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

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© Copyright Karl Heinz Brisch Munich 2012. All rights reserved. Safe Education Safe Education for Parents for Parents Mentor training module II SAFE SAFE Karl Heinz Brisch Pediatric Clinic and Polyclinic Dr. von Hauner Children‘s Hospital Department of Pediatric Psychosomatics and Psychotherapy University of Munich ®

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

Page 1: © Copyright Karl Heinz Brisch Munich 2012. All rights reserved. Safe Education for Parents Safe Education for Parents Mentor training module II SAFE Karl.

© Copyright Karl Heinz Brisch Munich 2012. All rights reserved.

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

®

Page 2: © Copyright Karl Heinz Brisch Munich 2012. All rights reserved. Safe Education for Parents Safe Education for Parents Mentor training module II SAFE Karl.

© Copyright Karl Heinz Brisch Munich 2012. All rights reserved.

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."

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Overview I

• Postnatal adaptation

• Fears

• The three of us - parenthood

• Interaction and its disorders

• Video sensitivity training

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Overview II

• Circle of safety

• Day care

• Partnership

• Family of Origin

• Exercises

• Open questions

• Outlook

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“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

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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.

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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

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“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

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Mothers introduce themselves

• Preparation in small groups

• Introduction in the group

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Fathers introduce themselves

• Preparation in small groups

• Introduction in the group

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The “family group introduces itself

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

• How do we experience ourselves as three or more?

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We three or four?

MotherFather

Baby

Siblings

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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• …………….??????

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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

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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

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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

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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

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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

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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

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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!!!

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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

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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?

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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

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Videotaped practice examples

• Diapering

• Nursing

• Playing

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Adaptation – processing the birth

• Exchange in the group about the birth

• Exchange about positive and negative experiences

• Traumatic experiences– individual psychotherapy

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Adaptation and grief workThe real versus the fantasized child

• Temperament

• Abilities

• Powers of resistance

• Threat

• Effect on owning personality

• Effect on partnership

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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

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Ideals versus reality

• The ideal mother -- the real mother

• The ideal father -- the real father

• The ideal baby -- the real baby

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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

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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

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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!

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“Resources” exercise

• Safe place

• Vault

• Tree exercise

• Helpful helpers

• Lighting

• Remote-control

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Day care

• Babysitter

• Family members

• Day mother

• Crib

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“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

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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

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“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

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“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

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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

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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

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Day care and attachment

• 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

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Day care and attachment

• 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

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Day care and attachment

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

• Control group– 24% of children under maternal care

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Day care and attachment

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

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Day care and attachment

• 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

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Day care and 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

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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

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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

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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

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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

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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