Dyadic Psychotherapy for Early Relationship Disorders: A Case Study
Keren, Miri, Spitzer, Sarah, Tyano, Samuel, The Israel Journal of Psychiatry and Related Sciences
Abstract: Specific treatment modalities, such as dyadic psychotherapies, have emerged, based on the notion that in cases of very early relational disorders, the patient is the parent-infant relationship. The aim of this paper is to present a case study of such a relational disorder which took place as the result of a complex interplay between the infant's biological risk factors and the parents' psychological risk factors. The emphasis is on the technique and the course of the dyadic psychotherapy of the mother and her three-year-old child, where the main goal was to change some of the intrapsychic and interpersonal processes specifically related to pathological motherhood. The theoretical background is briefly presented, while emphasizing the criteria for choosing one approach among the different kinds of dyadic psychotherapy.
Winnicott's famous sentence (1), "There is not such a thing as a baby," set the process of viewing the maternal fantasies about her infant as one of the major building blocks for the infant's construction of a sense of identity. Mannoni (2) emphasized the need to understand the role of the young child's psychotic symptom(s) in the individual myth of his parents; for doing so, she argues for a conjoint child-parent psychoanalytic cure. Fraiberg (3, 4), a psychoanalytically-oriented social worker, worked mainly with mothers of babies coming from disadvantaged backgrounds with disturbed patterns of parenting, went further by placing the maternal representations at the core of the parent-infant clinical situation and emphasized the catalysator role of the infant's presence; she suggested viewing the baby as the object of parental transference. Soon after, Lebovici (5) was a pioneer in breaking the "anti-behavior" psychoanalytic approach, arguing that the observation of the real interactions is not an obstacle to the unfolding of the unconscious representations. Lebovici introduced the notion of the dialectic between the real and the fantasied interactions, between the interpersonal and the intrapsychic. He defined the role of the therapist as the one who makes the bridge between these two.These conceptualizations marked the beginning of "infant psychiatry" of a psychoanalytic inspiration. From then on, dyadic psychotherapy became the main therapeutic approach for early parent-infant relationship disorders. In the following years, various trends developed within this approach, both in Europe and in the United States, as a combined result of having to face different types of psychopathology by therapists with different theoretical approaches. Stern, both a psychodynamically-oriented clinician and a observational researcher, did not introduce a new therapeutic approach, but rather proposed a unified view of parent-infant psychotherapy, which stems from his conceptualization of the dyadic (or triadic) psychotherapeutic setting (6). Stern argues that when a child is born, the mother (and to some extent, the father) undergoes a unique developmental stage characterized by a new intrapsychic organization with emotions, fantasies, anxieties and wishes specific to the state of motherhood, called "the motherhood constellation." This intrapsychic material impacts on the quality of the representations she forms of her infant; these, in turn, reflect in her interactions with the baby, who experiences these interactions as satisfying or frustrating, and develops an affective and cognitive representation of "being with Mom"; this representation expresses itself in the baby's (non-verbal) behavior, which in turn is understood by the mother according to her internal representations. Each of them develops cognitive and affective representations of the interactions ("schemas-ofbeing-with"). The sum of these representations will finally define the overall quality of the relationship. The therapeutic setting is diagrammed as following:
The triangle symbolizes the setting in which verbal and non-verbal interactions take place between therapist, parent and child. …