Journal of Applied Developmental Psychology 30 (2009) 563–566 Contents lists available at ScienceDirect Journal of Applied Developmental Psychology Book review An integrative approach to child–parent psychotherapy Alicia F Lieberman, Patricia Van Horn, Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment Guilford, New York, 2008, ISBN: 978–1–59385–675–5 (cloth), 366 pp., $40 Child–parent psychotherapy (CPP) consists of an approach to performing psychological interventions for young children who have experienced stressful events that have strained their attachment relationships with their caregivers CPP builds upon and carries forward the infant–parent psychotherapy (Lieberman, Silverman & Pawl, 2000) inspired by the groundbreaking work of Selma Fraiberg Fraiberg (1980) elaborated infant–parent psychotherapy as a way to correct psychological disturbance in children during the first years of life CPP extends Fraiberg's approach through the first years of life Drawing upon attachment theory (Ainsworth, Blehar, Waters & Wall, 1978; Bowlby, 1980), the psychoanalytic tradition (Erikson, 1950; Freud, 1933/1964), neuroscience (LeDoux, 1998) and current theory and research on developmental psychopathology (Cicchetti & Sroufe, 2000), child–parent psychotherapy builds upon the fundamental assumption that development occurs through relationships While this principle holds for virtually all psychological development, it is especially applicable to young children whose interactions with caregivers provide the emotional foundations for further psychological development Although infants enter the world with a variety of pre-attuned capacities, an infant's first psychological capacities function primarily with reference to their caregivers Young children are dependent upon their caregivers to provide protection, to attend to basic needs, and to foster a sense of emotional security that provides the foundation for healthy development Thus, to address psychological dysfunction in young children, it is not possible to focus simply on the individual child Instead, it is necessary to focus on the emotionally-charged parent–child relationship However, soon after we acknowledge the centrality of the parent–child relationship, our attention is necessarily drawn to the myriad of processes that frame and help constitute that relationship These include the psychological profile of a child's caregivers; the caregivers' developmental and relational histories; the network of interpersonal relationships in which the caregivers function; the cultural beliefs, values and practices of caregivers; as well as the operation and expectations of social service agencies Lieberman and Van Horn articulate six basic principles of child–parent psychotherapy: CPP typically consists of joint parent–child sessions that focus on the child's free play and spontaneous parent–child interaction Individual sessions with the caregiver(s) are employed in circumstances in which a judgment is made that fostering a caregiver's development independent of the child is necessary; The CPP therapist acts to “translate” the developmental and emotional meaning of a child's emotions and actions to the parent; The target of treatment includes the both the child's and the caregiver's adaptive conflicts, including a parent's difficulty in providing sensitive and developmentally appropriate care; CPP fosters parent–child activities that foster mutual pleasure, interpersonal trust and understanding; Different clinical modalities are introduced depending upon the particular needs of the child and parent; Treatment begins with the introduction of simple and direct intervention strategies, and moves toward more complex strategies as warranted Consistent with attachment theory, CPP is based upon the core principle that “feeling lovingly protected is the cornerstone of early mental health” (p 10) Toward this end, CPP therapists work to establish child–parent relationships within which children can feel safe, secure and protected from physical and emotional harm Throughout their volume, Lieberman and Van Horn adopt a consistently developmental perspective in their work The particular interventions initiated with both the child and the caregiver must take into account the developmental level and capacities of the child Much of CPP is aimed toward assisting parents to provide care for their children in developmentally sensitive ways CPP as an integrative approach to psychotherapy A limitation on many traditional modes of psychotherapy is their relative separation from the contexts of everyday life The within-session world is not configured or peopled in the same way as is the world outside of therapy Among adults, for example, doi:10.1016/j.appdev.2009.04.001 564 Book review psychotherapy typically occurs between a client and a therapist through the medium of talk within a therapist's office With young children, psychotherapy often occurs in the context of pretend play interactions between a therapist and a child Application of skills and meanings acquired in therapy to the world as it exists outside of therapy is something that is often left to the client In contrast, CPP approximates, as best as possible, the in vivo contexts of everyday life as it occurs between children and parents It does this in many ways First and foremost, it treats the child and the parent together as an organized system To address the mental health of the child, it is essential to foster development in the parent's capacity for caregiving Toward this end, the parent is invited to participate as a partner in the therapeutic process The parent's perspective, values, cultural background and dignity are treated as central aspects of the therapeutic process One of the therapist's goals is to bridge the gap between the parent's existing skills, values and beliefs and novel ways of thinking about and interacting with the child Second, in CPP, it is understood that in order to assist the child, it is often necessary to provide independent therapeutic support for the parent(s) Such independent sessions are not simply necessary to foster development of the parent's skills, they are also founded upon the idea that a caregiver's actions — even when are difficult to accept — often occur against the backdrop of a series of obstacles that make effective caregiving difficult Throughout CPP, there is an emphasis on supporting the dignity of the parent while simultaneously fostering development Third, while much of CPP occurs in the therapist's office, as needed, the therapist may visit the home to fashion interventions based on more ecologically sensitive assessments Most importantly, within-session pretend play includes the parent, child and therapist As a result, everyday issues and ways of relating arise in both direct and symbolic ways The toys that are provided in the play therapy sessions include those that, for children who have experienced trauma, have the capacity to evoke emotional themes in the child (e.g., parent and child dolls; doctor's kit; ambulance; animal dolls; police officers, etc.) The evocation of such emotional themes provides opportunities for helping parent and child develop strategies for coping with emotion Whether or not play interactions evoke trauma-related themes, the therapist is able to (a) “translate” the meaning of the child's actions, thoughts and feelings to the parent; (b) provide interpretations of the meaning of the child's and the parent's behavior as they arise in the context of play; and (c) model more effective meanings and ways of interacting with the child in a developmentally appropriate and emotionally-sensitive manner How CPP fosters development Basseches and Mascolo (in press) have suggested that, across different forms of therapy, therapists promote developmental change through the provision of three basic classes of therapeutic resources: attentional support, interpretation and enactment A therapist offers attentional support when she assists the client in attending to and articulating the meaning of the client's experiences (e.g., “How did it feel, thinking about that?”) Interpretation occurs when a therapist draws from her own theoretical system to offer ways of understanding experience (e.g., “I think you learned to be angry without wanting to, and the anger comes out suddenly before you know it”) Enactment occurs when a therapist guides, directs or participates in the creation of novel experiences (e.g., coaching a parent who is trying to calm a child) Although virtually all modes of therapy invoke each category of therapeutic resources in some way, some forms of therapy tend to privilege one or another class of resources In restating and reframing a client's statements, Rogers' (1961/1995) person-centered approach draws heavily on the provision of attentional support Psychoanalysis (Malan, 1979/1995) tends to privilege the therapist's interpretation of a client's experience Cognitive behavior therapy (Farmer & Chapman, 2008) relies heaving on the production of novel behavior and experience through training, direction and other forms of enactment CPP brings together each of categories of therapeutic resources in an integrated way At its core, CPP brings child, caregiver and therapist together in the enactment of spontaneous caregiving practices within the context of pretend play Within the context of continuously available emotional support to both the child and parent, Lieberman and Van Horn identify a series of modes of intervention that CPP works to achieve Forms of attentional support include (a) providing an emotionally supportive context to allow caregivers to articulate their own understanding, perspectives and values Used in conjunction with attentional support, forms of interpretation include (b) putting a child's feelings into words for both the parent and the child; (c) providing emotionallysensitive interpretations of parent's experience (especially those drawing upon memories of emotionally positive interactions between the parent and child); and (d) mediating co-construction of a trauma narrative that allows parents and children to consolidate painful experiences and memories into a coherent perspective Finally, novel experiences and behaviors arise in child– parent–therapist enactments that involve (e) modeling and encouraging developmentally appropriate interaction with children; (f) encouraging developmentally appropriate touch and affection; and (g) modeling optimal protective behavior of children CPP is applicable to a wide range of adaptive conflicts in children Lieberman and Van Horn suggest that such adaptive problems fall along a stress–trauma continuum, ranging from local developmental perturbations through broader disturbances to diagnosable disorders They provide a series of concrete illustrations of the many therapeutic principles upon which they elaborate in their book To illustrate the application of CPP, consider Lieberman and Van Horn's analysis of the use of CPP in the treatment of what they classify as a developmental perturbation An otherwise competent but depressed mother expressed concern that she did not experience pleasure in caring for her 4-month old baby She was referred to CPP when she broke down in tears when a pediatrician asked, “How are things going?” The baby exhibited a serious facial expression and would often avert his gaze when his mother or the clinician attempted to engage him The child was, however, able to be soothed by the mother and father during times of distress Lieberman and van Horn write: The first step in the intervention consisted of using emotional support and developmental guidance to help the mother become more conscious of her appropriate responses to her crying baby and of his ability to be soothed by her care This Book review 565 approach proved clinically helpful in strengthening the mother's self-esteem and gave her hope that she could gradually expand her responsiveness to him As treatment progressed, the therapist guided the mother's attention to her inner experience in response to the baby's different expressions of emotion The mother reported that whenever the baby became happily excited, she cringed with fear that he would quickly revert to being serious and withdrawn if she could not sustain his enthusiasm due to her depression The therapist guided her in experimenting with smiling and language in response to the baby's enthusiasm As she did so, the mother found that, contrary to her fears, the baby did not escalate his excitement beyond her capacity to tolerate it This realization allowed her to respond to an increasingly broad range of her baby's signals The baby became more expressive… the mother's mood brightened in response and she was no longer depressed by the time the treatment ended when the baby was months old (pp 144–145) This excerpt illustrates the integrative nature of CPP as the therapist worked to assist the mother in in vivo enactments with her child The therapist not only used attentional support strategies to elicit the parent's understanding of her relation to her child, but also to focus the client's attention on her own experiences in response to the baby's moment-to-moment emotional expressions This allowed the therapist to provide interpretations of the mother's effective interaction strategies with the child Given the therapist's interpretations of information provided by the mother's descriptions, the therapist was able to coach the mother's attempts to modulate her own emotional actions in relation to her child's emotional expressions The therapist's interventions rippled through the mother–child dyad: the mother become more confident, effective and less depressed; the child became more emotionally animated and responsive to the mother Intervening with compassion, respect and humility When reading this book, time after time we were struck with what we take to be the enormous capacity for compassion and humility in descriptions of the activities of CPP therapists Many of the cases described in this volume involve children who have been maltreated in some way by their parents These include a girl who witnessed her father stab her mother; a boy who witnessed his father physically assault his mother; a mother who failed (in the presence of the therapist) to assist the therapist in stopping a child who was trying to climb out of a window; a parent who force-fed her infant who had been refusing food It would be easy for readers to demonize parents who perpetrate such actions Indeed, it was sometimes difficult for the therapists themselves to withhold their own emotional reactions during treatment with caregivers whose actions affected their children negatively However, mindful that maltreating parents often bring forward their own emotional difficulties and relationship histories, the therapists described in Lieberman and van Horn's volume worked to reflect and build upon what was benevolent and positive in their clients For example, in response to a father's statement that he intended to continue to participate in CPP sessions even after a therapist indicated the necessity of referring the father to the Department of Social Services following a physical incident with his son, the therapist used the following positive framing of the father's actions: You are reminding me of how hard you tried to be a good son when you fell down the stairs instead of pushing back at your father when you were trying to defend your mother… Now you are angry with me, but you are going to go through the emotions of respecting me and coming to see me because you care so much about your son, just like you cared so much about your mother (p 203) This compassionate rendering of the father's actions did not have the desired effect of repairing the threat to the client– therapist relationship In an act of humility, the therapist acknowledged that she may have come across to the client as critical rather helpful In her apology, the therapist said, “It must have felt like I betrayed you…I am very sorry that I just left a message about this instead of waiting to speak with you directly.” Psychological intervention with infants and young children all but forces us to adopt a holistic and developmental perspective to treatment CPP brings together multiple modes of therapeutic intervention in a therapeutic milieu that approximates the everyday contexts in which parents and children must ultimately act In this regard, CPP's relational and contextualized approach provides a model not only for psychological intervention with children, but for bringing psychological treatment out of the confines of the therapist's office for older children and adults as well References Ainsworth, M D S., Blehar, M C., Waters, E., & Wall, S (1978) Patterns of attachment Hillsdale, NJ: Erlbaum Basseches, M., & Mascolo, M F., (in press) Psychotherapy as a developmental process New York: Routledge (RT57306.indb M) Bowlby, J (1980) Attachment and loss, Vol I–III New York: Basic Books Cicchetti, D., & Sroufe, L A (Eds.) (2000) Reflecting on the past and planning for the future of developmental psychopathology Development and Psychopathology, 12, (pp 255−550) Erikson, E (1950) Childhood and society New York: Norton Farmer, R., & Chapman, A (2008) Behavioral interventions in cognitive behavior therapy: Practical guidance for putting theory into action Washington, DC: American Psychological Association Fraiberg, S (Ed.) (1980) Clinical studies in infant mental health: The first year of life New York: Basic Books Freud, S (1933/1964) New introductory lectures Harmondsworth: Penguin LeDoux, J E (1998) Fear and the brain: Where have we been and where are we going? Biological Psychiatry, 44, 1229−1238 Lieberman, A F., Silverman, R., & Pawl, J H (2000) Infant–parent psychotherapy In C H Zeanah (Ed.), Handbook of infant mental health, (2nd ed.) New York: Guilford Press 566 Book review Malan, D H (1979/1995) Individual psychotherapy and the science of psychodynamics, (2nd ed.) London: Arnold Rogers, C R (1961/1995) On becoming a person: A therapist's view of psychotherapy Boston: Houghton Mifflin Michael F Mascolo Department of Psychology, Merrimack College, North Andover, MA 01845, USA E-mail address: MMascolo@Merrimack.edu Corresponding author Michael Basseches Department of Psychology, Suffolk University, 41 Temple Street, Boston, MA 02114, USA E-mail address: mbassech@suffolk.edu ... occurs between children and parents It does this in many ways First and foremost, it treats the child and the parent together as an organized system To address the mental health of the child, it is... therapist is able to (a) “translate” the meaning of the child' s actions, thoughts and feelings to the parent; (b) provide interpretations of the meaning of the child' s and the parent' s behavior... interactions between the parent and child) ; and (d) mediating co-construction of a trauma narrative that allows parents and children to consolidate painful experiences and memories into a coherent perspective