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Psychotherapy with Infants and Young Children: Repairing the Effects of Stress and Trauma on Early Attachment.
A. E. Lieberman & P. Van Horn The Guilford Press: New York, 2008. 366. pp, US$40.00.
This book provided information about treatment modalities for children who face stress and trauma in their early years. It was written by two prominent clinicians who are known for their clinical expertise with childhood trauma.
In the first chapter, the authors presented their child parent psychotherapy (CPP) approach specifically designed for children from birth to their fifth birthday. The term CPP instead of infant parent psychotherapy or toddler parent psychotherapy was used to illustrate commonalities across infancy and early childhood.
The second chapter elaborated the stress-trauma continuum and how young brains and bodies react to it. The discussion on interpersonal trauma and the implications of a failure to provide protection to children was poignantly illustrated through clinical vignettes. The authors paraphrased children’s statements to safeguard their confidentiality, however the authentic air portrayed by clinical scenarios remained unharmed.
Chapter 3 was the heart of this volume. Here, readers were led to the inner sanctum of the relational therapies. It tabulated the twelve principles of early child development; common sense statements that are often omitted from clinicians’ interventions. Some of those principles are: “separation distress is an expression of the child’s fear of losing their parent,” and, “memory starts at birth.” A further example was, “babies and young children remember experiences long before they can speak about them.” (Page 83). There was a range of guidance provided from how to choose ports of entry to providing unstructured reflective developmental guidance, modeling appropriate behavior, insight oriented interpretation, assessing traumatic reminders through trauma narratives to retrieving benevolent memories.
The next two chapters focused on the assessment process providing multiple clinical pearls to intervene with perturbations in early relationships. These chapters provided information on the clinical parent who is a “not good enough parent“.
Chapter six, “Ghosts and Angels in the Nursery” described much more about the process of uncovering traumatogenic memories when the child is exhibiting a disorder rather than a simple perturbation. I was slightly disappointed with this chapter. I was hoping to learn different ways of wakening these angels in the nursery, meaning the factors relating to resilience. I thought there was too much focus on the ghosts in the nursery in this chapter.
Chapter seven described three variations in treatment using CPP. The point made through three beautiful clinical vignettes was that CPP need not always be dyadic in nature. This was an important chapter because in reality, clinicians may not always find a dyad suitable for CPP in a classical sense.
The chapter titled “Lapses in Attunement” is a “must-read” for psychotherapy trainees. Several obstacles to therapeutic attunement were described and common mistakes such as overidentification with the child at the expense of the parent or vice versa were candidly discussed. This chapter also touched upon the importance of clinical supervision.
The ninth chapter described how the CPP would look when seen through different systems of care. There was useful discussion of the obstacles to a therapeutic relationship with parents in the child protection system. Reading about how to handle troubled parents when the assessments are mandated, affirmed for me that resistance shown by these troubled parents was universal and needed a system integrated approach. There were useful hints on the limits of confidentiality when the CPP is provided as a mandatory treatment. This chapter also described systemic problems in resolving dilemmas faced by traumatized children. Although the case examples came from the USA, they seemed so similar to our own plight in providing systemically cohesive treatment plans for traumatized children.
The last chapter “Closing Thoughts” discussed the limits of psychotherapy and ambiguities around it. In spite of ambiguities, it was suggested that CPP can address traumatized children’s needs in the following categories: responding realistically to danger, differentiating between remembering and reliving, normalizing traumatic responses, and placing the trauma in perspective.
The authors stated that the book could appeal to “clinicians with a wide range of experience, from seasoned practitioners to graduate students and interns in psychology and social work and residents in psychiatry.” (Page XI). I beg to differ here, this is not a book for the novice, in fact, it might provide a false notion to the inexperienced that the main therapeutic tool described in this book, CPP, is the only authentic treatment modality.
In summary, the authors emphasized that CPP is a relationship therapy rather than a dyadic therapy, that its ultimate goal is the child’s mental health, and that it is based on three conceptual frameworks — psychoanalysis/attachment theory, stress and trauma work and developmental psychopathology. There was not much emphasis in describing the empirical evidence pertaining to relationship modalities. I hope that the next edition will make that its priority.