Introduction

In this chapter, we focus on the issue of mother–infant relationship psychotherapy with perinatally depressed mothers, as prenatal and postnatal depression is the perinatal disorder most thoroughly understood from a research perspective . More specifically, we address key questions that perinatal practitioners may face in their routine clinical work with new mothers and their infants. Why should we engage in parent–infant psychotherapy for depressed mothers? What is the scope of parent–infant psychotherapy? What kinds of therapy are currently available for perinatally depressed mothers? We then focus on the concept of attachment from the infant’s perspective, and of caregiving, including bonding issues, from the mother’s perspective. Infant–mother psychotherapy for perinatally depressed mothers has mainly been studied by attachment theorists and attachment–informed therapists. The relationship between maternal attachment, postnatal depression, and caregiving and infant’s attachment system can best be understood in a developmental and transactional model, in which timing of events, number of risk factors, and number of resilience factors are all taken into account . Attachment-based parent–infant models are particularly helpful in the context of maternal perinatal depression. Perinatal depression is a particularly complex situation, but its relation to unresolved trauma and losses in the mother’s childhood is clear One of the main goals for research in psychotherapy for mother–infant attachment is to bridge the gap between research and clinical practice, as we have to establish the best practice parameters for perinatally depressed mothers and their infants . The ‘attachment component’ is particularly strong in the conceptual model, which focuses on psychodynamics as an underlying factor of postpartum depression (compared with solely ‘hormonal factors’), as attachment-based interventions have shown greatest effectiveness and efficiency in the treatment of perinatal depressive disorders.

Perinatally depressed mothers and the risks of child-negative outcomes

The evidence-based report of the US Agency of Health Care Research and Quality proposed the notion of postnatal depression to define an episode of major or minor depression occurring during pregnancy or the first 12 months after birth . Perinatal depression (prenatal and postnatal depression) is a complex situation, involving the (future) mother but also a developing infant and, to some extent, the whole family . This complexity calls for an integrated and shared work of perinatal health practitioners, as well as for the development of new treatment modalities (i.e. parent–infant groups, parent–infant co-therapy [Wendland J, unpublished data]). In the first book on parenthood and mental health , jointly edited by infant and adult psychiatrists, Cox and Barton highlight the necessity of collaborating between adult psychiatric teams and infant mental health professionals .

Several meta-analyses have confirmed that infants of perinatally depressed mothers are at risk for a large array of negative outcomes, including attachment insecurity (particularly disorganised attachment), social skills deficits, cognitive difficulties, behaviour problems, and later psychopathology . According to Forman et al. , one hypothesised pathway for transmission of risk is parenting. Therefore, special attention should be given to infant–mother psychotherapy. In a meta-analysis, Lovejoy et al. confirmed that parenting of depressed mothers can be largely affected by their mental condition. Goodman and Brand found that, in perinatally depressed mothers, the following was more frequent in parenting compared with non-depressed mothers: negative maternal affects (less positive behaviours); hostile behaviours (e.g. disrupted affective communication, and negative or coercive behaviours); withdrawal behaviour (e.g. disengagement and abdicative behaviour) or inconsistency (e.g. insensitivity) in parenting is more frequent with perinatally depressed mothers than with non-depressed mothers. Maternal perinatal depression can present as a complex clinical phenotype, and its effects may be heightened when this condition is co-morbid with other mental disorders, such as psychotic or severe personality disorders . Evidence shows that deficit or atypical parenting behaviour mediate the effects of maternal depression on adverse child outcomes . A recent study found that adequate stroking by the mother may mediate the impact of perinatal depression on the child .

Perinatally depressed mothers and the risks of child-negative outcomes

The evidence-based report of the US Agency of Health Care Research and Quality proposed the notion of postnatal depression to define an episode of major or minor depression occurring during pregnancy or the first 12 months after birth . Perinatal depression (prenatal and postnatal depression) is a complex situation, involving the (future) mother but also a developing infant and, to some extent, the whole family . This complexity calls for an integrated and shared work of perinatal health practitioners, as well as for the development of new treatment modalities (i.e. parent–infant groups, parent–infant co-therapy [Wendland J, unpublished data]). In the first book on parenthood and mental health , jointly edited by infant and adult psychiatrists, Cox and Barton highlight the necessity of collaborating between adult psychiatric teams and infant mental health professionals .

Several meta-analyses have confirmed that infants of perinatally depressed mothers are at risk for a large array of negative outcomes, including attachment insecurity (particularly disorganised attachment), social skills deficits, cognitive difficulties, behaviour problems, and later psychopathology . According to Forman et al. , one hypothesised pathway for transmission of risk is parenting. Therefore, special attention should be given to infant–mother psychotherapy. In a meta-analysis, Lovejoy et al. confirmed that parenting of depressed mothers can be largely affected by their mental condition. Goodman and Brand found that, in perinatally depressed mothers, the following was more frequent in parenting compared with non-depressed mothers: negative maternal affects (less positive behaviours); hostile behaviours (e.g. disrupted affective communication, and negative or coercive behaviours); withdrawal behaviour (e.g. disengagement and abdicative behaviour) or inconsistency (e.g. insensitivity) in parenting is more frequent with perinatally depressed mothers than with non-depressed mothers. Maternal perinatal depression can present as a complex clinical phenotype, and its effects may be heightened when this condition is co-morbid with other mental disorders, such as psychotic or severe personality disorders . Evidence shows that deficit or atypical parenting behaviour mediate the effects of maternal depression on adverse child outcomes . A recent study found that adequate stroking by the mother may mediate the impact of perinatal depression on the child .

Parent–infant psychotherapy

In her seminal book Pregnancy: an inside story , Raphael-Leff gives a detailed account of the targets and techniques of therapy during pregnancy and postpartum. Mother–infant psychotherapy is, however, a relatively new treatment model within perinatal psychiatry . Infant–mother psychotherapy, more commonly referred to as parent–infant therapy (PIT), is probably the hallmark of infant mental clinical practice. It is an interpersonal therapy focused on relationships, in the physical presence of both mother and infant, or both parents and infant. It is based on several assumptions: (1) the relationship with the professional is expected to serve as a ‘corrective emotional experience’ for both parents and for children; (2) establishing a therapeutic alliance between the parents and professional is considered as a first step in parent–infant psychotherapy; and (3) the trans-generational perspective is at the core of PIT. Fraiberg’s Ghosts in the nursery are painful or disturbed early childhood experiences originating in the mother’s past, which can haunt the present mother–infant relationship if they remain unaddressed or unresolved. To facilitate the development of more adaptive parenting by the mother, Fraiberg believes that it is important to address the mother’s unresolved attachment conflicts as well as more secure and less disorganised attachment between the mother and her infant. A recent randomised-controlled trial of infant–mother psychoanalytically informed treatment has shown that this treatment is effective in lowering maternal depression symptoms and in improving the relationship between the mother and infant .

The goal of PIT is to help the parent–infant dyad or triad to have more synchronous or adaptative behaviour, and to improve their co-operation in everyday life . Stern-Bruschweiler and Stern described three modalities of conducting a PIT: (1) working on the parent’s representation of the infant; (2) focusing on the level of interactions between the parent and the infant; and (3) working from the level of the infant’s behaviour. Puura and Kaukonen described three main types of infant psychotherapies: the first is based on Fraiberg’ model, described by Lieberman as ‘psychodynamically oriented parent–infant psychotherapies’ . In this group, brief psychoanalytically oriented infant–parent psychotherapy can also be included. This is described by Cramer and Palacio-Espasa as therapy centred on the parents’ representations of the infant, similar to Daws’ psychodynamic work with parents of sleepless infants. The second type of therapy is behaviourally oriented parent–infant therapy, embedded in the field of cognitive–behavioural therapies. The first model is McDonough’s ‘interactional guidance’, which uses video feedback and is based on videos of parent–infant interactions as part of the intervention. Similarly, Field’s work involves direct interactional coaching of mothers on several aspects of the interaction to improve parent’s attention to the baby’s cues. The third type of therapy is ‘integrative infant–parent psychotherapy,’ which integrates both psychodynamically informed therapeutic approaches and cognitive–behavioural therapy. These interventions are most frequently conducted by practitioners who have received psychodynamic training. This type of intervention gathers a panel of different techniques, such as emotional support, developmental guidance, and psychodynamic interpretation, based on several theoretical orientations, including attachment theory, object relation theory and interpersonal and family systems approaches . Infant–parent psychotherapy is an example of this type of therapy, combining interactional guidance with psychodynamic interpretative techniques.

In a different level of intervention, two of the best-known interventions or rather prevention programmes for maternal depression have been validated in their effectiveness: (1) watch, wait and wonder ; and (2) the STEEP program (steps toward effective and enjoyable parenting), associated with different levels of training .

Perinatal depression: pre-and post-natal interventions

Few interventions have address maternal depression during pregnancy, despite the importance of this period for maternal and infant outcomes . The pregnant woman might have to face considerable emotional upheavals in this period . These include the relationship to the fetus and the mother-to-infant bonding in the early postpartum period. Nanzer et al. proposed a four-session intervention based on Cramer and Palacio-Espasa’s mother–infant intervention , called parenthood-centered psychotherapy, and consists of two prenatal and two postnatal sessions. The method focuses on changing problematic representations of parenthood and on improving the ability to hold a parenting role.

Infant–mother psychotherapy for postnatally depressed mothers

In 1999, Milgrom et al. observed that the mother–infant interaction needed to be specifically targeted by programmes treating maternal depression. Postpartum depression is considered a disorder that unfolds within specific interpersonal and social contexts . A depressed mother has to be viewed as an adult with depression as well as a depressed parent interacting with her child . Treating maternal depression without addressing her parenting behaviours does not sufficiently protect children from the potentially negative effects of having a depressed mother . Mother–infant psychotherapies offer a unique opportunity to repair disruptions in the mother–infant relationship. Cicchetti et al. highlighted the need for interventions focusing on parent–infant relationship. For Nylen et al. a treatment that targets the mother–infant relationship may have greater potential in providing a resilience factor against the potentially damaging effects of postpartum depression on early emotional and cognitive development of the child, and outcomes are beneficial for the mother as an adult as well as for the child. According to Cicchetti et al. ignoring relational issues in depressed mothers may perpetuate maternal depression. For example, the child may experience behavioural problems, and this may lead to feelings of guilt in the mother arising from the fear that her depression has interfered with effective parenting.

Mothers with postpartum depression might be difficult to reach therapeutically, as some of them might not recognise and accept their depression diagnosis.5 Women with depression who have difficulties in facing their diagnosis might be less willing to receive treatment. They might also try to present as less depressed than they feel to avoid stigmatisation . This challenges early recognition of maternal depression . Women with postnatal depression have increased rates of non-compliance with intervention strategies and higher drop-out rates in clinical trials . Women from low socioeconomic backgrounds are more likely to be depressed, and they also might face practical challenges in adhering to treatment (e.g. car fares) that are not directly linked to their depression.

Different infant–parent psychotherapy approaches with depressed mothers

The four different infant–parent psychotherapy approaches include (1) cognitive–behavioural therapy, which emphasises the ‘here and now’ of directly observed behaviours during mother–infant interactions. With maternal depression, this approach is used mostly in group-therapy settings, but some therapists also use it as part of dyadic therapy . Milgrom’s cognitive–behavioural approach, for example, focuses on the mother’s difficulty in engaging in face-to-face interactions with their infants. This difficulty is described as ‘an important and negative force’, which can impinge on the infant’s development because it affects the infant’s ability to ‘attend, process information and regulate emotions’ . Milgrom’s intervention programme, ‘baby HUGS’ (happiness, understanding giving and sharing), is designed specifically to help depressed mothers and their infants. The intervention scheme is based on three structured group sessions, each of them addressing a major theme in the context of postpartum depression: (1) play and physical contact; (2) learn to observe your baby and to understand your baby’s signals; (3) and examine your feelings and how you respond as a parent to your infant’s cues.

A second approach in infant–parent psychotherapy with postnatally depressed mothers is ‘interactional guidance’. Jung developed the ‘keys to caregiving’ programme . This intervention programme aims to help parents understand and to respond adequately to their infant’s behaviours. The goal is to increase expressions of positive affect in the infant. Five weekly group sessions commence when the infant is 3 months old. Keys to caregiving aims to help mothers in developing effective ways of managing and comforting their infant when the infant is distressed, understanding the meaning of their infant’s behaviours, and finding contingent responses to their infant, strategies that lead to more positive interactions between mothers and infants.

A third model of infant–parent psychotherapy are home-visiting programmes or home-based interventions. Programmes exist for both high-risk families and low-risk families, such as the ‘Kopp’ programme for depressed mothers and their babies . These home-based programmes are described in greater detail in other papers in this issue of Best Practice and Research Clinical Obstetrics and Gynaecology .

The fourth group of infant–parent psychotherapy interventions are psychodynamically informed approaches . These interventions focus on the therapeutic alliance between mother or parent and the therapist, which allows exploration and enhancement of mother–infant interactions by providing corrective supervision or guidance to increase maternal sensitivity and responsiveness. Thus, one could talk about dyadic parent–infant therapy when the following criteria are met: (1) parent and infant are equally kept in mind by the therapist (i.e. a therapeutic alliance also needs to exist with the child); (2) the therapist’s role is less psycho-educational or directive and rather supportive of the parent–infant relationship by focusing on the individual dyad’s strengths. This contrasts to ‘corrective supervision’, which assumes that there is an absolute truth and that the therapist knows best (or at least better than the parent). Aims of this interventional approach are to promote maternal feelings of competence as a caregiver, to improve maternal sensitivity and the quality of mother–infant interactions , and to promote secure attachment of infant to the parent . Toddler–parent psychotherapy is an example of this psychodynamically informed interventional approach. It was specifically designed for postnatally depressed mothers with usually weekly joint sessions for mother and infant. The focus is not just psycho-education of the mother but rather improvement of the mother’s relationship with the infant, and communication of maternal affective attunement and maternal responsiveness to child cues . Toddler– parent psychotherapy is based on attachment theory and on Fraiberg’s model of joint mother–child intervention. It requires a therapist who is trained to address how the mother’s internal representational models of attachment relationships are enacted in her relationship with the toddler. It is hypothesised that mothers can alter their insecure internal representational models of their attachment relationship with their child through a corrective emotional experience within the context of the therapeutic relationship . More positive mother–child interactions facilitate child functioning across various developmental domains. Toddler– parent psychotherapy enhances adaptive mother–child interactions by creating a relational context that facilitates the toddler’s self-development and helps mothers achieve more developmentally accurate expectations of their child. Finally, as cognitive–behavioural therapy and psychodynamic approaches tap into different components of postpartum depression, attachment issues might best be addressed by a combined psychodynamic and cognitive–behavioural therapy approach with a therapist who is trained in both, and is able to adapt to the individual mother’s treatment progress.

Different parent–infant psychotherapy approaches with depressed mothers

A major clinical challenge is to determine what interventional approach might help an individual family most effectively . Two issues need to be addressed to make this decision. The first is risk assessment. It needs to be determined if (and to what degree) the individual depressed mother might have difficulties in interacting with her child, thereby putting her child’s development of healthy attachment patterns at risk (risk assessment). The second is choice of interventional approach. It needs to be determined whether specific characteristics in the individual mother–infant dyad could best be targeted by one or several specific interventional approaches, as described above. Van Doesum et al. have summarised how comparative outcome research needs to address these issues so that clinical decision making can be facilitated. Importantly, the child’s age also needs to be taken into consideration, as it influences both risk assessment and choice of optimal interventional approaches.

The results of four meta-analytic studies on attachment and caregiving issues can help inform clinicians in the choices they make in practice . The results strongly support the need to start any intervention with a thorough risk assessment, as they showed marked variability in risk of child attachment insecurity in the context of maternal depression. Many depressed mothers in the studies reviewed did not show any difficulties in parenting . Three moderating variables were identified that clinicians need to take into account during the initial risk assessment of each individual dyad: first, characteristics of maternal depression need to be considered. Brief, non-recurrent or subclinical depression might bear less severe consequences upon the mother–child relationship . Episodes of clinical depression, chronic or recurrent episodes or comorbid axis I or axis II disorders are more strongly related to difficulties in parenting, thus putting the development of healthy child attachment at risk. Importantly, even in high-risk samples, effects of maternal depression on child attachment security are significantly heterogeneous .

A second moderating variable between maternal depression and child outcome is the dyad’s social context. The meta-analytic studies highlight the cumulative effect of stress factors upon caregiving and upon quality of infant’s attachment status. The effect of maternal depression on parenting and on quality of infant’s attachment status vary significantly between low-risk or high-risk samples.

For these reasons, the relationship between maternal attachment, depression, care giving and the infant’s attachment system might best be understood in a developmental and transactional model, in which timing of events, number of risk factors, and number of resilience factors in mother and child are jointly taken into account.

Attachment-informed assessments as part of parent–infant psychotherapy

Therapeutic decisions need to be based on precise assessments of issues related to attachment and care giving, at the individual, dyadic, family and social context level . Such assessments will result in the identification of risk and resilience factors that can moderate the effect of maternal depression on child outcome . Identification of the mother’s attachment style, for example, can help determine which type of attachment-informed intervention might be most efficient for the individual mother–infant dyad .

In addition, the choice for initial assessment tools will depend on whether the aim is prevention or intervention . on the reason for referral, and on the age of the child. Assessment of infant attachment will include categorisation of security and insecurity, as well as signs of attachment disorganisation. Maternal care-giving assessment will include disorganising behaviours, particularly in a mildly stressful situation, as a brief separation, in a play situation or in a feeding situation. In a second step, maternal factors are assessed that can contribute to hampering of maternal care giving and to altering maternal sensitivity, such as life stressors, or other psychopathologies . This information is necessary to help the clinician choose which type of attachment-informed treatment would be most appropriate to the individual family’s situation, and to answer specific questions related to choice of treatment: does the baby have any special needs? (e.g. is the baby irritable or temperamentally ‘difficult’?) . The assessment of the mother’s attachment style is important also because it relates to her own experiences as a child; it therefore takes intergenerational developmental pathways into account . Knowledge about these individual pathways allows for optimal tailoring of the intervention to the individual family’s needs. Maternal-attachment system, or more precisely, her state of mind regarding attachment, can be considered as both a resilience factor or as a risk factor . The maternal-attachment system can mediate the impact of maternal depression on infant attachment . It also is an important factor for the establishment of a therapeutic working relationship with the mother. The mother’s state of mind regarding attachment has become a growing focus in clinical work, as attachment-related states of mind can influence parental receptivity to therapeutic interventions . Some clinical guidelines are now available that can help us make inferences about parental attachment-related states of mind .

Similarly, assessment of the mother’s attachment style is a first step in assessing her relationship to her partner. Several research studies have shown that the non-primary caregiver also plays an important role in dyadic treatments that focus on the primary caregiver-child relationship (in most societies the primary caregiver most often is the child’s mother). The attachment style of the mother’s partner can mediate the effect of the mother’s attachment style on child outcome , and can be a protective factor for the primary caregiver–child relationship in the context of maternal depression , Infant–mother psychotherapy will likely be most efficient if close collaboration exists and the mother’s partner is continuously involved in the therapeutic process, if available. Finally, the assessment of interpersonal and social stressors is important as they can affect the mother’s ability to focus on her child’s needs and undermine her availability. The greater the number of risk factors, the more likely the family will require additional support .