Two-Person Relational Psychotherapy: Infants and Preschool Age Children

, Jeffrey R. Strawn² and Ernest V. Pedapati³

(1)

Division of Psychiatry and Child Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

(2)

Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, USA

(3)

Division of Psychiatry and Child Psychiatry Division of Child Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

Every child at play behaves like a creative writer, in that he creates a world of his own, or, rather, rearranges the things of his world in a new way which pleases him.

—Sigmund Freud

We open this chapter with Freud’s masterful quote that captures the role children have as active participants in their development. For many years, infants were thought of as being dependent and unaware of the world around them (Mahler et al. 1975). The work by early developmental researchers—including Bowlby, Spitz, Emde, Stern, etc.—helped elucidate that infants were hardwired to develop complex abilities for social reciprocity, and if raised by parents with “good enough” capacities for affective attunement, the infants were quite busy in meaning-making processes. Tronick and Beeghly (2011) state, “In developing systems, such as human infants, sufficient resources must be obtained to enable them to increase their coherence and complexity and to self-organize new capacities.” Further, Bretherton and Munholland ’s (1999) work reinforced the notion that interactions between infants and their parents gave meaning to their shared experiences, with the development of internal working models of attachment giving coherence to their relationships. When infants have emotionally available and affectively attuned parents, they develop secure working models in relating with others. When parents provide a secure base for the infant, it increases the likelihood of the infant acquiring the emotional resources needed in the short run, and in the long run, these growth-promoting social interactions will contribute to self-regulatory capacities and resiliency. Over time, infants become part of a larger and more complex system, and they become more flexible and better able to reorganize when confronted by day-to-day discontinuities in their care.

Two busy, securely attached infants

We informally asked two of our colleagues, who had each recently given birth to a child, how many people had held and jovially interacted with their child during their first three months of life. The first colleague laughed and said, “In our culture we have very close and large families; my son has interacted with more than 30 family members and friends. He loves all the excitement.” The second colleague shared that her son had interacted with more than 10 family members and also loved the excitement.

This example aptly captures the idea that the emotional experiences that can promote the infant’s self-regulatory capacities are dependent on the variations in the quality and intensity of early social interactions. These capacities are sculpted by the relationship between the infant, parent, and family within the backdrop of contextual and cultural factors. Brief periods of disorganization in everyday life of the parent–infant relationship are inevitable and normative. The two healthy and secure infants described in the example will learn to develop self-regulatory abilities that allow having the psychological skills needed to tolerate everyday demands, such as being hungry, needing their diaper changed, etc. Infants attempt to make coherent meanings of the variations in the environment, through a combination of their own unique temperamental traits and the self-regulatory abilities they develop. It is not surprising that infants who have limited exposure to growth-promoting social interactions have difficulties with self-regulation and closeness throughout their life.

When life is not as idyllic for the infant and their parent’s emotional availability is unpredictable, the infant will have difficulty developing meaning-making processes and self-soothing abilities. The experience from chronic parental inconsistency can lead to altered brain development, compromised socioemotional functioning, stunted mental growth, and even death (Nelson et al. 2007). As an example, infants that avoid interactions with other people for fear that these people may have similar characteristics as the original intrusive parent may experience short-term relief from anxiety. However, in the long run, it will be detrimental and lead to limited growth-promoting social engagements with others and potential long-term developmental consequences (Beeghly and Cicchetti 1994; Tamis-LeMonda et al. 1996; Sroufe 2009). As such, these infants exhibit affective and behavioral reactions consistent with sadness, anger, withdrawal, and disengagement. Furthermore, they likely experience significant anxiety and fear due to the loss of organization, they become easily dysregulated, and their sense of self is threatened. Parental depression and anxiety, as well as infant medical, behavioral, and temperamental issues, can result in prolonged periods of dyadic disorganization and maladaptive infant outcomes. Child health clinicians can help parents anticipate the normal periods of disorganization and assist parents to develop optimal parent–infant relationships (Beeghly and Tronick 2011). Infants with harsh and unresponsive parents learn that by minimizing the interactions with their parents, they increase the likelihood of survival, albeit without developing the adaptive self-regulatory mechanisms needed for continued psychological growth (Cicchetti and Barnett 1991). This significantly increases their risk of long-term maladaptive and insecure attachment relationships with others in later life (Fraley and Shaver 2000). Andersen (2003) describes early periods of development as critical windows of opportunity essential for “brain wiring.” Further, Pearson et al.’s (2013) work with depressed mothers and their babies finds that “treating maternal depression antenatally could prevent offspring depression during adulthood, and that prioritizing less advantaged mothers postnatally may be most effective.”

10.1 Psychodynamic Psychotherapy in Infants and Preschool Age Children

The reasons why parents of infants and preschool age children seek help are generally due to feeding, developmental, or behavioral difficulties. As such, the child psychiatrist or clinician will benefit from using the contemporary diagnostic interview (CDI, Chap. 8) in order to understand the child’s unique attributes—temperament, cognition, cognitive flexibilities, and internal working models of attachment—albeit in a rudimentary form due to age and within the context of the environment in which they live (including family and culture considerations). Careful attention should be given to the norms of development (see Appendix A). During this age, meaning-making processes, social reciprocity, and the ability to regulate affective states, as well as the improvement of their motor skills, become central in the infant’s or child’s development. It is important to note that the maturation process can be uneven with regard to innate temperamental and cognitive attributes, further influenced by the availability of the parents or caregivers for the affective attunement needed for maturation. Language is a major milestone that typically occurs at the 18-month-old mark. Consequently, the two-person relational psychotherapist of infants and preschool children will need to understand the role parents and caregivers have played in the child’s developmental process.

10.2 Adam

History of Present Illness

Adam was an 11-month-old male infant referred by his pediatrician for failure to thrive. Though no organic cause was identified, the pediatrician was concerned that if no behavioral solution were found, a gastrostomy tube (G-tube) would have to be placed for feedings. The pediatrician recognized the psychological consequences of such intervention. It is not unusual for child psychiatrists to be consulted in such cases.

The week prior to the appointment, the family had celebrated Thanksgiving at a friend’s house. However, Adam became very upset and irritable. Despite many efforts by his parents to comfort him, he refused to eat for over 14 h. As this pattern was becoming more common, his pediatrician placed a nasogastric (NG) tube (which was present at the time of the appointment) in Adam for involuntary feedings.

Past Medical History

Though his birth and delivery history was unremarkable, Adam had a long history of diagnoses and medical procedures despite his young age. Soon after birth, he was diagnosed with milk protein allergy and acid reflux. Within the first few months of his life, he was diagnosed with severe craniosynostosis (a birth defect in which one or more of the suture lines between the bones of an infant’s skull close prematurely, before their brain is fully formed). By his fourth month, he had undergone an esophagogastroduodenoscopy (EGD), a chromosome analysis, a computed tomography (CT) scan of the head, and a magnetic resonance imaging (MRI) scan of the brain. The results confirmed severe craniosynostosis. After having corrective surgery, at his follow-up appointment with the surgeon, it was noted that Adam’s surgical site was healing normally, although “the infant cried repeatedly during the exam. His mother reports this is typical in new environments for him.” Five months later, the surgical team felt that the defect had been adequately corrected, although they noted a mild developmental delay “due to the fact that he was quite a poor eater.” He had fallen below his weight and height developmental curves, and their pediatrician gave him the diagnosis of “failure to thrive .”

Past Family History

Adam’s father was a 32-year-old man who worked as a delivery driver. He spoke about having a conflicted relationship with his own parents. As a child, he suffered from low self-esteem, which worsened when, as an adolescent, he developed motor tics—eye blinking, oral–buccal movements, and chewing fingernails. “They always made fun of me. I was and am always anxious.”

Adam’s mother was a 27-year-old woman who struggled with a significant amount of pain due to endometriosis and polycystic ovarian problems. She also had a history of an anxiety disorder that she did not have treated, “I was ashamed to get help for it.” She reported that she had never flown in an airplane and said that she would never fly, because she would be sure that it would be time for her demise due to anxiety: “I couldn’t handle it.”

Adam’s First Appointment with the Child Psychiatrist

Upon greeting Adam’s parents for the first time, the child psychiatrist noted that the parents seemed ready to share their anxieties, as they promptly exclaimed, “No offense, but we feel very bad that Adam has to see a child psychiatrist; he is not even a year old.” The parents experienced the consultation as an ominous sign of their failures, rather than as an opportunity to find ways to help their child. The child psychiatrist’s first intersubjective experience was that of genuine sadness for the parents; they conveyed a pervasive feeling of being inadequate as parents.

From a two-person relational psychology perspective, the parents intersubjectively were experienced as using an internal working model of ambivalent/anxious attachment, and both displayed a slow-to-warm-up temperament style. As the interview progressed, it became clear that the parents had frequently cocreated experiences in which they conveyed to physicians and other caregivers the implicit sense of insurmountable fear they had of not being adequate parents. The child psychiatrist intersubjectively felt that there were actually three people in the office that needed consoling.

Within the framework of a contemporary diagnostic interview (CDI, Chap. 8), the child psychiatrist made use of comments that helped create an atmosphere of safety for the anxious parents. He complimented the parents about the nice outfit their son was wearing and the sophisticated stroller they were using. From a nonverbal standpoint, when the parents conveyed a sigh of relief, the child psychiatrist intersubjectively experienced in the here-and-now moment that he had helped them feel validated as caring parents. They proudly shared that they had saved money for such a high-quality stroller because they wanted “the best for our first child.” With this, the child psychiatrist intersubjectively felt hopeful for them. Nevertheless, in the next comment, they conveyed the nature of their chronic patterns of an ambivalent/anxious internal relational knowing: “With all this stress, he will likely be our only child. We are not good parents.” With these comments, the child psychiatrist intersubjectively experienced them as having constant feelings of anxiety and feeling inadequate as parents.

As anticipated, the parents’ affect became more anxious as the consultation evolved. Exasperated, they said: “We don’t know how to be good parents. He started vomiting almost every day since he was 10 months old. By the end of the day, we would run out of outfits; we had to keep buying more. Our families told us we were not good parents. We now know they were right.”

Allowing Subjectivities to Meet: Developmentally Informed Mental Status Exam

Adam was a cute and likable 11-month-old child. Surprisingly, in the first appointment, he was eager to interact with the child psychiatrist and had a full range of facial expressions for most of his affective states. He stuck his tongue out, imitating the child psychiatrist. He smiled and allowed for gentle touch. The child psychiatrist subjectively felt surprised at the child’s resilience and sophisticated capacities used to engage in social reciprocity with a stranger. It was as if he were hungry for interaction. The child psychiatrist asked the parents if they would allow their child to crawl in the office. The child psychiatrist proceeded to sit on the floor, and as soon as Adam was allowed to crawl, he began to play with some of the age-appropriate toys and looked with a smile at the child psychiatrist for social referencing. In the next interpersonal sequence, after the child psychiatrist asked Adam’s parents’ permission to hold him and reached out for him, Adam expressed discomfort and became anxious and irritable. Intersubjectively, the child psychiatrist felt that Adam had found the optimal distance comfortable for him when relating with others. When the distance was infringed—when the child psychiatrist tried to hold him—he noticeably let others know that this was not comfortable. He was playful and engaging as long as there was a safe distance between him and the other person. These in-session interactions highlight the value of nonverbal communication.

Without losing sight of the parents, the child psychiatrist noticed their excitement seeing their son happy and playful, although it was also noticeable that they seemed unaware that they had been invited to join in the playfulness. What intersubjectively puzzled the child psychiatrist was that Adam’s parents had shared that they were overwhelmed with their child being difficult to console in new environments, which was not the case in the child psychiatrist’s office, also a new environment.

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