Child-Parent Psychotherapy: Overview, Benefits, and Effectiveness

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Child-Parent Psychotherapy: Overview, Benefits, and Effectiveness

THC Editorial Team December 2, 2021
Jozef Israels, Mother and Child on a Seashore, 1890, The Art Institute of Chicago (article on child-parent psychotherapy)
Jozef Israels, Mother and Child on a Seashore, 1890, The Art Institute of Chicago

Contents

Child-parent psychotherapy, or CPP, is a trauma-informed therapeutic approach used with young children and parents who have experienced violence or trauma. This type of psychotherapy focuses on restoring the child’s normal functioning and development and their attachment to the caregiver. CPP is primarily used with children up to age five. It is an evidence-based approach to treating mental health and attachment issues in children who have witnessed violence and experienced trauma.

What Is Child-Parent Psychotherapy?

CPP is a relationship-based therapeutic approach that therapists use to treat children who have experienced trauma and are experiencing resultant mental health, emotional, attachment, or behavioral issues.1 Therapists who use CPP conduct sessions with children and their primary caregivers and focus on the family’s strengths to improve the relationship between the children and their parents.

Through CPP, a relationship is formed between the therapist, parent, and child that focuses on helping children regulate emotions and process trauma to restore their healthy development and functioning. The therapist also tries to enable the parent and child to regain feelings of safety and trust within their relationship.1

The History of Child-Parent Psychotherapy

Broadly, CPP is rooted in developmental psychology, attachment theory, psychoanalysis, trauma theory, and developmental psychopathology.1 It also includes interventions used in cognitive behavioral therapy (CBT) and works to create internal nurturing and positive care models.

CPP grew out of the work of American child psychoanalyst, author, and social worker Selma Fraiberg and her colleagues, psychologist Edna Adelson and social worker Vivian Shapiro, in creating interventions for infants and parents during the mid-1970s. Fraiberg used psychoanalysis to address problems in maternal relationships with infants caused by intergenerational trauma and published a paper entitled “Ghosts in the Nursery” in 1975 describing her approach.2 According to Fraiberg, parents who experience trauma during their early childhood transmit the unresolved conflicts they experienced to their infants.2

Alicia F. Lieberman, a professor and the vice-chair for academic affairs in the department of psychiatry at the University of California, San Francisco, took Fraiberg’s concepts a step further with her 2005 paper entitled “Angels in the Nursery.” In the same manner as Fraiberg’s inherited “ghosts” of early childhood trauma, Lieberman posited that the positive experiences of a caregiver’s infancy can protect their child from some of the inherited trauma.3

Finally, CPP draws from the attachment theory concept of the secure base developed by British psychologist, psychiatrist, and psychoanalyst John Bowlby in the 1950s.1 This theory states that for an infant to develop secure attachment, a caregiver must act as a safety net from which the infant can explore their environment.4 The strategies used in attachment theory can help develop the sense of safety and security that CPP hopes to cultivate.

How Child-Parent Psychotherapy Works

In CPP, therapists focus on helping children achieve healthy development in every domain. Practitioners view a young child’s mental health within the context of their relationship with their primary caregiver. Therapists work to build and support the relationship between the parent and child and enable improvements in communication, empathy, and reciprocity.1 CPP therapists also encourage the child’s development of positive ways to resolve conflict, achieve cognitive growth, and accurately test reality.

The first phase of CPP is the foundational phase, which has the goals of assessment and engagement. This may last four to six sessions and includes sessions with just the caregiver and therapist, who co-create a treatment plan based on the child’s needs and the family’s cultural values. During this phase, the therapist begins to gather information, including the presenting problem; previous treatment; demographic, risk, and protective factors in the family; and child-rearing cultural values and practices.

Additionally, the therapist consults the caregiver about traumatic and stressful experiences in the child’s life and the lives of the caregivers. This phase of CPP also includes the therapist’s observing the child when interacting with both their caregiver and the therapist and assessing the child’s developmental functioning.1

The foundational phase is completed after the feedback session, a session with the parent to finalize the co-created treatment plan. This is also when the therapist develops the formulation triangle, which connects the child’s symptoms to their origins and addresses the causal connections through treatment. If the caregiver’s trauma surfaces as a key cause for the child’s symptoms, the therapist may also develop a parental formulation triangle that links the caregiver’s trauma to their current functioning, perception of their child, and parenting strategies.5

From there, CPP is delivered through joint sessions with the child, parent, and therapist. The therapist will use different age-appropriate interventions and strategies to create a partnership between the child and the parent. For example, a baby will not comprehend a verbal explanation of treatment, so in this situation, the parent is trained to learn to read and respond to the child’s signals. A toddler or preschooler, however, may respond better to a simple explanation and be able to respond with feeling words to describe their emotions, so the child can participate more actively in treatment. The therapist might also provide developmental guidance, model appropriate behavior, give emotional support and crisis intervention, and provide other types of help.1

Intervention Modalities

Because CPP draws from several disciplines of psychotherapy, it uses many different treatment methods to promote healthy development and support the caregiver-child relationship.1,5 Common strategies include translating behavioral meanings, modeling appropriate protective behavior, retrieving and creating benevolent memories, and providing emotional support.

Translating Behavioral Meanings.

Children see their caregivers as all-powerful and see themselves as the cause of the caregiver’s moods and behaviors. Because of this, when a traumatic event occurs, the child may believe that the caregiver made it happen or failed to stop it from happening. They also may believe that they are responsible for the traumatic event because of their behaviors or thoughts. CPP uses words, play, and physical contact to correct these false beliefs in the child.1

Modeling Appropriate Protective Behavior.

Especially when they have experienced violence or trauma, caregivers and children often have inaccurate ideas of safety and danger. When a parent has perpetrated trauma unto the child, the child has a distorted perception of what constitutes a dangerous situation and how to protect themselves from it. In this situation, the therapist takes an active role in the treatment by protecting the child from danger by acting as the parent ought to and then discussing the action afterward.1

Retrieving and Creating Benevolent Memories.

This method strives to look for goodness in both the child and the caregiver. CPP encourages them to recall moments in which they felt loved and supported by one another and by others. For the caregiver, remembering these moments, especially their youth, motivates them to provide moments like these for their child. The therapeutic environment can also create such moments and memories between caregiver and child, which they can draw from in the future.1

Providing Emotional Support.

The therapist can provide emotional support to both the caregiver and the child in various ways. They can use their words and actions to show respect and positive regard to their clients. They create a safe environment for self-expression and show pride and satisfaction in the clients’ accomplishments throughout treatment. This is a particularly integral part of treatment for clients who face discrimination or poverty because it can help affirm their natural human right to dignity and respect.1

Common Applications of Child-Parent Psychotherapy

Child-parent psychotherapy is typically used for children between the ages of zero and five who have experienced one or more traumatic events. Some types of adverse childhood experiences that might be addressed through CPP include:5

  • exposure to violence, particularly domestic violence, with the primary caregiver as the victim
  • sexual abuse
  • death of a close family member or loved one
  • abuse or neglect
  • environmental adversities
  • mental illness in the caregiver
  • harmful parenting practices

Child-parent psychotherapy might be used to treat the following conditions:5

The Potential Benefits of Child-Parent Psychotherapy

The potential benefits of child-parent psychotherapy include improvements to both the child and parent individually and their relationship. Children and parents who undergo CPP might experience the following benefits from therapy:5

  • reduction of PTSD symptoms
  • improvements in the symptoms of comorbid anxiety or depression
  • reduction in the child’s behavioral problems
  • improvement in emotion regulation
  • increase in the child’s cognitive functioning
  • more secure attachment between the child and parent
  • improved self-perceptions
  • increased empathy of the caregiver for the child
  • improvement in the caregiver’s positive interactions with the child

Effectiveness of Child-Parent Psychotherapy

Many studies have been conducted on the efficacy of CPP as an intervention for children and parents who have experienced trauma. In a 2019 study conducted by Lieberman and her colleagues from the University of California department of psychiatry, Rosemary Bernstein and Adela Timmons, 113 mothers with children aged two to six who had been exposed to interpersonal violence and at least one other trauma were split into two groups, the larger of which received CPP. The researchers found via the IFEEL Picture System that mothers who received CPP with their infants overcame their bias toward fear and anger when interpreting their infant’s facial expressions and therefore were better able to provide more responsive, nurturing parenting.6

A 2021 study examined the use of CPP as an intervention for mothers with depression and their children. Researchers from the University of Rochester in New York recruited 130 mothers with depression and treated them with CPP over weekly sessions for an average of 58 weeks. The researchers used the Diagnostic Interview Schedule, the Beck Depression Inventory, and the Strange Situation to measure symptoms and progress. They found that attachment security levels increased for toddlers whose mothers suffered from depression when they had received CPP as an intervention.7

In a 2021 study from the University of Nebraska, researchers examined the outcomes of 448 parents involved in child dependency and neglect court cases. The researchers looked at the court records of the cases and compared the outcomes of parents and children who received CPP to those who did not. The parents and children who received CPP showed a higher reunification and successful case closure rate than those who did not.8

A 2005 randomized controlled study involving 75 mothers and their preschoolers found that mothers and preschool-aged children with PTSD following exposure to domestic violence had better outcomes with CPP than those who did not receive this type of intervention. The researchers, Lieberman and colleagues, found that the children showed reductions in behavioral problems and PTSD symptoms, and the mothers also showed reduced feelings of distress and PTSD symptoms, as measured by surveys such as the Child Behavior Checklist and the Clinician Administered PTSD Scale.9 Numerous other studies have also found that CPP can result in positive outcomes in children’s development and improvements in attachment and relationships between parents and children.

Summary/Key Takeaways

Child-parent psychotherapy is an effective intervention for young children and parents who have experienced trauma. This type of therapy might help children to develop healthily after trauma and increase the security of their attachment to their primary caregivers. Research continues to demonstrate the efficacy of CPP for young children whose relationships with their primary caregivers are impaired because of exposure to trauma.

References

  1. Lieberman, A. F., Ippen, C. G., & Dimmler, M. H. (2019). Child-parent psychotherapy. In Carrión, V. G. (Ed.), Assessing and treating youth exposed to traumatic stress (pp. 223–238). American Psychiatric Association Publishing.
  2. Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry, 14(3), 387–421.
    https://doi.org/10.1016/s0002-7138(09)61442-4
  3. Harris, W. W., Lieberman, A. F., Padrón, E., & Van Horn, P. (2005). Angels in the nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 26(6), 504–520.
    https://doi.org/10.1002/imhj.20071
  4. Bretherton, I. (2013). Revisiting Mary Ainsworth’s conceptualization and assessments of maternal sensitivity-insensitivity. Attachment & Human Development, 15(5), 460-484.
    https://doi.org/10.1080/14616734.2013.835128
  5. Dimmler, M. H., Ippen, C. M. G., & Lieberman, A. F. (2018). Child-parent psychotherapy: A trauma-informed treatment for young children and their caregivers. In Zeanah, C. H. Jr. (Ed.), Handbook of infant mental health (4th ed.; 485-499). The Guilford Press.
  6. Bernstein, R. E., Timmons, A. C., & Lieberman, A. F. (2019). Interpersonal violence, maternal perception of infant emotion, and child-parent psychotherapy. Journal of Family Violence, 34(4), 309–320.
    https://doi.org/10.1007/s10896-019-00041-7
  7. Guild, D. J., Alto, M. E., Handley, E. D., Rogosch, F., Cicchetti, D., & Toth, S. L. (2021). Attachment and affect between mothers with depression and their children: Longitudinal outcomes of child parent psychotherapy. Research on Child and Adolescent Psychopathology, 49(5), 563–577.
    https://doi.org/10.1007/s10802-020-00681-0
  8. Hazen, K. P., Carlson, M. W., Cartwright, M. L., Patnode, C., Cole‐Mossman, J., Byrns, S., Hauptman, K., & Osofsky, J. (2021). The impact of child‐parent psychotherapy on child dependency court outcomes. Juvenile and Family Court Journal, 72(1), 21–46.
    https://doi.org/10.1111/jfcj.12191
  9. Lieberman, A. F., Van Horn, P., & Ippen, C. G. (2005). Toward evidence-based treatment: Child-parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child and Adolescent Psychiatry, 44(12), 1241–1248.
    https://doi.org/10.1097/01.chi.0000181047.59702.58

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