V: Evidence-Based Infant Mental Health Models that Utilize Play Therapy Practices
Using the Healing Power of Relationships to Support Change in Young Children Exposed to Trauma: Application of the Child– Parent Psychotherapy Model
Winnicott says it best when he stated that “there is no such thing as a baby ... if you set out to describe a baby, you will find you are describing a baby and someone” (Winnicott, 1964). This means that a baby does not function as a blank slate, but in context of relationships with others. Therefore, when these relationships become strained due to trauma or toxic stress that impacts young children’s lives, these relational bonds are severed, creating a rupture in the parent—child relationship (Schore, 2001). Osofsky (2011) contends that “The ghosts of childhood that remain with adult women as they enter into relationships with their own infants must be called forth from the unconscious and invited into the treatment context to facilitate healing and change” (p. 215). When addressing the impact of intergenerational transmission of trauma, it is important to treat the parent-child relationship in order to strengthen the attachment bond, while providing a healthy and safe environment for parents to heal and become a “good-enough mother.”
Overview of Child-Parent Psychotherapy
Child-Parent Psychotherapy (CPP) (Lieberman Sc Van Horn, 2008), is an evidence-based relationship intervention to help young children, birth to five years old, and their caregivers after exposure to trauma (Lieberman, Ghosh Ippen, Sc Van Horn, 2015). CPP is based on the premise that young children function within the context of caregiving relationships. According to Winnicott (1964):
Having reached the child, we try to look at his world with him, and to help him sort out his feelings about it, to face the painful things and discover the good things. Then we try to consolidate the positive things in the child and in his world, and to help him make the most of his life.
During these dyadic sessions, play is used as a modality to help parents understand how their children internalize feelings and unconscious emotions are expressed. Piaget (1951) describes this as “A way of bridging the gap between child’s inner world and the reality of the world outside” (p. 147). CPP is divided into two phases: (1) the Assessment and Engagement Phase; and (2) the Intervention and Termination Phase.
Assessment and Engagement Phase
During the assessment and engagement phase, the clinician works closely in establishing a trusting relationship with the caregiver to gather information that will be the driving force of the treatment process. This process also helps the clinician gain insights in helping the parents develop an awareness and understanding into how the trauma has affected the child. In doing so, the clinician utilizes the Life Stressor Checklist Index-Revised (Wolfe et al., 1996) which is an intensive trauma instrument that focuses on trauma from a developmental life span perspective. This instrument helps the clinician gain insights into the intergenerational aspect of the caregiver’s trauma in order to help the caregiver understand its impact on the child’s level of functioning. Another important tool that is employed is the Working Model of the Child Interview (Zeanah, Benoit, & Barton, 1986). This tool is a semi-struc- tured interview that includes a series of questions and probes that allows the clinician to help parents reflect on their own upbringing and how it has impacted their perception of parenting and their view of the child. This tool also allows the clinician to employ two interventions that are important to the process: “Ghosts in the Nursery” and “Angels in the Nursery” (Fraiberg, Adelson, &C Shapiro, 1975; Lieberman, Padron, Van Horn, & Harris, 2005).
In gathering information from the child’s perspective, several instruments are utilized to capture both developmental concerns and issues relating to the child’s exposure to trauma that have affected the attachment relationship. These instruments are the Traumatic Events Screening Inventory- Parent Report Revised (Ghosh Ippen et al., 2002), which assesses trauma exposure in the child and its impact on the child’s behavior; The Ages and Stages Questionnaire (ASQ:SE and ASQ:3) (Squires, Twombly, Bricker, & Potter, 2009) are both developmental screening tools that are also utilized to capture developmental risk factors that may have impacted the child as a result of the child’s trauma exposure. The child is also observed in the natural environment, home, or preschool, to address the level of functioning. Additionally, The Crowell Assessment (Crowell &C Feldman, 1988; Heller et al., 1998) is utilized to assess the parent-child relationship and is an important observation tool that was developed to be used to assess parental interactions during playful and stressful times in order to determine the quality of the attachment relationship between the child and the caregiver. In this procedure, parents are provided with a series of instructions and the dyad interaction is observed behind a two-way mirror. The observation consists of play, structured tasks, and a brief separation and reunion phase. This procedure helps set the foundation for the feedback session, which often provides information to the caregiver regarding their affect and attunement towards the child during the tasks provided. During this process, reflective questions are asked to help the parents wonder as they try to keep the baby in mind (Fonagy et al., 1991). Viewing of video clips during the feedback session helps parents understand the child’s perspective, as well as helping them view the child through a different lens, based on the impact of the traumatic experience (Schecter et al., 2(X)6).
Intervention and Termination Phase
During the intervention and treatment phase, the goal of CPP is to the help the child build a relationship with his or her caregivers. Play is utilized as a modality to address various issues such as helping the child to engage in developmentally appropriate play activities with caregivers, helping the parents prioritize safety within the relationship with their child, increasing the parent’s understanding of their child’s behavior and/or functioning when they become triggered by trauma reminders, and helping the parent and child improve affect regulation. In the termination phase of CPP, the clinician helps prepare the parent and child for termination through planning, discussing their progress throughout the treatment process, and in helping the parents prepare for their transition from therapy by identifying positive ways of building on strengths learned throughout the experience.