Psychotherapy with Infants and Young Children, by A. F. Lieberman and P. Van Horn
For the beginning and intermediate-level clinician, Psychotherapy With Infants and Young Children by Alicia F. Lieberman and Patricia Van Horn offers a clear and careful description of the therapeutic process and provides many good examples of the nuts and bolts of therapeutic technique. It is refreshing to see a well-supported, empirically evaluated treatment that incorporates a nuanced understanding of dynamics; attachment; family interpersonal processes; and the complicated, multifaceted conflicts—intrapsychic and interpersonal—that are often present in many families referred for treatment. Using an approach that is heavily influenced by John Bowlby and later work on attachment, the authors provide a very thoughtful guide to therapy with families of young children. Their numerous case examples often provide excellent, specific examples of what therapists can say or do to nudge families toward better coping and more mutual relationships. They are also refreshingly frank in discussing times when, on later reflection, they would have said or done something slightly different.
There is a terrific section in Chapter 9 on the different situational demands and timeframes for action confronting Child Protective Services (CPS) workers, who often must respond quickly in a crisis, and therapists, who often have the luxury of longer term assessments. This section ought to be required reading for any therapists with dealings with CPS, as CPS decisions, which are often made under difficult circumstances and for high stakes, are often treated with disregard by therapists.
Despite these notable strengths, the book could have done a better job in two areas representing the two extremes of the therapeutic continuum. At one end there is the question of the cases they have labeled “perturbations,” or the mildest level of relationship problem, and whether these warrant formal psychotherapeutic intervention. Many of the examples labeled as perturbations seemed to describe common reactions to common developmental challenges. For example, the couple who had minor conflict after the unexpectedly difficult birth of their child and began to have
different experiences during the day. Mr. Adams was immersed in pursuing a career …, while Mrs. Adams had taken a 6-month leave of absence … and missed the social and intellectual stimulation of her work life. After 2 years of being happily married they now found themselves at odds with each other. (p. 150)
This example, at least as described, would seem to describe a very large number of couples, especially dual-career couples, making the transition to parenthood.
Although some additional social support during this transition would be welcomed by many, not all suboptimal responses warrant therapy. There is no discussion of the downsides of therapeutic intervention. Regarding diagnosis, were they able to use a V code, or did they have to use an Axis I diagnosis to access insurance? If the latter is true, were the symptoms severe enough to warrant the possibilities of future problems obtaining health insurance, life insurance, or employment? Would family therapy be the best intervention here, or could a similar outcome be achieved if resources were devoted to caregiving respite or a support group for new parents? Or even no intervention? Here, as elsewhere, the authors make very little mention of maturational processes. This seems particularly surprising in a book devoted to early childhood. It would be very useful to have more explicit guidelines about when struggles with developmental challenges cross the line into problems warranting formal intervention.
At the other end of the continuum is the issue of how well suited therapeutic solutions are for the most intractable social problems. Just as Lieberman and Van Horn seem to assume the appropriateness of therapy for relatively mild cases of distress, they also do not much question whether it is useful in the most severe cases. One section of Chapter 8 describes the difficulties working with families facing overwhelming amounts of trauma and adversity as “lapses in attunement” (p. 246). It is far from clear that an individual or family-focused intervention will have much impact in relation to the repeated severe traumas to which many people are exposed. Although the authors do acknowledge these issues to some extent, they stop short of questioning the therapeutic enterprise in such cases and imply that individual parents should be able to adequately provide for their children despite an almost total lack of resources and support, and likewise they seem to suggest that individual therapists should heroically engage with the system until these families' needs are met. There are numerous settings in which such highly traumatized, disadvantaged families make up a high percentage of clients, especially longer term clients, and it is not clear how individual therapists would be expected to pursue multiple service coordination. For all of the families in their caseload? If not, for which ones? How would this affect caseloads? Billing? Many therapists may have such heroic impulses, but burnout can be very high for people working with these populations, and there are often few clear guidelines about how much therapists can or should do. Once again, the relative benefits of psychotherapy relative to other possible interventions also receives very little attention.
The severe end of the continuum is especially important in this book because child–parent psychotherapy was developed, at least in part, through work with clients facing fairly serious problems by traditional outpatient standards. Perhaps more details on the administration of their clinic would be useful. Certainly if nothing else they provide better-than-average supervision to therapists, and perhaps more of it than is often available to frontline workers. It would be fascinating to know more about the administrative and financial structure of exemplar programs such as the one Lieberman and Van Horn have developed, especially as the best way to allocate health care resources is becoming an increasingly urgent policy question. These authors have clearly forged an approach that is useful for families dealing with a variety of types of problems, and almost every detail of their approach could be helpful for others attempting to serve families with similar problems.
Sherry Hamby, PhD
Sewanee, the University of the South
Department of Psychology
Sewanee, TN 37383