Incorporating Play into Child–Parent Psychotherapy as an Intervention with Infants Exposed to Domestic Violence

Allison Golden and Veronica Castro

Introduction

It has been said that “the emotional quality of our earliest attachment experience is perhaps the single most important influence on human development” (Sroufe tk Siegel, 2011). The relationship between an infant (children ages 0-3) and their parent (refers to infant’s primary caregiver) shapes the internal and external experiences of that infant’s life, from birth through adulthood. According to the Center on the Developing Child at Harvard University (2017), through serve-and-return interactions via timely, responsive, sensitive caregiving, an infant’s brain begins to build neural pathways that set the stage for the infant’s capacities to regulate emotion and behavior, engage in social relationships, learn, and develop. One of the most important mechanisms for serve-and-return interactions between parent and infant is play.

Early Childhood Trauma

Early childhood trauma can last a lifetime. When an infant experiences trauma, particularly when it is interpersonal in nature, it impacts the infant’s developing brain; understanding of self, others and the world; academic success; and adult mental and physical health (Ludy-Dobson & Perry, 2010; Lieberman & Van Horn, 2008; Romano, Babchishin, Marquis, &c Frechette, 2015; Felitti, 2010). Neuroplasticity, the brain’s capacity to reorganize in response to internal factors and the external environment (Shaffer, 2016), in the first few years of life, highlights the importance of early intervention to interrupt the negative impacts of trauma, and change the trajectory of an infant’s current and future functioning.

John Bowlby (1982) recognized that the infant engages in heightened attachment behaviors toward the mother, such as seeking proximity, clinging, and crying, during times of stress or fear. When their mother is not present, either physically or emotionally, to provide the comfort and protection the infant is seeking, the infant is left to utilize whatever minimal coping skills they possess. This often results in aggression, withdrawal and/ or emotional dysregulation, all behaviors which may elicit negative reactions from the mother, further damaging the sense of trust the infant feels in the mother’s ability to provide comfort and protection. As the parent—infant attachment is the foundation for brain development, infanthood mental health and long-term well-being, it follows that it is the focus of attention in the treatment of early childhood trauma.

Child-Parent Psychotherapy (CPP)

Child-Parent Psychotherapy is an approach that incorporates multiple theoretical approaches including psychoanalytic, attachment, developmental and trauma theories, as well as techniques from cognitive behavioral and social learning therapies (Lieberman Sc Van Horn, 2008). This approach recognizes the attachment relationship between parent and infant as the basis for which infants create internal representations of themselves and others. It helps them to understand danger and safety and feel able to explore the world around them in order to develop capacities required for all areas of childhood development (Lieberman &c Van Horn, 2008). Thus, CPP identifies the parent-infant relationship as the agent of change and the “client” in the therapeutic environment. This dyadic therapy focuses on repairing the negative impact of trauma on the parent—infant relationship, and the resulting behavioral and mental health difficulties of young children. It strives to strengthen the parent—infant relationship by renewing a sense of safety and trust in their attachment relationship.

Treatment utilizing CPP is completed in three phases: assessment and engagement; core intervention; and recapitulation and termination. The purpose of the assessment and engagement phase is to gain a better understanding into the parent-infant relationship, presenting symptoms, and trauma history of both the infant and the parent. Additionally, goals during this phase are to determine sources of danger, promote safety and instill hope, and to create a treatment plan with the parent in which the trauma will be addressed through the parent—infant sessions. The core intervention in this phase is the creation of a “trauma frame” in which the parent begins to link the infant’s symptoms and challenges with their traumatic experiences. And to create an environment that feels safe enough for the parent and infant to “speak the unspeakable” and tolerate difficult emotions in order to allow for relational repair (Lieberman, Ghosh Ippen, & Van Horn, 2015). During the core intervention phase, the trauma frame is introduced to the parent and the purpose for therapy is explained. Then through the words, behaviors, and experiences of the parent and infant individually, and the spontaneous interactions that present between them, the therapist looks for opportunities to intervene. These opportunities are known as “ports of entries” (Lieberman et al., 2015) where therapists utilize a variety of strategies in an effort to make therapeutic progress toward one of the CPP goals. The last phase of recapitulation and termination is focused on supporting the parent and infant to recognize the changes that occurred throughout sessions, helping the dyad prepare for and process the impending termination of services, as well as addressing how to maintain the gains made and manage challenges in the future.

As Child-Parent Psychotherapy is rooted in Infant—Parent Psychotherapy, one of the unique characteristics of this dyadic model is its acknowledgement and attention to the impact of intergenerational pathology, or as Fraiberg, Adelson, Sc Shapiro (1975) referred to it, as the parent’s “ghosts in the nursery.” Parent’s experiences of childhood trauma may interfere with their ability to recognize or appropriately respond to their infant’s need for care and protection (Lieberman et ah, 2015), and often the infant’s resulting traumatic stress behaviors act as triggers to the parent’s repressed feelings of fear and helplessness (Fraiberg et ah, 1975); thus initiating their own protective mechanisms. These protective mechanisms often result in parental behaviors of criticism, aggression, and withdrawal, furthering the infant’s view of the parent as non-protective, and even dangerous. During parent- infant sessions, the CPP therapist is attuned to ways in which the parent’s own history may be affecting their behaviors toward the infant, and may engage the parent in individual sessions to explore this further (Lieberman et ah, 2015). CPP also recognizes the importance of the parent’s “angels in the nursery” (Lieberman, Padron, Van Horn, Sc Harris, 2005); the experiences of love, safety, and security in the parent’s childhood relationships. This expands the parent’s ability to view their childhood experiences as a whole, and in turn, experience increases in self-esteem and hope for the future (Lieberman et ah, 2015), thus promoting their use of similar positive parental behaviors toward their infant.

CPP has exhibited efficacy in both randomized controlled studies and longitudinal studies (Ciccehtti, Rogosch, Sc Toth, 2006; Toth, Rogosch, Manly, Sc Cicchetti, 2006; Lieberman et ah, 2005; Lavi, Card, Hagen, Van Horn, Sc Lieberman, 2015; Lieberman, Weston, Sc Pawl, 1991; Toth, Maughan, Manly, Spagnola, Sc Cicchetti, 2002) and is considered a research supported intervention for children ages 0-5 who have experienced trauma (The California Evidence-Based Clearinghouse for Child Welfare, 2006-2019).

Benefits of Parent-Infant Play in Infant Development

Play has been described as the “leading source of development” for children (Vygotsky, 2016/1966) and has been linked to increased brain development and executive functions, self-regulation, cognitive learning, literacy and language skills, physical health, social skills, and reduced behavioral challenges in children (Brown Sc Eberle, 2018; Milteer et ah, 2012; Whitebread, 2010; Schore, 2012). Play in the parent—infant relationship not only produces benefits in a multitude of areas in children’s development; it also strengthens the parent—infant relationship itself (Ginsberg et al., 2007). Receiving a parent’s full attention and interest, provides infants with the message that they are important, loved, and accepted for who they are, which increases their selfesteem, competence, and their sense of relational safety. In times of breaks in attunement, play can assist in strengthening a repair, allowing the parent and infant opportunities to understand each other’s experiences and connect through shared enjoyment (Olff et ah, 2013). This process of repair is vital to the infant’s understanding that the relationship can manage difficulties, which increases a sense of safety (Rees, 2007). Furthermore, parent- infant play, in which mothers provide affection and fathers provide stimulation, has neurobiological benefits for parents, increasing brain levels of oxytocin, which produces feelings of connectedness and stress reduction (Feldman, Gordon, Schneiderman, Weisman, &c Zagoory-Sharon, 2010; Olff et ah, 2013).

The Utilization of Play in CPP

Virgina Axline (1974) described play as an infant’s “natural medium” and acknowledged the use of non-directive play therapy to provide an infant with opportunities to utilize play as a way to express feelings, so they may be brought out in the open in order to be released, understood and managed. Axline stated that infants need to feel free to express themselves fully and test out ideas, and require the adult participant to be accepting, understanding, and reflective in their observations, in order to allow the infant to better understand their experiences.

CPP also recognizes that infant’s communication is most unrestricted through play, and therefore utilizes play as the primary modality during parent—infant sessions. Play is viewed as a vehicle for infants to tell their stories, experiment with realities, and express feelings freely. Play not only offers the opportunity for infants to describe their internal experiences, but allows for the infant to organize traumatic experiences and repair them by trying out different endings and gaining a sense of control over situations that once produced feelings of helplessness (Reyes &c Lieberman, 2012). While the infant is playing, therapists work to support parents in witnessing their infants play and tolerating the stories that unfold. Play provides a port of entry for the therapist to act as a mediator, making meaning of an infant’s symbolic expressions, so that the parents may better understand the impact of trauma on the infant and have an opportunity to offer acknowledgement, attunement, and empathy. One of the goals of CPP is for the parent to join the infant in play in an effort to co-construct a different, healthier meaning of the trauma. The therapist supports this endeavor, and then promotes the parent—infant relationship’s capacity to move from enacting, to reflection and meaning making, to enjoyment in devel- opmentally appropriate activities (Lieberman et al., 2015).

 
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