Open door review

Further psychoanalytic studies

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Overview

 
 

The Geneva Early Childhood Stress Project: The effects of maternal interpersonal violence-related posttraumatic stress on the parent-toddler relationship and subsequent child social-emotional development

Schechter, D. S., Suardi, F., Manini, A., Cordero, M., Sancho Rossignol, A., Gex-Fabry, . . . Rusconi Serpa, S. (2014). How do maternal PTSD and alexithymia interact to impact maternal behaviour? Child Psychiatry and Human Development 46(3):406-417.

Moser, D.A., Aue, T., Favez, N., Kutlikova, H., Suardi, F., Cordero, M.I., Rusconi, S., Schechter, D.S. (2015). Violence-related PTSD and neural activation when seeing emotional male-female interactions. Social, Cognitive, and Affective Neuroscience 10(5):654-653.

Schechter, D.S., Moser, D.A., Reliford, A., McCaw, J.E., Coates, S.W., Turner, J.B., Rusconi, S., Willheim, E. (2015 epub Feb 20). Negative and distorted attributions towards child, self, and primary attachment figure, among posttraumatically stressed mothers: What changes with Clinical Assisted Videofeedback Exposure Sessions (CAVES)? Child Psychiatry and Human Development, 46(1), 10-20.

Schechter, D.S., Rusconi-Serpa, S. (2014). Understanding how traumatized mothers process their toddlers' affective communication under stress: Towards preventive intervention for families at high risk for intergenerational violence. In Emde R, M & Leuzinger-Bohleber (Eds). Early Parenting Research and Prevention of Disorder: Psychoanalytic Research at Interdisciplinary Frontiers (pp. 90-118). London: Karnac Books.

Brief Summary

The Geneva Early Childhood Stress Project (GECS-Pro) Phase 1 was officially launched in 2010 at the Research Unit of the Child and Adolescent Psychiatry Service, Department of Pediatrics, University of Geneva Hospitals and Faculty of Medicine. The GECS-Pro is funded by the Swiss National Science Foundation as part of the National Center for Competence in Research on the Synaptic Bases of Mental Disorders (NCCR-SYNAPSY) as well as the Gertrude von Meissner, Prim’Enfance and the Oak Foundations. The GECS-Pro is a prospective longitudinal study that in Phase I (2010-2014) has included over 100 mothers of children ages 12-42 months.  The study focus is to understand how maternal interpersonal violence exposure and related posttraumatic stress disorder (PTSD) affects the mother-child relationship particularly with respect to mutual affect regulation and the development of self-regulation of affect, arousal, and aggression in the child.  The project examines psychological, behavioral physiologic, neuroimaging, and epigenetic data of both mother and children individually and in interaction in an effort to identify potential endophenotypic differences that contribute to the intergenerational transmission of violence and related psychopathology.  A second focus of the GECS-Pro is to understand how child displays of negative affect, helplessness, and dysregulation impact the traumatically stressed parent, her mental representations of the child marked by her attributions to the child’s personality, and her caregiving behavior.  Related to this second focus, we have further developed an experimental intervention technique the Clinician Assisted Videofeedback Exposure Session(s) or « CAVES » that had been developed as part of the principal investigators prior IPA-funded research in New York.  This intervention is being further developed into a 12-16-session manualized brief psychotherapy the Clinician Assisted Videofeedback Exposure-Approach Therapy or « CAVEAT ».  While the GECS-Pro Phase 1 will be ending recruitment in December, 2014, Phase 2 will be beginning in the spring, 2015 which will focus on longitudinal follow-up the children from Phase 1 at ages 5-9 years in an effort to identify individual differences with respect to aggressive versus anxious-depressed behaviors and symptoms.  A second planned project within Phase 2 involves a controlled trial of the CAVEAT with a new cohort of 30 mothers and children ages 12-42 months.

Methods / Design

In Phase 1, Each mother-child pair was evaluated and videotaped over the course of a screening session plus 2 evaluation sessions and the CAVES session.

Measures included

Screening visit : Geneva Socio-Demographic and Treatment History Questionnaire, Traumatic Life Events Questionnaire, Brief Physical and Sexual Abuse Questionnaire, Symptom Checklist-90

Maternal interview :  Working Model of the Child Interview with Reflective Functioning Probes (WMCI-RF), Clinician Administered PTSD Scale (CAPS), Structured Interview for the DSM-IV (SCID) Mood Disorders Module, PTSD Symptom Checklist-Short Version, Beck Depression Inventory-II, Hopkins Dissociative Symptom Checklist

Mother-child visit :  Modified Crowell Parent-Child Interaction Procedure with serial salivary cortisol and DNA sampling and coding via the CARE-Index (done) and AMBIANCE (planned), Infant-Toddler Social-Emotional Assessment (ITSEA), Disturbances of Attachment Interview, Parenting Stress Index—Short Form, Ages and Stages Questionnaire

CAVES :  CAVES Semi-structured Interview,  Maternal Attributions Rating Scale (MARS), WMCI-RF selected items, the Personality Disorders Questionnaire-4 (PDQ-.4)

The majority of mothers were eligible for and participated also in an fMRI scanning session that included a Hamilton Anxiety Scale and a Post-MRI Interview about their reaction to fMRI silent film stimuli. 

All mothers were recontacted one year after their participation in the study to complete the Reflective-functioning Questionnaire and the Child Behavior Checklist

Methods/design : In Phase 2, Each child will be evaluated and videotaped over the course of 2 evaluation sessions.  Measures will included : The MacArthur Story-Stem Battery with Mentalization Subscale, the Test for Emotional Comprehension, the Traumatic Events Screening Inventory—Child Version (TESI-C), the Schizophrenia and Affective Disorders Schedule—Child Version (K-SADS), the Child Dissociative Checklist, the Trier Social Stress Test for Children with salivary cortisol and DNA sampling, EEG with affect matching task, the Victim-Bullying Questionnaire

Results of GECS-Pro Phase 1

Most recently, the Geneva Early Childhood Stress Project  (Schechter et al., 2014; Moser et al., 2014 ; Schechter & Rusconi-Serpa, 2014) has  found the following:

1. Maternal IPV-PTSD severity is correlated with maternal alexithymia and that both are positively correlated with parenting stress and negatively correlated with maternal sensitivity (Schechter et al., 2014).

2. Both maternal IPV-severity and parenting stress are negatively correlated with the mean percentage of methylation of the NR3C1 gene for the glucocorticoid receptor (Schechter et al., submitted).

3. Low cortisol baselines in mothers  and low cortisol reactivity to laboratory stressors (i.e. separation and exposure to novelty) in the children (ages 12-42 months) (Preliminary analyses reported: Schechter DS.  Understanding how traumatized mothers process their toddlers' affective communication under stress: Towards preventive intervention for families at high risk for intergenerational violence.  Symposium on Attachment and Psychopathology in Families at Risk (Ute Ziegenhain, Chair; Klaus Schmeck, discussant).  European Congress of Developmental Psychology, Lausanne, 6-9-2013.  Final analyses are pending.

4. IPV-PTSD mothers' toddlers show a significantly lower stress response than those of non-PTSD mothers (ref).  And IPV-PTSD mothers' neural activity in response to a) child-parent separation vs. play and b) adult male-female interactions  that are menacing vs. neutral vs. prosocial both reflect cortico-limbic dysregulation with less ventro-medial prefrontal cortical activity among PTSD mothers than non-PTSD mothers (Moser et al., submitted; Moser et al., 2014). 

5. Children of  IPV-PTSD mothers vs. non-PTSD mothers from 12-42 months and then from 24-54 months, show a) greater attachment disturbances, and b) less cooperativeness during play with mother on observational measures, and c) greater internalizing and externalizing behavior on maternal report measures.  (Preliminary analyses reported: Schechter DS.  Understanding how traumatized mothers process their toddlers' affective communication under stress: Towards preventive intervention for families at high risk for intergenerational violence.  Symposium on Attachment and Psychopathology in Families at Risk (Ute Ziegenhain, Chair; Klaus Schmeck, discussant).  European Congress of Developmental Psychology, Lausanne, 6-9-2013.  Final analyses are pending.

6.  Maternal PTSD severity is correlated significantly with negativity of maternal attributions towards her child, her primary attachment figure from childhood, and herself with only a significant decrease in negativity of attributions towards her child over the course of the 3-session evaluation that includes a CAVES (single-session) (see Schechter et al., 2014)

Discussion

We are using an approach towards evaluating  violence and maltreatment-exposed mothers and their children from early childhood on that involves an integration of psychoanalytically-informed, psychiatric, and developmental neuroscientific measures in order to characterize risk and resilience with respect to theintergenerational transmission of violence and related psychopathology and determinants of individual differences.  We are also developing and evaluating parent-child videofeedback-based interventions that are targeted to supporting maternal affect regulation and reflective functioning upon clinician-assisted exposure to child negative affect, helpless states, and distress that in the context of maternal PTSD might well otherwise have been avoided. Outcomes include change of the quality of maternal attributions.

Contact

Daniel S. Schechter (PI), Sandra Rusconi Serpa (Co-PI), Francesca Suardi, Aurelia Manini, Ana Sancho Rossignol, Axelle Kreis, Gaëlle Merminod,  Dominik A. Moser, Tatjana Aue, Virginie Pointet, Isabel Maria Cordero, Ariane Giacobino, Ludwig Stenz, Wafae Adouan, Alexandre G. Dayer, Christoph Michel, Michel Rossier, François Ansermet (Department Chair)

Email: daniel.schechter@hcuge.ch

Email: sandra.rusconi-serpa@hcuge.ch

The Montevideo study of attachment and narratives

Altmann de Litvan, M. (2015). Encuentros clinicos madre-infante "Estructuras relacionales subyacente en procesos psicoterapeuticos breves" {Clinical encounter of mother and child: Underlying structures of mother-infant interaction at brief psychotherapeutic processes}. Ediciones Biebel, Buenos Aires.

Altmann de Litvan, M. (2014). Diferentes caminos hacia la Mentalización: Exploración de los estados prereflexivos y su relación con el sì mismo, AÑO I - NUMERO II – ABRIL 2014, Revistametalizacion.com.

Altmann de Litvan, M.; Procopio, R.; & Szteren, L. (2014). Intervenciones en psicoterapia madre-bebé tendientes a disminuir el riesgo de un apego inseguro. En Torres, B.; Causadioas, J.; & Posadas, G. (2014). La teoría del apego: investigación y aplicaciones clínicas. Psimatica Editorial S.L. ISBN: 9788488909879.

Brief Summary

This is a process study of psychoanalytic infant – mother consultations. It attempts to bring the advances of psychoanalytic process research in the traditional consulting room encounter to the applied context of mother – infant interaction. This is a therapeutic setting that shares some features with the psychoanalytic but, in addition has a developmental focus.

Ten mother baby dyads were selected at random from the regular treatment program at the Pediatric University Hospital in Montevideo. The babies were aged from 3 to 18 months and showed psychofunctional disorders. The dyads received 3 to 4 therapeutic interviews. The goal of these psychoanalytically oriented consultations with mothers and their babies is to help the mother to better understand her emotions, especially when interacting with her child in the therapeutic situation itself. A psychotherapeutic objective is to enable the mother to (re)adjust to her baby in direct response to its non-verbal interventions by connecting the baby’s gestures and behavior with emotions and by verbal expressing of emotions. The verbal exchange of therapist and mother is being empirically assessed using computer assisted language measures. Narrative Style is measured using a computer-based measure of Referential Activity developed by Mergenthaler & Bucci. The analysis of the text material utilizes the Cycles Model Program (CM, available from the Ulm Textbank website). The non-verbal interactions between mother and baby during the interview will be empirically assessed using Massie and Campbell’s attachment indicators (gazing, vocalizing, touching, affect, proximity, holding), both from mother to baby and the baby to mother, following the word block segmentation. Subprojects were:

- The study of risk in attachment

- The study of productivity in the session according to clinical and empirical criteria

- The validation of the Therapeutic Cycles Model into Spanish language

- The study of the impact of interventions in the developmental process

- The implementation of training programs for health care groups and mothers in the topic of attachment

- The Underlying structures of the mother-infant interaction at brief psychotherapeutic processes

 

The psychotherapeutic interviews had an effect on the attachment indicators: the subjects changed from the extreme points (insecure, avoidance and over-anxious) towards the middle range (secure attachment). In the last sessions both mother and baby are closer to the middle range (3: secure attachment), and all the attachment indicators are closer to the middle range in the last sessions both in the mother and the baby. All linguistic and non-verbal variables were correlated in a block by block basis and no significant correlations were found between the verbal measures in the mother and therapist’s speech and the attachment indicators in the mother-baby dyad (Pearson correlation). Moments of productive speech between mother and therapist were not always moments of activation of the non-verbal indicators between mother and baby. These results showed the independence of the 2 levels: therapeutic discourse, and the non-verbal exchanges between mother and baby. Patterns of mother-baby interaction for each dyad were found using Box & Jenkins times series analysis. The interchanges that are repeated during the interpersonal communications and can be conceptualized as patterns of interaction –automatic procedures of how to relate with others and the world. These patterns constitute ways of organizing experience; schemes to coordinate affects, ideas, actions, which together with fantasies activate our unconscious processes. The relevance of these patterns for psychotherapy roots in that they are the ports of entry to therapeutic action, to “moments of meeting” that constitute the way to change the mental organization at a procedural level. One year old cases were analyzed in depth at empirical and clinical levels. The authors found that each dyad has a particular and unique pattern of interaction.

Evaluation

In interpreting the present results, several limitations to this study should be considered. One of the problems of this study is the limited number of cases. Nevertheless, for many of the sub-studies performed the sampling frame was the number of blocks of 150 words. This design enabled the study of the relationship between verbal and non-verbal measures but didn’t permit the study of the reasons for the changes that take place during the psychotherapeutic process.

Overall, the study has several strengths. First, the data showed that this model of psychotherapeutic intervention had a positive impact on the attachment indicators as measured by Massie and Campbell. Second, moments of productivity in the verbal exchange between the mother and the therapist are not necessarily moments of activation of non-verbal attachment indicators between the mother and the baby. These results may have practical implications for therapeutic interventions. In order to improve the mother’s attachment to the baby these interventions should stimulate her to gaze, to vocalize and to touch the baby and also to avoid using abstract words as a means of communicating with the baby.

Contact

Dr. Marina Altmann de Litvan

Rambla Armenia 3783 piso 10

Montevideo 11326, Uruguay

Email: marina.altmann@gmail.com

Psychoanalytic Practice in Latin America

Parada Franch, N., & Altmann de Litvan, M. (2006). La formación analítica y la actividad analítica profesional en América Latina. [The relation between analytical training and professional activity in Latin America]. Sub-comité de Educación Investigación de FEPAL.
Marucco, N., Devoto, T., Altmann de Litvan, M., Mion, C., Yamhure, E., Passos, M., . . . Baptista Franca, J. (2012-2014). Còmo ven los analistas el futuro del psicoanálisis en Amèrica Latina. Estudio cualitativo. {How do psychoanalysts see the future of psychoanalysis in Latin America?}. Comitè de Educaciòn de FEPAL.

Summary

Psychoanalysts and candidates (more than 200) from all Latin American societies and groups participated on a survey (representative sample) that aimed to gather their opinions and experiences about several aspects of their training and their professional practice.

This study found that in some Latina American countries, psychoanalysts –more than candidates- had a negative perspective of the future of psychoanalysis in their country.

This finding was the root to develop the qualitative study “How do psychoanalysts see the future of psychoanalysis in Latin America?” The aim of this project, developed by the Education Committee of FEPAL was to know the vision, perceptions and evaluation of Latin American analysts about the difficulties they find in their real professional practice and how they see the future of psychoanalysis.

30 young psychoanalysts and former Training Directors from all Latin American countries were interviewed.

We found 4 positions or perspectives about the future in the interviewees: (1) a good and better future, (2) a good future if psychoanalysts and psychoanalytic institutions are able to make some changes, (3) good and will stay as it is, and (4) a difficult future.

The study deepens in the analysts perspectives in each country.

Contact

Alejandro Garbarino

Montevideo / Uruquay

Email: garba08@gmail.com

Scenic memory of the Shoah – on the transgenerational transmission of extreme trauma in Germany

Grünberg, K. (2013). Scenic Memory of the Shoah—“The Adventuresome Life of Alfred Silbermann”. The American Journal of Psychoanalysis, 73(1), 30-42.
Grünberg, K., & Markert, F. (2012). A psychoanalytic grave walk—Scenic memory of the Shoah. On the transgenerational transmission of extreme trauma in Germany. The American Journal of Psychoanalysis, 72(3), 207-222.
Grünberg, K., & Markert, F. (2017). Child Survivors: Stolen childhood— Scenic Memory of the Shoah in Jewish child or adolescent survivors of the Nazi persecution. The American Journal of Psychoanalysis, 1-23.

Summary

The research project in the Frankfurt Sigmund-Freud-Institut pursues the goal of comprehending the transmission of Jewish survivors' persecution experiences to their sons and daughters, under the specific circumstances which apply in the "land of the perpetrators".

The study focusses on the way in which the Shoah is recalled through a process of scenic memory rather than in a primarily verbal manner and on its effect on the next generation. Our basic assumption here is that it conveys those central aspects of the trauma, which excluded language from the start. This approach is based on the concept of scenic understanding proposed by Alfred Lorenzer, which is similar to the concept of enactment. For Lorenzer the most significant access to unconscious memories is obtained by the scenic approach, for his initial question is: "How can the non-verbal be grasped in language?" With the scenic understanding he wants "to understand [...] the incomprehensible".

Method

A particular characteristic of the study consists of a specific mode of research corre­sponding to the “multi-sited ethnography” approach (George Marcus): the Holocaust survivors living in Germany are not observed in a single “field” but in various contexts, including analyses, psychotherapies, psychotherapeutic self-experience groups, in video interviews, house visits, or at the “Meeting-Place for Survivors of the Shoah”, so that the study includes observations from both clinical and non-clinical settings. We will be presenting vignettes based on these sources.

The processes of the scenic memory of the Shoah are at first investigated from the dif­ferent perspectives of the two research analysts, who supervise each other. The non-Jewish German psychoanalyst and the Jewish analyst in Germany belong to different generations. Their different research perspectives are important because the transmis­sion configurations diverge and because the contrasting views expand and deepen the study of the treatment processes. In terms of the Freudian notion of "Healing and Research" the treating analyst is the starting point and basis for the study of trauma transmission. In addition, external supervisors who also examine the psychosocial effects of the Holocaust in Germany, Austria, Israel and the United States, are included in the research process.

As the transmission of the trauma is not directly observable, it must be interpreted her­meneutically. Firstly relevant scenes or vignettes are selected and described phenome­nologically. The subsequent analysis of these scenes follows the basic idea formulated by Lorenzer, "to understand all the material on the model of dream interpretation”. The transference and counter-transference processes which occur in the analytic work with Holocaust survivors and their descendants, play a central role.

The transmission of trauma is investigated from working with survivors of the Holocaust and members of the Second and Third Generation. In each setting the analysts enter into a relational process. With "evenly hovering attention" they observe how the survivors shape the scenic memory of the Shoah. The decisive criterion for determining the character of such a scene is founded in the analysts' countertransference reaction: that is, when their feelings and fantasies indicate a "getting-in-touch" with the extreme trauma. This may be a hint of something catastrophically intolerable, a sense of annihilation, anxiety, pain, compassion, powerlessness, despair, hopelessness, senselessness, depression and mourning, but also bodily sensations such as shuddering, tears and paralysis. The inner eye may show images of menace and persecution from concentration camps; the inner experience is about surviving, self- or object-loss, about non-verbal expression of the place "where language cannot reach" (Hans Keilson).

In the next step of the evaluation, the experts are involved in the investigation process. The expert supervision will be carried out by psychoanalysts and psychologists, sociologists and cultural studies specialists who are familiar with hermeneutic approaches and analytic methods. Following the model of psychoanalytic case-supervisions the clinical and non-clinical material will be worked on with the aim of achieving a consensual conceptualization of scenic trauma transmission in the various individual cases. If necessary several expert sessions will be held.

Goal

The goal of the study consists in generating hypotheses from the empirical material about how and in what way, specifically in Germany, the extremely traumatic experiences of the Nazi extermination of the Jews are transmitted by survivors to the following generations.

Contact

Dr. Kurt Grünberg

Sigmund-Freud-Institut

Myliusstraße 20

60323 Frankfurt/M