctuations, conflicts, developments, and regressions.

Sexual trauma at the origins of psychoanalysis
It is true that, after 'giving up' the theory of seduction, Freud's thinking heavily focuses on psychic reality, the instinct-fantasy axis, the structural organization of personality, and the intrapsychic origins of conflict. However, we still find in it unequivocal references to the founding role of the environment where the child grows, in terms of both structuring and traumatic implications.

Hence, in 1911 the well known clause: "as long as maternal care is included", emphasizes the absolute inadequacy of the psychosomatic organization of the infant (hilflosigkeit) to stay alive only for even just a single moment without the environmental support. This idea opens the way not only to the thinking of authors such as Winnicott, but also to the more recent developments of a relational perspective in psychoanalysis, which include its clinical applications within the domain of the early mother-baby relationship.

However, while it is acknowledged that the protection against stimuli is a more important function for the living organism than their reception (1920), seduction can always open a breach through such a protective barrier. If it is not always the paternal seduction, the idea of early seduction by the mother occurs persistently, as the satisfaction of long repressed wish impulses, firstly qualified as perverse (1910).
The boundaries between reality and fantasy become vague, as in 1932 Freud mentions a seduction fantasy by the mother in the preoedipal history of the girl. Soon thereafter Freud adds that here fantasy touches the ground of reality, since it was really the mother who, in the handling necessary for the care of the girl's body, aroused, and perhaps elicited for the first time, pleasant feelings to the genitals.
Finally, the definition of perverse disappears in 1938, when Freud maintains that the mother, taking care of the child's body, becomes its first seducer.

It would be impossible in a few pages to go through these two theoretical paths, which, rooted in the thought of the founder of psychoanalysis, have constantly carried out a fertilizing function along the development of psychoanalysis through their moving closer, diverting and intertwining.

Therefore, I shall just illustrate a few factors of continuity and possible dialogue between the theoretical and technical foundations of a few models of psychotherapeutic work within the realm of the early parent-child relationship and the theorizing of psychoanalysts seemingly distant from this clinical field.
I would like now to highlight some crucial issues of a few models of parent-infant psychotherapy.

Selma Fraiberg
Parent-infant psychotherapy was firstly developed in 1975 by Selma Fraiberg, aiming to throw out what she named the ghosts in the nursery, which reproduce troubles and sufferings from one generation to the next, and result in severe disturbances of the early parent-infant relationship. In these situations, in spite of the persistence of explicit and chilling memories of events of childhood abuse, violence, and desertion, what parents cannot remember is the inherent affective experience. The pivotal pathogenic mechanism is one of identification with the aggressor. The infant-parent psychotherapy is therefore aimed to allow the reemerging in the parents of repressed or split-off affects inherent to the conscious memory, in order to break up the compulsion to the repetition of the past in the present. Some important features of Fraiberg's approach are: meeting the patients needs, home intervention (psychotherapy in the kitchen), presence of the baby in the setting, timeliness.

Among Fraiberg's coworkers, Stephen Seligman (1994) emphasizes the opportunity of stimulating a progressive synergy of adaptive responses in a time of developmental crisis such as the birth of a new child and in a context where the relationship is the patient.

Daniel N. Stern
Starting from the consideration that comparable outcomes are seemingly achieved by different models of parent-infant psychotherapies, Daniel Stern proposes a unified approach based on components common to all therapeutic techniques. The first one is the clinical context, which he portrays as composed by always present and working elements, mutually dependent and dynamically related. Any therapeutic intervention that modifies one of these elements will end up affecting all the other ones. The only difference between different therapeutic models is their using different "inlets" to this system. The second shared factor is what Stern names motherhood constellation, which is the dominant organization of mother's psychic life in the post-partum, based on the axis mother's mother-mother-baby. The result is a different view of the therapeutic alliance and of the use of transference and countertransference dynamics, which leads to a "good grandmother's transference" and, at the end, to a corrective emotional experience.

Stern concludes that supplying a therapeutic framework based on the alliance and the transference within the motherhood constellation will promote most of the therapeutic elements common to the different approaches to parent-infant psychotherapy.

Bertrand Cramer and Francisco Palacio-Espasa
The approach put forward by Cramer and Palacio-Espasa is focused on the dynamics between the intrapsychic and the interrelational domains.
They outline the role both structuring and pathogenic of the mother's identifying function, stemming from different kinds of projective identifications. Externalizing and empathetic projective identifications, more or less coercive, ensure intense libidinal cathexis of the baby, whereas narcissistic and expulsive projective identifications exert a deforming action on the baby's needs and on the mother's representation of her child. The integration efforts exerted by the infant usually allow him to develop a genuine feeling of identity. On the other side, a disturbance of the mother-infant system is a sectorial structure different from any other pre-existing maternal pathological condition, but unstable and hence responsive to short therapeutic interventions.

In the infant-mother psychotherapy it is crucial to adopt a bifocal view, to focus on both the intrapsychic and interrelational domains. Only by doing so, is it possible to discover the symptomatic interactive sequence, described as an instance of interaction failure due to the emergence of a maternal unresolved conflict shared with the baby.

The changing factors pertaining to short infant-mother psychotherapies pointed out by Cramer and Palacio-Espasa are: re-introjection of parental projections; change of parental interactions and representations; transformation of the mother's investments on to the baby.

Sandor Ferenczi
One source of the theoretical elaboration about the very early stages of life is found in the psychoanalytic work with deeply regressed patients, a field pioneered by Sandor Ferenczi. He developed the theoretical path Freud had officially dropped after he had realized that sexual traumata his patients reported were often the product of fantasy rather than memories of actual events. Ferenczi's paper on the confusion of tongues between adults and the child (1932) restates the importance of sexual trauma (and of deprivation) as a pathogenic agent.

Due to the opposition between child erotism characterized by tenderness and adult erotism characterized by passion, there is a substantial, unsolvable difference of language, which by necessity results in an early grafting of passional love tinged with guilt onto an innocent and immature individual.

The concept of confusion of tongues, however, does not support any simplistic traumatic theory where a sheer relationship of direct causality connects the event and the pathological outcome. Through experiencing new ways of relating with his agonizing patients, Ferenczi discovered a new perspective of deferred action (après-coup) of trauma effects. What turned out to be traumatic, rather than the actual occurrence, was the denial and the prohibition of its consideration, interpretation and understanding by the adult involved with the child in the traumatic event (1932).

The traumatized child is therefore struck dumb by the paralyzing effect, and is left with no other way out of it than the introjection of the aggressor, which allows the extra-psychic event to become intra-psychic. Moreover, there is a loss of thinking faculty or, at least, of expressing one's own thought; the personality nucleus reacts in an autoplastic way, with a kind of mimicry, just like the Winnicottian false self.

Other effects of trauma pointed out by Ferenczi, and evocative of Winnicott's later conceptualizations, are the disposition to mature not only emotionally but also intellectually through a pathological traumatic progression or precociousness. The child needs to turn into a sort of psychiatrist of the adult devoid of inhibition, or loses contact with the various fragments of personality, up to atomization.

Donald W. Winnicott
According to Winnicott, the environment where the individual grows up is so important to have him maintain that the infant and the mother's care constitute a whole thing (1969), that the environment is part of the infant (1969), and, finally, in his well known expression, that there is no such thing like a baby. Winnicott's conceptualizations are all essential when we consider the domain of mother-infant relationship:
the dyad as a psychosomatic system; the mother's empathy on which the infant's existence depends, addressing the need rather than the wish, and facilitating the process from non-integration to integration;
the primary maternal preoccupation as a state of high and exclusive sensitiveness towards the infant;
the holding, which allows the appearance of a limiting membrane between the infant's "me" and "not-me" and protects the baby from trauma;
the effects of trauma, where it is the reacting as such that breaks off and annihilates the being. Winnicott adds that the birth of hatred in the individual, following an environmental failure that allows the impingement by an incomprehensible reality, is unbearable and, hence, traumatic.

When Winnicott (1969) emphasizes that the mother and the infant reach mutuality in different ways, he seems to follow the path that, from Ferenczi's confusion of tongues, leads towards Laplanche's theory of generalized seduction and Aulagnier's violence of interpretation. Moreover, he warned that instinctual satisfactions and object relations themselves are a threat to the ongoing personal existence of the individual. With this respect too, we can wonder whether these threats are as well inalienable ingredients of the earliest experiences of relationship with the primary environment.

M. Masud Khan
Introducing his concept of cumulative trauma, Khan (1963) draws attention to the traumatic quality of events which are not just that when taken into account one by one, but become traumatic only cumulatively and retrospectively, silently working and building up through childhood and adolescence. These events result from failures of the maternal protective role, involving not only meeting the baby's anaclitic needs, but also defending him from the mother's unconscious love and hatred. Khan too, then, does not overlook the participation of unconscious factors in the dyadic relationship and the logical consequence that this protective role may be, and actually is, charged with the mother's personal needs and conflicts. The repeated impingements suffered by the child result in an active collusive mother-infant relationship, where the main psychic mechanism is identification, marked by an incorporating and projective quality.

The specific pathogenic reactions that ensue fit very consistently in with Ferenczi's conceptualizations, further expanded by Winnicott: premature and selective development of the Ego; particular sensitiveness to the mother's moods, with an imbalance of aggressive impulses; dissociation between an archaic bound of dependence and anticipated independence; false identification-like union with the mother and Ego's preoccupation for the mother which replaces the true object cathexis; a peculiar kind of organization of the child's body Ego.

Finally, Khan doubts whether these failures of the maternal protection may be recognized at the moment of their actual happening. It just sounds like an invitation to add the missing piece of the mosaic of a mother-infant relationship clinical practice, something that actually happened with the publication of "Ghosts in the Nursery" (1975) ten years later.

Piera Aulagnier
The inextricable link between the unfolding psyche of the infant and the family environment is defined by Aulagnier in terms of primary violence by the adult who "interprets" the child even before its birth, thus giving rise to a kind of shadow spoken about and presumed by the speaking mother, which as soon as the infant is there, will project on to its body and take its place. According to Aulagnier, indeed, every subject was born in a speaking space, which is basically organized by the parents' discourse and wishes. In particular, the mother's speech is attributed the function of word-provider, a structuring function for the child's psyche since it bears meaning and is representative of the order outside.

The maternal knowing about the body of the infant is a privileged tool of the primary violence, since it translates the category of the need into the domain of libidinal request by taking it into the area of wish dialectics. This looks like a reversed view of Winnicott's thinking, advocating that the word "need" should take the place of the word "wish" in order to characterize what happens in the area of primary maternal preoccupation.

Aulagnier emphasizes that the reality offered by the mother to the infant, though already shaped by the mother's psyche and, hence, made representable, cannot be devoid of remnants that have eluded control of repression. She is, then, for the baby both donor (provider) of the (unconscious) wish, an essential gift for the psychic structure, and the one who expresses a prohibition which anticipates the baby's wish itself.
The body is initially the only means for the infant to express his non-correspondence to the spoken shadow, such as a different sex from the expected, or a deficiency, something lacking, i.e. sleep, growth, motion, phonation. Later on, the thinking, as the first function out of the mother's control, becomes the child's only tool for autonomy and refusal.

In this light, the risk of a pathological evolution is identified with the risk of excess, i.e. with the mother's wish of preserving what is legitimate and necessary for a period of life only. Should this occur, a secondary violence shall interfere with the child development.

Jean Laplanche
In his "New foundations for Psychoanalysis" (1987), Jean Laplanche follows Freud's path from the theory of "restricted" seduction, where there is always a perverse father, to the early seduction, where there is the mother who provides the first bodily care for the baby, that in turn is "polymorph perverse". In its relationship with the adult world, the newborn is deeply unadjusted and in a condition of pre-maturation both from the point of view of adaptation, and from the sexual point of view since it cannot adequately react to the sexuality it is confronted with. The typical activity-passiveness relationship relevant to the adult-child relationship is due, then, to the greater richness of the parents' psyche, richness that constitute its weakness as well, since it is made up of factors unknown to the subjects themselves. The original seduction is just this basic condition where the adult offers the child both non-verbal and verbal signifiers charged with unconscious sexual significance. The child's impossibility of carrying out the work of mastering and symbolizing these enigmatic messages, is bound to leave unconscious remnants, which indeed in this theoretical context undertake a founding role since they give birth to drives. Accordingly, Laplanche emphasizes that there is no direct contradiction of nature between the instinctual and the inter-subjective, between the instinctual and the cultural. Sexual drive, peculiar to man, did not originally stem from the biological, though it is linked to it at the subsequent genital level.

This interesting theoretical development, arising from the purpose of putting a few basic concepts of psychoanalysis to work just in the areas where their contradictions and insufficiencies are more evident, has further elaborated these ideas so that they are charged with explicative potentials unexplored at the time of their conception. This outstretching is welcomed because of the extension of the interest and application field of current psychoanalysis to less differentiated areas of the mind. Here is, then, a chance to connect these and other conceptual nuclei to clinical areas in development, such as that of the infant-parent psychotherapy.

It is in such areas that there is often a great temptation of excessive pragmatism, as well as the tendency to refuse well-defined theoretical and experiential roots. The justification stems from the timing of the intervention required by the presence of a very young child, who is living in a condition of risk or of ongoing injury, from the concreteness and corporeality not only of the mother-infant relationship but also of the communication established with the therapist, and from the priority attributed to objectively valuable results rather than to other features more difficult to demonstrate.

However, even the assumption shared by the different approaches, according to which the patient is the relationship, does not require ignoring the inner world of the individuals who are involved in this relationship. Being able to generate hypotheses based on what is going on within this relationship, even if this is not immediately observable and referable, surely leads to a greater possibility of understanding, symbolizing and transforming.

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