PA-IMH breakfast 1-8-16

 At the January 8, 2016, infant mental health breakfast, Una Majmudar and Nina Mendez of the Health Federation of Philadelphia presented on the clinical implementation of Child-Parent Psychotherapy (CPP) in the Child Parent Project. Una is the program manager and Nina a family therapist in the program. Children being treated as part of this project are involved with the child protective system, with possible issues including problems of the custodial parent, the other parent, substance abuse, and so on. CPP is carried out dyadically with the child and caregiver.

CPP is an evidence-based trauma intervention developed under the auspices of Alicia Lieberman. It is unique in that the “client” is seen as the relationship between adult and child, not as either individual. The treatment lasts from 9 to 12 months and involves weekly hour-long sessions. Unlike many manualized treatments, CPP does not prescribe the focus of each of a series of meetings, but instead assesses at every session how the relationship looks through the “lens” of safety, of attachment, of developmental progress, of “ghosts in the nursery”, and of “angels in the nursery”. CPP asks how a parent and child can move past a traumatic event, but also considers concrete needs like housing.

Nina Mendez presented a case being treated with CPP. A 4-year-old girl who had been removed from her mother because of inadequate housing and other issues like the mother’s incarceration and drug and alcohol use was seen along with her mother. She had lived briefly with her biological father, whom she had never met before, but now was with a grandmother. The mother’s strengths were seen as her willingness to attend drug and alcohol treatment and to plan for their future, and her real dedication and longing for her daughter to feel safe and protected. The little girl had been described as hyperactive and defiant, but was also smart, talkative, playful, and imaginative. She responded enthusiastically to interesting activities like nail-painting that she could do with her mother and Nina. Using a CPP method, these were regulated by a “time timer” giving 15 minutes for each. The timer was set by the child, who responded with increased calmness to this structure.
The daughter’s aggressive behaviors had been ignored by the mother in the past rather than interpreted. CPP helped them discuss past events of domestic violence, to distinguish between “then and now”, and to establish safety plans for the future. As part of CPP, the program also worked to help the child attend the same school as her older brother, supporting her feeling of safety and security.

When events connected with this dyad made the therapist very frustrated and angry on their behalf, the reflective supervision aspect of CPP came into play. Reflective supervision allowed the therapist to have a safe space in which she could examine her thoughts and feelings in a trauma-informed way, in a parallel process to what the mother and child were doing. She could then self-regulate and be available to help the mother create a safe space for the child. 
 A lengthy discussion of audience questions followed the case presentation. One attendee asked about doing CPP with preverbal children. Una commented that this could work well, providing timely interactions as mother cares for a younger child. Discussion of “ghosts in the nursery” can be done, and this approach can be helpful for depressed mothers. A second question was about the use of CPP for children older than 5 or 6; the intervention was not developed for those children, who are developmentally ready to work with the therapist themselves rather than in the dyadic setting. An audience member asked about a research component of the 5-year Child Parent Project grant; this is in place and focuses on efficacy and reunification as well as on a cost analysis. A final question addressed training in CPP. This is not available for individuals, but is done through a network of learning collaboratives and is available only to people with master’s or doctoral level training.  Further information is available at www.nctsn.org.