© Copyright Karl Heinz Brisch Munich 2012. All rights reserved. Safe Education for Parents Safe...

Safe Education for Safe Education for ParentsParents

Mentor training module II

SAFESAFE

Karl Heinz BrischPediatric Clinic and Polyclinic

Dr. von Hauner Children‘s Hospital

Department of Pediatric Psychosomatics and Psychotherapy

University of Munich

John Bowlby

"Bindung ist das gefühlsgetragene Band, das eine Person zu einer anderen spezifischen Person anknüpft und das sie über Raum und Zeit miteinander verbindet."

Overview I

• Postnatal adaptation

• Fears

• The three of us - parenthood

• Interaction and its disorders

• Video sensitivity training

Overview II

• Circle of safety

• Day care

• Partnership

• Family of Origin

• Exercises

• Open questions

• Outlook

“Weather chart"

• How‘s baby doing today?

• How am I doing today?

• How are both of us doing today?

• What I urgently need to tell

The babies introduce themselves

• Separately, mother/father introduce their baby in the group as if they were the baby themselves. To do this, they must imagine themselves into the inner world and experience of their baby.

Happy moments

• Moments of happiness

• Moments of joy

• Moments of agreement

• Moments of happy surprise

• Moments à trois

• Five positive adjectives for your relationship with your baby

“Unhappy" moments

• Moments of unhappiness

• Moments of fear

• Moments of dissonance

• Moments of helplessness

• Moments of loneliness

• Five “heavy“ adjectives for your relationship with your baby

Mothers introduce themselves

• Preparation in small groups

• Introduction in the group

Fathers introduce themselves

• Preparation in small groups

• Introduction in the group

The “family group introduces itself

• Who all belongs to the new “family“ or family group?

• How do we experience ourselves as three or more?

We three or four?

MotherFather

Siblings

Questions, questions, questions

• Spoil• Sleep• Nurse• Dangers when exploring• Setting limits and frustration• Playing alone and together• Babysitter• Partnership• Rivalry• Traveling and vacations with baby• …………….??????

Preconditions for the development of secure attachment in the child

• Sensitivity on the part of the caretaker

• Emotional availability

• Clearing up misunderstandings

• Recognizing projections

• Clarifying notions of the ideal

AAI (1)

• Semi-structured interview

• Questions– description of the family situation– relationship to the parents with earliest memory– five adjectives for your relationship to your

parents in childhood– closeness to mother and/or father

AAI (2)

• Questions– help when “not feeling well" (sorrow, fear,

illness)– first separation from parents– rejection by parents– threats by parents– effect of parents on personality– explanation for behavior of parents

AAI (3)

• Questions– loss of important attachment figures– changes in the relationship with parents– reactions to separation from own child

• real child

• imagined child

– learning from childhood experiences

Assessment of the AAI

• Scientific assessment very complicated

• Suspicion of unresolved trauma– trauma is reported– symptoms of posttraumatic stress– coherence of speech flow– dissociative phenomena

Unprocessed trauma in the mother/father

• Disordered interaction and disorders in affective communication with the infant

• Fearful maternal behavior

• Fear-inducing maternal behavior

• Helpless maternal caregiving behavior

Triggers for traumatic memories in the parents

• Triggers in the behavior of the infant, – crying, worry, pain, neediness – desires for attachment, closeness– separation, boundaries

• Triggers in affective arousal

• Unconscious processes!!!

Reenactment of trauma

• In the interaction with the infant– rejection of desires for closeness -- avoidance– violence– abrupt break off of actions– overstimulation (sexual-sensory)

• In affective communication– transfer of traumatic affects

• rage, shame, agitation

Video feedbackSensitivity training

• The action level– What are the mother, father, and they be doing?

• The motivational level– Why do they behave this way?

• The emotional level– How does feel to you?

• Empathic level– What would I do if I were the mother, father, or baby in

this scenario?

Feedback

• Ego messages• At least 2 positive responses BEFORE

critical response• Always begin work with positive

interactions• Caution with critical responses• Follow up critical responses with “AND"

positive responses

Videotaped practice examples

• Diapering

• Nursing

• Playing

Adaptation – processing the birth

• Exchange in the group about the birth

• Exchange about positive and negative experiences

• Traumatic experiences– individual psychotherapy

Adaptation and grief workThe real versus the fantasized child

• Temperament

• Abilities

• Powers of resistance

• Threat

• Effect on owning personality

• Effect on partnership

Bonding of the parents

• Emotional availability

• Capacity for sensitive care

• Empathy with the child‘s needs

• Recognition of unclear agitation in the parents themselves -- trigger points

Ideals versus reality

• The ideal mother -- the real mother

• The ideal father -- the real father

• The ideal baby -- the real baby

Me as mother

• Physical changes• Psychological changes

– protection– worries and fears

• Relational changes– with partner– with own children– with own parents– with own friends

• Development of postnatal attachment - bonding

Me as father• Physical changes• Psychological changes

– protection– worries and fears

• Critical phases and responsibility• Relational changes

– with partner– with own children– with own parents– with own friends

• Development of postnatal attachment - bonding

Partnership and “egoism“

• Time for exchanges

• New things to talk about

• Time for activities together

• Time for sexuality

• Time for vacation

• Time to be alone!

“Resources” exercise

• Safe place

• Vault

• Tree exercise

• Helpful helpers

• Lighting

• Remote-control

Day care

• Babysitter

• Family members

• Day mother

• Crib

“Natural” separation situations

• Going to sleep• Parents‘ night out / the babysitter arrives• Kindergarten

– overnights

• Enrollment in school• Country day school • Transfer to next school• Free time / vacation

Preparation for separations

• Time for transition / separation• Buildup secure attachment with replacement

attachment figure• Rituals• Announcements• Availability• Admits to pain and sadness• Understand and withstand anger

“Unnatural” separation situations (1)

• Moves / migration / flight• Admission to hospital• Parental divorce• illness of one parent – emotional separation

– cancer– addiction / alcoholism / psychosis– chronic disease / multiple sclerosis

“Unnatural” separation situations (2)

• Unexpected death of an important reference figure– child / fetus

– parent

– friend

– grandparents

– teacher• natural cause of death

• accidental death without farewell

• suicide

The experience of separation as psychotrauma

• Sudden occurrence

• Over-stimulation of autonomic nervous system

• Loss of attachment figure - security

• Neither fight nor flight possible

• Nightmares

• Dissociation of memories

• Triggers of flashbacks

Day care and attachment

• Study of the US National Institute of Child Health and Development

• 1364 families and their children

• Follow-ups at 6, 15, 24 and 36 months

• Forms of day care– grandparents/relatives

• in the parents‘ home• in the caregiver‘s home

– Day care centers of varying quality– Babysitter

• in the parents‘ home• in the caregiver‘s home

• Variation– the quality of day care– number of hours per day and week– Beginning day care

• from birth

• 4-6 months after birth

• 7-15 months after birth

– all social classes different

• First year of life– 76% non-maternal day care

• Control group– 24% of children under maternal care

Results• Risk of insecure attachment increases if

– mother‘s behavior is insensitive– high number of hours in daycare– constantly changing care arrangements

• These effects did not occur when the mother-child relationship was good

• Summary– Quality of the mother-child relationship as a

relatively robust determinant of attachment outcome

– Poor quality day care is a risk factor if the mother-child relationship is already stressed -- more frequent insecure attachment

– High quality day care is a protective factor for children with very insensitive mothers -- more frequent secure attachment

• Summary– Care and support for mothers with sensitivity

problems– High quality of day care

• Long adjustment times (min. 3-4 weeks)

• Latchkey child caretaker of 1:2 (3)

• Sensitive reference person is a constant

• Regular day plan

Day care and aggression

• Contradictory results (late effects)

• effect of – quality of the parent-child relationship– characteristics of the child (sex-boy)

• Secure attachment is a protective factor

• Fewer effects of early day care

• Poor quality of day care

Mother‘s fears

• Spoiling child• Child in parents‘ bed• Eating and sleeping• Lack of support from partner• Illnesses• Stress with family of origin• Loss of female attractiveness• Loss of profession and end of career

Father‘s fears

• Spoiling child

• Child in parents‘ bed

• End of sexuality

• Lack of support from partner

• Stress with family of origin

• Child as a burden on career

Steps toward forming a SAFE group (1)

• Find a co-facilitator – couple • Find an organizational partner (e.g., family

education center)• Find a large space • Advertise in the local press and distribute flyers• Organize individual care• Organize a hotline • Organize cooperative arrangements with local

psychotherapists

Steps toward forming a SAFE group (2)

• Start with approximately 5-6 couples• Conduct AAI interviews• Distribute the trauma questionnaires• Be reachable• Question the parents empathetically• Get supervision • Enjoy the babies‘ development and the parent-

child relationships

© Copyright Karl Heinz Brisch Munich 2012. All rights reserved. Safe Education for Parents Safe...

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