When I trained at Fraiberg’s Child Development Project in the late ‘70s, it was easy to imagine that there was one model of infant parent psychotherapy to be learned and mastered. Training was naturally an integral part of our work since the entire field of infant mental health was a new development. Much has changed in infant mental health training since then, with elements that are encouraging as well as worrisome.
In the early days, many who came into the field had a background in psychodynamic psychotherapy, which was still the predominant therapeutic model. Those who came from a background in child development were grounded in Bowlby’s attachment theory. Bowlby’s notion of “working models” nicely spanned developmental, psychoanalytic and cognitive-behavioral conceptualizations. For the working clinician, however, the upshot of Bowlby’s work was to understand the importance of relationships, for the child, the parent and the therapist. The centrality of relationships in infant mental health has important implications for training and education, particularly as it runs counter to major trends in graduate training and agency practice. The result is that training in infant mental health is even more challenging, as well as essential, than before.
There are encouraging trends for infant mental health training. Intellectually, attachment theory is more developed, validated, and diversified than before. With the current work on disorganized attachment, the Adult Attachment Interview, and conceptualizations of attachment disorders in young children, the theory describes parents and children much more like those seen in infant mental health programs. There is a much greater understanding of the role of trauma in the development of both baby and parent. Additionally, newer therapeutic approaches can contribute useful pieces to infant-parent psychotherapy, but they must be adapted to our goal of changing and strengthening infant-parent relationships.
Dan Stern’s elegant formulation of different interventions targeting different portals in the infant/parent relationship has saved the field from unnecessary polarization between interventions. It seems well understood that there is not ONE model to learn, but multiple formulations of problems and interventions. The result, however, is that the therapist needs more sophistication—integrating, alternating and adroitly shifting approaches to choose the most promising intervention in the moment.
While attachment theory and the practice of working with parents and infants keep us focused on the centrality of relationships, much of the academic world has moved in other directions. With greater emphasis on cognitive-behavioral approaches, “manualized” interventions and brief therapy, new graduates coming to infant mental health often come with quite different experiences. They have been taught more about cognition and behavior, less about affect. They know more about behavioral outcomes and less about a relational focus. They are more familiar with treatment manuals and less about “being with.” They may be less likely to have been in therapy themselves. They may have had no experience with reflective supervision. Countertransference may be a foreign concept.
We are challenged, more than ever, to train and educate infant mental health practitioners to focus on the relational process, with infants, parents, colleagues and supervisors. In addition to providing knowledge, trainers and supervisors can assume less about what new infant mental health professionals know about themselves and their personal histories. With agencies under greater stress and practitioners under greater pressure, it is even more important, but perhaps more difficult, to create a haven of safety to support the therapeutic process.
Providing infant mental health service teaches one that the real work happens before there is anything resembling traditional therapy. Perhaps I am now more cognizant of the work that must precede meaningful training and supervision. We may have to fight for truly reflective training and supervision when these things are not seen as priorities or “a given.” It is exciting to have more and more meaningful and relevant information to include in infant mental health training. At the same time, it is a great challenge to provide training to therapists who have had little preparation to be reflective. And it is a further challenge to provide supervision to therapists who are overextended and appear to have little time to think deeply about themselves or the work that they are doing in ways that support relatedness and self-awareness.