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,
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.
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.
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.
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.
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
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.
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.
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
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.
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
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.
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.
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.
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).
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.
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.
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.
(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.
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.
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
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.
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
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
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.
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.
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.
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.
Aulagnier, P. (1975). La violence de l'interpretation. Du pictogramme
à l'énoncé. Paris: Presses Universitaires de France.
Cramer, B., & Palacio-Espasa F. (1993). La pratique de psychothérapies
mères-bébés. Paris: Presses Universitaires de France.
Cramer, B. & Stern, D. N. (1988). Evaluation of changes in mother-infant
brief psychotherapy: a single case study. Infant Mental Health J., 9,
Ferenczi, S. (1909). Introiezione e transfert. In Opere, Vol. I. Milano:
Ferenczi, S. (1912). Il concetto di introiezione. In Opere, Vol. I. Milano:
Ferenczi, S. (1923). Il sogno del poppante saggio. In Opere, Vol.III.
Milano: Cortina, 1992
Ferenczi, S. (1932). Diario clinico. Milano: Cortina,1988.
Ferenczi, S. (1949). Confusion of tongues between adults and the child.
Int. J. Psychoanal., 30, 225-230.
Fraiberg, S., Adelson, E. & Shapiro, V. (1975). Ghosts in the nursery:
a psychoanalytic approach to the problem of impaired infant-mother relationships.
J. Amer. Acad. Child Psychiat., 14, 387-422.
Fraiberg, S., Shapiro, V. & Cherniss D. (1983). Treatment modalities.
In Call, J. D., Galenson, E., Tyson, R. L. (eds.), Frontiers of Infant
Psychiatry. New York: Basic Books.
Freud, S. (1910). Un ricordo d'infanzia di Leonardo da Vinci. In Opere,
Vol. VI. Torino: Boringhieri.
Freud, S. (1911). Precisazioni sui due principi dell'accadere psichico.
In Opere, Vol VI. Torino: Boringhieri.
Freud, S. (1920). Al di là del principio di piacere. In Opere,
Vol. IX. Torino: Boringhieri.
Freud, S. (1932). Introduzione alla psicoanalisi (Nuova serie di lezioni).
In Opere, Vol. XI. Torino: Boringhieri.
Freud, S. (1938). L'uomo Mosè e la religione monoteistica. In Opere,
Vol. Xi. Torino: Boringhieri.
Khan, M. M. R. (1974). The privacy of the Self. London: Hogarth Press.
Laplanche; J. (1984). Nouveaux Fondements pour la psychanalyse. Paris
: Presses Universitaires de France.
Lieberman; A. F. & Pawl, J. H. (1993). Infant-parent psychotherapy.
In Zeanah, C. H. (ed.), Handbook of Infant Mental Health. New York: Guilford
Seligman, S. (1994). Applying psychoanalysis in an unconventional context.
Infant Mental Health J., 49, 481-520.
Stern, D. N. (1995). The motherhood constellation. A unified view of parent-infant
psychotherapy. New York: Basic Books.
Winnicott, D. W. (1945). Lo sviluppo emozionale primario. In Dalla pediatria
alla psicoanalisi. Firenze: Martinelli, 1975.
Winnicott, D. W. (1956). La preoccupazione materna primaria. In Dalla
pediatria alla psicoanalisi. Firenze: Martinelli, 1975.
Winnicott, D. W. (1960). La teoria del rapporto infante-genitore. In Sviluppo
affettivo e ambiente. Roma: Armando, 1970.
Winnicott, D. W. (1965). Il concetto di trauma in relazione allo sviluppo
dell'individuo all'interno della famiglia. In Esplorazioni psicoanalitiche.
Milano: Cortina, 1995.
Winnicott, D. W. (1969). L'esperienza di mutualità tra madre e
bambino. In Esplorazioni psicoanalitiche. Milano: Cortina, 1995.