1 INTRODUCTION

Most pregnant women have a desire to give their babies the best possible environment and care, yet many parents with adverse childhood experiences (ACEs) struggle to do so. The phenomenon is known as the intergenerational transmission of ACEs. It includes harm that directly and indirectly may affect children through abuse and neglect, domestic violence, substance abuse, mental illness, and incarceration. The paradox of repeating negative generational patterns has been explored for decades (Bowlby, 1973; Fraiberg et al., 1975; Main & Goldwyn, 1984; Sroufe et al., 2005). A wealth of research has demonstrated the enduring negative consequences of ACEs on adulthood and parenthood (Belsky et al., 2009; Felitti et al., 1998; Sroufe et al., 2005; Thornberry et al., 2003). In particular, having multiple ACEs increases the risk of illness, substance use, and violence, representing significant risks for the intergenerational transmission of adversities (Hughes et al., 2017). It has proven difficult to break the intergenerational cycle of traumas, maltreatment, and neglect, even for the most internationally recognized treatment programs (Eckenrode et al., 2010; Howard & Brooks-Gunn, 2009; Kitzman et al., 2010).

The perinatal period marks the transition from one generation to the next, holding the risk of repeating old relational patterns but also the potential for change. Hence, it is a promising phase for addressing intergenerational adversities and focusing on promotive factors in treatment (Lieberman et al., 2020; Narayan et al., 2018; Slade et al., 2019). Perinatal psychotherapy is a term used to cover a field of treatment developed for pregnancy and early childhood, lending its framework from attachment-based interventions, trauma-informed methods, parent-infant psychotherapy, social work, and individual psychotherapy with adults (Lieberman et al., 2011). The patient is perceived as the entire caring system, including the baby, the pregnant woman, the partner, the couple, and at times the family at large. There are multiple ports of entry for interventions in perinatal psychotherapy, consisting of practical and medical assistance, crisis interventions, partner and social support, and parent-child interactions. Commonly, there is also a focus on psychoeducation about life adversities and stress, identifying intergenerational transmissions of dysfunctional and benevolent patterns, internal working models, and the baby's developmental needs (Lieberman et al., 2020; Sadler et al., 2013).

The many ports of entry allow flexible and tailormade therapy but also challenge the therapists’ ability to navigate the complexity, calling for a high level of therapist reflective capacity. Reflective capacity is related to mentalization and refers to the capacity to identify, understand, and conceptualize mental states in oneself and others (Fonagy et al., 2002). Therapist reflective capacity can broadly be defined as the reflective work taking place in therapy, as discussed in the present study, or more specifically be assessed as the level of reflective functioning (RF) by the RF scale (Fonagy et al., 1998). Assessment of therapist reflective functioning has been done by applying the RF scale on the therapist's relationship with their own caregivers through the Adult Attachment Interview (Cologon et al., 2017), and in relation to specific patients through applying the RF scale on The Therapist Interview at Midphase (Reading et al., 2019). Research on the impact of therapist reflective functioning on therapy processes and outcomes is scarce (Cologon et al., 2017; Reading et al., 2019), but high therapist RF in relation to specific patients has been found to be positively associated with greater depth of exploration in therapeutic sessions, addressing and repairing alliance ruptures, and a better outcome at 6-month follow-up (Reading et al., 2019).

Although a few treatment interventions for families with ACEs have been developed and tested empirically, more research is needed to inform the continued development of interventions (Alink et al., 2019; Lavi et al., 2015; Leeners et al., 2006; Slade et al., 2020). To the best of our knowledge, few studies have explored the therapists’ experiences of perinatal psychotherapy, and even fewer studies have focused on the experiences of parents coming from generations of trauma, violence, and neglect. Notable exceptions are Salomonsson's qualitative study of therapists’ experiences of mother-infant psychoanalytic treatment (Winberg Salomonsson & Barimani, 2018) and Ward's paper “Mothers’ thinking and babies’ survival” portraying a series of extreme cases also involving child death (Ward, 2005). The aim of the current study was to explore therapists’ experiences and reflections in relation to their perinatal psychotherapeutic work when addressing the intergenerational transmission of adversities as part of a continuous effort to develop effective interventions for this group of patients.

2 METHOD

2.1 Study design

To explore the specificities of therapeutic work with intergenerational adversities in pregnancy and early childhood, such as violence, abuse, traumas, and neglect we have conducted a qualitative study using individual interviews and a follow-up focus group with therapists in the perinatal field. The present qualitative study is part of a more extensive Norwegian mixed-methods study on families with ACEs, addressing the overarching research question: “To repeat or not to repeat—how to interrupt the intergenerational transmission of adversity in pregnancy and early childhood?”

2.2 Study setting, recruitment, and participants

The study took place at a Child and Adolescent Mental Health Service (CAMHS) in the South-East region of Norway, attending to families from pregnancy to adulthood. The therapists participating as informants in the study were part of a perinatal team assessing and treating families from pregnancy through the first 5 years of life. The team has developed a perinatal psychotherapy treatment consisting of arena-flexible weekly interventions altering practical assistance, psychoeducation, couples’ treatment, individual, dyadic, and triadic psychotherapy. The families are referred by General Practitioners, local health centers and hospitals, as well as child protection services. It is a public clinic, attending to a diverse socio-economic group of patients, comprising both native Norwegians, migrant workers, and refugees free of charge. For the present study the therapeutic work with pregnant women with high ACEs conceptualized as 4 or more ACEs measured by the ACEs scale (Felitti et al., 1998), was the focus of interest when interviewing the therapist.

All the therapists in the team were invited to participate in the study, and there were no exclusion criteria. All seven clinicians were able and willing to participate in the individual interviews and the follow-up focus group. Collected demographics include age (31–42), years of working in the perinatal field (1.5–11 years, M = 4.6 years), and formal education (one educational psychologist, one medical doctor, and five psychologists).

2.3 Data collection and material

The participating therapists were interviewed individually, and in a follow-up focus group to facilitate in-depth reflections and discussions. Semi-structured individual interviews were chosen to facilitate explorative dialogues about each participant's experiences. A topic guide structured around the following five themes was developed for this study, 1) Experiences with perinatal psychotherapy with families with multiple adverse childhood experiences, 2) the perinatal treatment program, 3) therapist factors, 4) alliance work, and 5) suggestions for further development of the perinatal treatment for families with high ACEs. Follow-up questions were used to explore the themes further.

The individual interviews were conducted face-to-face by the first and second author from 14.05.2020–12.06.2020, at a time chosen by the participant. Most interviews lasted about 90 min (range 69–106 min). The interviews were digitally recorded and transcribed verbatim by the first author. After completing the initial analysis of the individual interviews, 10 themes were identified, and five of them were chosen for further exploration in the focus group. Three of the themes were chosen by the research team and two by the therapists in the focus group. The selection of themes secured a mix of top-down and bottom-up perspectives. The topics derived from the individual interviews that were left out of the focus group constituted part of the data set as a whole and were included in the further analysis of the material (See Figure 1).

The focus group was held at the clinic in October 2020 and lasted 2 h. It was conducted, recorded, and transcribed verbatim by the first author. All therapists participated, but two participated online due to corona-restrictions.

2.4 Data analysis

Transcripts of the audiotaped interviews and focus group constituted the data for this study, and were analyzed by applying reflexive thematic analysis (Braun & Clarke, 2019). The analysis was conducted according to Braun & Clark's six steps; 1) familiarization, 2) coding, 3) generating initial themes, 4) reviewing and developing themes, 5) refining, defining and, naming themes, and 6) writing up (Braun & Clarke, 2021). Each transcript was read through several times by the first and fifth authors, so they could become familiar with the content and take initial notes, before coding completely (See Supplement 1). Data extracts were organized underneath each subtheme and shared with the rest of the research team. The internal homogeneity and external heterogeneity criteria were applied to avoid an overlap of themes, and quotes were chosen to illustrate each subtheme.

A discussion in the research team regarding a description of the whole dataset versus a more detailed account of selected themes concluded with choosing the latter, due to the need for in-depth knowledge about perinatal psychotherapy with this specific patient group. The choice of themes was based on clinical relevance, with support in the dataset, and the potential of enriching the research field. The first author wrote the first draft of the manuscript for extensive feedback, and a continuous process of feedback loops with the research team resulted in the first author reviewing and refining themes and writing several drafts while reflexively working on the data material until the final draft was finalized.

2.5 Reflexivity

Reflexive thematic analysis is perceived as a subjective process requiring considerable analytical and interpretative work by the researchers (Braun & Clarke, 2021). Transparency of one's own situated knowledge is therefore critical. The first author is a white female Norwegian specialist in infant mental health with extensive clinical experience in the field of study and prior knowledge of the therapists involved. The rest of the research team comprises clinicians and researchers both within and outside the field of perinatal psychotherapy, including adjacent fields like adult psychology, infant mental health, and sociology.

3 RESULTS

The findings included in this article describe therapists’ experiences and reflections when addressing intergenerational adversities in perinatal psychotherapy. One overarching theme and two main themes with associated subthemes were derived from the data. The overarching theme was to maintain a reflective therapeutic capacity, which was perceived as the primary therapeutic tool for navigating the complexities of perinatal psychotherapy and tailoring treatment in all phases of therapy. The two main themes were (1) Alliance work when a caring system comes to therapy to fight generations of adversities and (2) The complex work of addressing generational adversities in perinatal psychotherapy. See Figure 2 for a complete overview of themes and subthemes. Quotes are used to illustrate the themes, with participant numbers used in place of names to maintain anonymity and FG when referring to the focus group.

3.1 To maintain a reflective therapeutic capacity

This theme highlights the reflective work of the therapists from the moment they read a new referral to the end of therapy, and the importance of maintaining it through all phases. The theme addresses different forms of reflective work undertaken by the therapists, concrete examples of in-therapy-reflections, and the idea that the therapists’ reflective capacity is influenceable and dependent upon a reflective and holding environment.

Different examples of forms of therapeutic reflective capacity

The therapists shared examples of the reflective work permeating all phases of perinatal psychotherapy. The most frequently shared was the preparatory work prior to meeting the families. Without exception, they emphasized the importance of staying open-minded despite the lengthy list of risk factors and failed attempts of previous therapy often described in the referrals. The shift from seeing the pregnant woman as an adult patient, with an extensive clinical record, to a woman in a new phase of life, bringing new possibilities of change, was highlighted by all the therapists.

“It is easy to feel burdened or have negative expectations when so many things have been tried before, but at the same time I can be quite optimistic initially and think that this is unplowed field. That it is exciting and rewarding to meet a new person that is pregnant for the first time. As a mum she is completely unplowed field” (4).

The second most shared example was the reflective work involved in handling worries concerning good enough parenting and the development and safety of the child(ren).

“To alternate between hope and optimism, and the frustration of not really reaching the family. How worried shall I be when they don`t let me in, how worried should I be when not coming into a position of helping, or how much time should I spend worrying before acting on the worries? It is a dilemma knowing what is good enough and not” (4).

Therapist reflective work came in different forms. The most frequently mentioned was the therapists` inner reflections during therapy sessions. These were in-the-moment reflections exploring and monitoring their own reactions and emotions, as well as the inner life of the patient(s) and the relation between them. Secondly the reflections took form of open dialogues with the caregivers, exploring the patient(s) experience of the alliance and the therapy process while modeling a reflective stance.

“I often find it helpful to pause and try to put into words what is happening: “I noticed that when this comes up, it looks like you pull away a little or maybe find it difficult to talk about?” He was notably irritated and frustrated when I tried to push a little, so I accepted full responsibility and said: “That is how we do it here, we explore things that can be hard and then I appreciate you telling me how it feels, so I can understand what you mean” (7).

Therapist reflective capacity: An influenceable state of mind

The reflective capacity of the therapist was perceived as an influenceable state of mind, vulnerable to stress, heavy workloads, strong reactions, and emotions. The therapists in the study were impacted by the lives and struggles of the families they met.

“You don`t feel like a good therapist for many of them. You get confused, feel insufficient, worried, asking yourself how controlling and forward-leaning should I be, versus reclined and think that you are the expert of your own life?” (5).

In the same way as with the caregivers, to cultivate a safe enough environment for the caregivers to reflect, the therapists needed a holding environment to maintain reflective. They pointed to the treatment team as their holding environment and focused on its role in helping them navigate stress, strong emotions, and reactions. The treatment team was perceived as a safe place to discuss difficult cases, be challenged when struggling to keep multiple perspectives, and receive support. It provided much-needed assistance for therapists working hard to maintain a reflective stance during challenging therapies.

“There is room in the team for discussions and an open-door policy to air out frustration and get feedback and support. That is something we have built up over the years. It is important to feel safe with colleagues, knowing that they want the best for you. Then you can be balanced with the patients and the caregivers, separating what`s mine and what comes from them” (3).

The therapists in the study argued that the work of addressing generational adversities requires a reflective stance, often under challenging conditions. Lack of framing by national guidelines and procedures, and the often-incompatible needs and wants of entire caring systems, are examples of these challenges. The two main themes in this article will, in different ways, further elaborate the ongoing reflective work involved in addressing intergenerational adversities in pregnancy and early childhood.

3.2 Alliance work when a caring system comes to therapy to fight generations of adversities

This theme captures the therapists’ experiences with challenging alliances when the patient is a caring system rather than an individual. The theme highlights the challenges of forming of therapeutic alliances with the parents on behalf of the child and the delicate therapeutic work required to repair relational ruptures, knowing that the consequences of interrupted therapy might directly harm the (unborn) child. It especially draws attention to the alliance work with families marked by relational traumas who reluctantly find themselves in therapy initiated by someone else and the importance of creating a safe enough alliance.

3.2.1 And the patient is…?

When the therapists talked about the patient in perinatal psychotherapy, they referred to the entire caring system, including the baby, the pregnant woman, the partner, the couple, and the family at large.

“It is the parent I need to form an alliance with, to help the child, but it is in a way neither the pregnant woman per se nor the child, who is the patient, more precisely it is the caring system” (2).

The parents were perceived as the port of entry to the child. Since the parents are not traditional individual patients but patients on behalf of their (un)born children, the therapist's role can take many forms. The therapists perceived their roles differently, seemingly colored by the therapists’ experience prior to entering the perinatal field. The therapists with extensive experience and formal training in individual therapy seemed more comfortable with parental therapy resembling individual therapy than the therapists with less training and experience, who leaned toward providing parenting guidance.

“I think we must dare to be a therapist for the parents, to create positive processes of change, and especially with those with generational issues. They need to feel met, in a way that initiates processes in them. Then many of them can try something new with their own child or tolerate the child in a different way” (1).

“It is about supporting the adult and show that you see the whole person and are concerned with how the mother or father is doing, understanding their hardship. … you shouldn`t be the therapist for the mother or the father” (3).

3.2.2 The almost impossible therapeutic task of keeping “everyone`s” mind in mind

According to the therapists, receiving an entire caring system in therapy poses new challenges to the therapeutic work. Balancing everyone's needs, especially conflicting parental and child needs, and the close-to-impossible task of keeping everyone's mind in mind became an extensively discussed theme.

“It is so easy to say that you need to think about both (parent and child), and incredibly difficult when being alone in the room” (FG).

“The dilemma arises when you follow the parent too far and don`t hear the alarm bells ringing for the child. Because, when you are in the process with the adult, you can get so absorbed with the small steps of development of the adult that we might forget to make sure the baby is doing ok. Then again, at times you take the child`s perspective, and struggle to understand what the adult faces, so there is something about having knowledge from both fields that come together in newborn and infants and find the good balance” (FG).

So how did the therapists handle conflicting and often incompatible needs? All the therapists took structural measures to safeguard the interests of both parties, like dividing therapy sessions between the adult and the child or invite a co-therapist to focus on the child. In-between the sessions, they actively used the treatment team to discuss the balancing of the parents’ need to have enough time to be able to trust and develop while actively monitoring the baby's needs. There was a sense of urgency and patience competing within the therapists.

“Does the child have time to wait for the parent to develop? Does the development happen fast enough, or are the basic needs met sufficiently for the child to have the developmental support needed, or doesn`t the child have time to wait, or what can we do to compensate while waiting on the mother`s or father`s development?” (FG).

“A keyword is to hurry up slowly. No matter how worried you are and how many interventions you offer, it takes the time required. There is no use in stressing, it doesn`t get any better for the child. I think we must tolerate a certain amount of uncertainty and discomfort and accept that we don`t fully know how this will end and make the best out of it based on the knowledge we have, trying to cooperate with those around the family” (5).

3.2.3 Forming a therapeutic alliance at an arm's length distance

Further adding to the complexity was forming an alliance with parents struggling with the aftermaths of painful relational experiences and developmental traumas. Especially challenging was the alliance work with families sent to therapy by someone else, either facing the threat of losing custody of their child(ren) or being left with a choice between the clinic and more invasive treatment.

“Many of them are survivors, often tough ones who have managed despite everything. They want to manage by themselves. I respect that, but it makes it difficult to reach them, or know what to contribute with. You are kept at an arm's length distance. They ask for help but alternate between fear of loneliness or abandonment and a tough appearance, a survivor. What side do you speak to? What do you mirror?” (5).

“It was a challenging alliance because the mother was sent here by child protection. I am used to getting some sort of alliance with those I work with, but with her and the partner, it felt as if there was no development in the alliance. There was a lot of rejection and fear in her. She believed that she didn`t need help, that she was fine and rejected all forms of goals or ways we could support her, and also a very deep-rooted skepticism to helpers, or that anyone could want something good for them” (5).

One of the therapists elaborated further on the challenges encountered when the idea of generational transmission of risk was not something the therapist and the patient shared, and how this could affect an already strained alliance.

“There are those who are sent here with very little worries themselves. Those are challenging processes because it is very difficult to form an alliance about why you are here. What shall we do, really? Some can say that they have their own problems, but that it has nothing to do with the child. Then I as a therapist become the carrier of the worry the parents are unable to carry, and the one to give it back to them in a form that they can receive. That is hard, but I believe in being empathic with them, asking myself why can`t they own their worry? What definitely doesn`t help is to confront them saying: “Pull yourself together!” (2).

On the other hand, some patients linked generational adversities to their own difficulties in the presence and explicitly wanted to break the cycle of the past.

“The more I got to know her, the more it became evident that her insecurity was related to her upbringing and an angry dad. She did not want to pass it on to the next generation, and was very clear about her goal: “I want to feel safe so I can pass on security to my child” (4).

So how did they work to form and develop alliances when meeting so many obstacles? The therapists were especially interested in challenging the idea of alliance being something you establish once and for all, mainly within the first few sessions.

“I am thinking about alliance research claiming that if there is no change or development in the alliance after 5 or 6 therapy sessions, you might as well end therapy… then we should have ended quite a few! When it comes to the idea that trust has to be there in order to progress, many of those we work with having developmental traumas and difficult childhood experiences, don`t have that basic trust in place. So, I think it is wrong to say that if trust is not there, we can do nothing, but there might be degrees of trust? Many never get that basic trust, but there is something there, a building of block by block” (FG).

They argued that creating a safe enough room for therapy was challenging, requiring small steps of building trust while being empathic with the client's difficulties and respecting their need for psychological defenses. Alliance work was seen as a delicate therapeutic process of “supporting a lot, exploring a little, and challenging a tiny bit.”

“To create a safe enough room was very challenging. She was a first time mum with an avoidant personality disorder and previous suicide attempts. She was very closed and probably scared someone would say she wasn´t good enough. She had so much self-loathing, and difficult feelings and thoughts concerning the baby in the womb. She could share some of it for brief moments, but when I tried to pursue it she became quiet and passive. It was hard to create the safe space where they could admit to it being challenging, or even say how it is. It made an impact on me, because I felt so powerless” (1).

“A lot of them have thought for a long time that they don`t want to have kids, because they are not cut out for parenting. Often there is a basic sense of self-loathing due to what they have suffered. One really must have respect for the coping strategies they have of rejecting, staying away, idealizing, choosing their own mother again. They need a lot of the defenses to get through the day. It is a balancing act and I think one balances by supporting a lot, exploring a little and challenge a tiny bit. It is an extremely difficult balancing act!” (5).

3.2.4 Rupture and repair—easier said than done!

A great concern for the therapists was the inevitable negotiations of ruptures and repair in the therapeutic alliance, and especially the discrepancy between what they referred to as the textbook version and their clinical experiences. According to the therapists the textbook version emphasized the therapeutic growth following successful negotiations of ruptures. Their clinical experiences though, spoke of potentially interrupted therapy processes and the subsequent negative consequences for the child, causing stress and anxiety in the therapists.

“I recognize that there is a great gap between what I think is optimal and would have liked to see and how it is. There is a lot of relational experience and security in experiencing a rupture and being able to repair. It gives a sense of competence for us as therapists, but also an important relational experience for the patient and an experience they can use when encountering ruptures and repair privately. But, in the clinic I feel that I tend to lose them more often than I repair with them” (4).

The therapists went to great lengths to minimize and prevent ruptures with the parents due to the possible strain it could have on the family and the uncertainty it could bring concerning the wellbeing and safety for the parents and the baby. The therapists had different ways of preparing the families for possible misunderstandings and ruptures.

“I thematize early in the treatment that it (rupture) probably will happen and try not to make a big thing out of it. More like, I probably will misunderstand you, unfortunately I am quite regular when it comes to that, but if I do not get it, I would appreciate you telling me. I often ask how it is for them to let me know, and if it is hard, how can I notice by looking at you? I try to be one step ahead. More like, it will happen, how do we deal with it when it does?”(2).

Despite the anxiety it caused, the therapists did not want to avoid ruptures altogether. Successful negotiation of ruptures was perceived as an important way of modeling relational repairs that could have spillover effects on the parent-child relationship. They aimed to model ways of taking responsibility and repair, to demonstrate alternatives to blaming, rejecting, fighting, or other forms of relational traumas experienced by many parents from families with high ACEs.

“Many of those with generational challenges, are affected by their relational experiences in varying degrees. Rupture and repair is one of the most important therapeutic tasks. It is in individual therapy, but also here, since we also have a therapeutic alliance with them… It is a very central focus in being parents, that you will experiences ruptures with the kids. It becomes a natural theme, when talking about parenthood” (5).

3.3 The complex therapeutic work of addressing intergenerational adversities in perinatal psychotherapy

This theme captures the therapists’ ideas of perinatal psychotherapy with families with high ACEs and the tailoring of treatment needed to reach the next generation. It includes their framing of the work through a self-made case formulation, their reflections on unblocking and building parental capacity, and the difficulty of knowing if it causes the change desired for both generations.

3.3.1 Case formulation for the caring system: A way of framing the work

According to the therapists, framing perinatal psychotherapy is challenging due to a lack of national procedures and guidelines, multiple ports of entry to therapy, and an ideal of therapeutic flexibility. The more inexperienced therapists leaned towards wanting more framing, while the more experienced cherished the flexibility and room for individual clinical judgment. The team had developed a case formulation for the caring system, inspired by Winters and colleagues (Winters et al., 2007), as a way of framing one's own praxis, in addition to the DC:0-5 system.

“The case formulation is useful as a framework for organizing the information gathered, but also to create a common understanding with the pregnant woman, about what the challenges really are, what difficulties we can reduce, and what we can add or strengthen that can be protective and good? What is realistic to address and not, or what can we work on here and what can be addressed by other services like child protection, family protection and labor and welfare?” (4).

3.3.2 Laying the foundation for intergenerational change: Reducing risk factors and increasing protective factors

The need for framing the perinatal work speaks to the complexity of addressing a wide range of possible risk and protective factors. The therapists all referred to a continuous negotiation of the therapist's role.

“I shall not be child protection services, but I need to understand that it has to be addressed. I cannot be labor and welfare services, but I need to make sure the person contacts them. I must work more in depth with the psychological themes, the traumatic relational experiences surfacing or abuse or mental health issues making it difficult to connect with the child. Themes like prenatal attachment or preoccupation with the child, representations of the child. I can often wonder if I am a little too analytical and reclined, that the family maybe would benefit from me being more hands-on, doing more concrete work. It is a system problem that families with very complex problems receive assistance that is too fragmented” (2).

3.3.3 Unblocking and building parental capacity

According to the therapists, the purpose of reducing risk factors and increasing protective factors is to free up parental capacity to be able to engage with the child and understand and meet its needs. The therapists talked about parental capacity as something influenceable, a capacity that can be blocked by stress, hardship, and traumas and built by adding new knowledge, skills, and experience.

“The thought is that I want to liberate as much parental capacity as possible. So, what is it that limits people's parental capacity? I want to lead them to a place where they experience the primary preoccupation, that Winnicott¹ wrote about, or have Stern`s themes of motherhood constellations². That you are preoccupied with yourself as a parent and the child, that is where you are supposed to be at birth. If you are preoccupied with other things, then we must try to solve that, so you can again focus on yourself as a parent and the child” (2).

Parental capacity was mainly perceived as emotional and reflective capacity. Emotional capacity was exemplified by prenatal attachment, expressed warmth and love towards the child, sensitivity, availability, responsivity, and ability to tolerate and regulate one's own and the child's emotions. Increased reflective capacity was perceived as increased engagement in and a sense of discovery and curiosity toward the child, less blaming of the child, and idealization of one's own role as well as increased mentalization of self and the child as separate beings.

3.3.4 The challenge of reaching both generations

Whether therapy really works wonders for the next generation or just the present was vividly discussed among the therapists. The possibility of investing increased parental capacity in other areas of life than the parent role and the child was acknowledged, as part of the complexity of reaching the child through therapeutic work with the parents. The therapists expressed deep respect for the work required of parents to fight generations of adversities and become the opposite of their own parents. It was perceived as a bumpy road of ups and downs requiring a long-term commitment.

“To create change is just extremely difficult! It is not just habits to be changed, patterns you are used to, but it is also incredibly difficult when you haven't experienced the change yourself, or even know what the change you talk about looks like!” (1).

“It is especially important to think long-term with families with intergenerational problems because it will not be solved by short-term therapy, there are so many maintaining factors around the family. So even if you do a really good inner work, it is not necessarily sufficient to create the change for the child” (FG).

The therapists openly discussed indicators of intergenerational change. They warned against doing the simple math of adding positives and negatives when evaluating change. Real change was defined as the change in how the parents perceived, felt, and interacted with the child.

“I look for mentalization and parental reflective functioning because it will be of great importance when it comes to how they can engage with the child, how they manage to adapt to the child`s developmental phases” (5).

“I am probably most concerned with warmth, that which lies intuitively in us when we receive someone. It might be when holding a crying newborn, feeling desperate and frustrated, but at the same time able to tolerate that feeling, and of course what you think and reflect and do in that situation. It is all tied together” (7).

“It is about how they talk about or reflect around the child. That they don`t blame the child but can see it in a greater context” (3).

“It has to do with not being so idealizing. That it is honest. Everyone has their strengths and difficulties, so if there are only difficulties or only strengths, then there is need for more work” (6).

They openly discussed the discrepancy between the need for more intensive outpatient treatment and family units, providing around-the-clock-services, and the increasing pressure on the therapeutic resources leading to less intensive treatment.

“It is really challenging, because it is a patient group needing a lot and with the resources we have today and the idea of cost-effectiveness, and all the referrals… our capacity is under pressure. We want to work home-based, and we want to be flexible, but if we get too many, then there will be less for everyone. Some need more intensive ambulatory work, resembling the treatment offered those above 6 years, or a family unit where you could assess and treat the adult, the couple and the child at one time” (FG).

4 DISCUSSION

To our best knowledge, the present study is one of few qualitative studies exploring the therapeutic challenges involved in addressing intergenerational adversities in perinatal psychotherapy from the therapist's point of view. The therapists especially addressed three themes; one overarching theme: To maintain a reflective therapeutic capacity, and two main themes (1) Alliance work when a caring system comes to therapy to fight generations of adversities and (2) The complex therapeutic work of addressing intergenerational adversities in perinatal psychotherapy. The three themes will be further discussed below, with an explicit focus on central aspects of each theme.

4.1 To maintain a reflective therapeutic capacity: The importance of a holding environment

The therapists in the study argued that maintaining a reflective and empathic stance was especially challenging when addressing intergenerational adversities in pregnancy and early childhood. They highlighted the complexity of the work, the lack of national guidelines, the urgency of reaching the child in time, and the severe consequences of continuous generational adversities as some of the most challenging aspects involved. The therapists spoke of how they were impacted by the lives and struggles of the families they met and how they worked individually and as a team to stay empathic and reflective over time.

The impact of trauma, deprivation, distress, and loss on therapists is well documented (Dalley, 2009; Emanuel, 2002; Slade et al., 2016). The need for exploring and processing one's own feelings, reactions, and experiences when witnessing so much emotional pain and helplessness has been highlighted by several authors as key to maintaining a reflective and empathic stance in therapy (Dalley, 2009; Slade et al., 2016; Tomas-Merrills & Chakraborty, 2009). Holding and being held seem to be closely related when the therapists team up with the families to fight generations of adversities in therapy.

4.2 Alliance work when a caring system comes to therapy to fight generations of adversities: “I want to feel safe so I can pass on security to my child”

What is the essence of alliance work when addressing intergenerational adversities in pregnancy and early childhood? “To create a safe enough space” was the term most frequently used by the therapists in the study. Alliance work has been extensively explored in psychotherapy research over the past decades (Bordin, 1994; Flückiger et al., 2018; Horvath & Symonds, 1991; Sharpless et al., 2010; Wampold & Imel, 2015). The importance of forming an emotional bond with the patient, agreeing on common goals and ways of working in therapy (Bordin, 1979), and negotiating ruptures (Eubanks et al., 2018) has been repeatedly emphasized. So, what can this study add to the body of alliance work? The therapists especially point to the continuous and delicate work of building trust all the way through therapy. They talk about the fragility of the small steps of trust and how easily it can be disrupted, leading to ruptures that are often hard to repair. The therapists paint a picture of vigilant parents, ambivalent to being in therapy, alternating between hard-to-reach self-sufficient survivors, and scared victims of generational traumas. They address the core concept of feeling safe enough with another human being to explore new ways of reflecting and relating, leading to corrective emotional and relational experiences transferable to the parent-child relationship.

What is it about feeling safe that makes it so crucial? According to the therapists in the study, lack of physical and emotional safety has been the everyday experience of growing up for many of the parents suffering from intergenerational traumas. It makes sense to protect oneself when early relational experiences have taught you the danger of relying on and being vulnerable to caregivers. To rest in another person's presence, whether it is a baby finding rest in the arms of a parent, or a parent finding rest in the presence of a therapist, is not a common experience for many parents with relational traumas. It is hard to provide safety for a baby when feeling unsafe, and it is a bold leap to trust a therapist.

It takes more than one to construct corrective experiences, implying that a safe space is not enough. The parent(s)’ willingness to take risks and overcome avoidance, fear, and ambivalence in trying and receiving something new is crucial (Hill et al., 2012). For a new self-other model to be incorporated, there is a need for repetitions over time (Dalley, 2009) and an active therapeutic identification of the impact and meaning-making of the corrective experience to facilitate consolidation (Hill et al., 2012).

The challenge of forming and maintaining a firm therapeutic alliance is in line with clinical and research findings (Baradon & Joyce, 2016; Dalley, 2009; Foll & Guedeney, 2016; Jones, 2009; Lieberman et al., 2020; Slade et al., 2018; Tomas-Merrills & Chakraborty, 2009; Winberg Salomonsson & Barimani, 2018). Years of accumulated knowledge from the trauma field has provided an understanding of the meticulous work of creating a sense of safety in the therapeutic alliance before adventuring into the work of emotional regulation and reflective work required to challenge familiar dysfunctional patterns of being together (Courtois, 2004; Porges, 2011; Van der Kolk, 2014).

The dilemma in parent-child therapies occurs when the process of building trust and safety collides with the baby's needs. “Hurry up slowly” was the expression of one of the therapists in the study when she talked about the difficulties of giving the parents time enough to trust while monitoring the safety and needs of the child. The balancing of competing needs and the urgency for the child to be safe and experience good enough parenting to develop adequately is ever-present. Where the line is drawn between acceptable and unacceptable parenting will depend mainly on contextual factors framed by overarching laws. The questions regarding how long a baby can wait and how we can compensate while working with (the child within) the parents are pressing questions to the therapists, finding resonance in the broader research and clinical realm (Baradon & Broughton, 2016; Jones, 2009; Lieberman et al., 2018; Slade et al., 2018).

4.3 The complex therapeutic work of addressing intergenerational adversities in perinatal psychotherapy: Back to “kitchen-table-psychotherapy”?

The goal of perinatal psychotherapy with families marked by intergenerational adversities is to interrupt the line of repetition. The question is how? How to help the parents to become the parent they wished they had, but do not always know what that looks or feels like? The therapists in the study acknowledged multiple ports of entry to perinatal psychotherapy, aiming at reducing risk factors and increasing protective factors to set free parental capacity. They spoke of the importance of multi-disciplinary treatment teams tailoring therapy to address the needs of each family. The work they describe resembles Selma Fraiberg's merging of social work and psychotherapy from the 1970's, better known as “kitchen-table psychotherapy” (Fraiberg et al., 1975), and is in line with perinatal psychotherapy described by a range of researchers in the field (Baradon, 2016; Jones, 2009; Lieberman et al., 2020; Slade et al., 2018; Steele et al., 2019; Suess et al., 2018; Tomas-Merrills & Chakraborty, 2009).

The therapeutic work of breaking generations of violence, abuse, and neglect is challenging, requiring patience, framing, and flexibility regarding when, where, for how long, and in what way therapy is offered. There is a discrepancy between the idea of flexible, tailormade, long-term commitments and the increasing pressure experienced by the therapists, due to an increasing number of referrals, systemic ideas of cost-effectiveness and time-limited therapies. This is especially evident when discussing possible developmental paths for the perinatal therapeutic work with the families they struggle to reach and help today. The therapists point in the direction of more intensive treatment, altering between home-based interventions, family units offering around-the-clock services, and closer cooperation with adjacent services like child protection services, adult mental health, and labor, much in line with other well-known treatment programs attending to the same patient group (Lieberman et al., 2020; Slade et al., 2018). They acknowledged that some families require a lot of help, from a range of services over a long period of time, because relational patterns that have been repeated for generations, are not always easily replaced by something new.

Strengths and limitations

This study has its strength in contributing rich descriptions of therapeutic work with intergenerational adversities in pregnancy and early childhood from the therapists’ perspective. The study's qualitative exploratory nature allowed the therapists to reflect upon and describe their experiences in detail, first individually and later in a focus group. However, there are limitations to point out. The therapists were recruited from the same clinic, and although there was a diversity in professional training, prior knowledge of adjacent fields, and years of experience, there was little gender, ethnic or cultural diversity. The therapists are probably representative of perinatal therapists in a Norwegian context today, but it is likely that greater diversity might have added to the richness of the data and possibly altered the study findings.

Another aspect worth mentioning is the first author's prior experience in the field of study and knowledge of the therapists. This likely facilitated a sense of trust, possibly contributing to a greater depth of exploration of the complexity and challenges in the therapeutic work. On the other hand, it may have limited the scope of interest and brought about a tendency to “jump to conclusions” closing further potential exploration. To address the possible disadvantages, the second author, firmly placed in an outsider position, both regarding the therapists and the field of knowledge, participated in developing the interview guide and conducting interviews. The analysis of the data was further complemented by all authors.

The findings in this study are to be perceived as a contribution to the ongoing building of knowledge of therapeutic work with intergenerational adversities and should be complemented by the perspective of the families receiving therapy and the therapists working in other parts of the treatment chain.

Conclusions and clinical implications

The findings from this study suggest that intergenerational adversities affect the present generation, the next generation, and the therapists working alongside the families. To feel safe enough when addressing generational patterns is essential for caregivers, babies, and therapists for different reasons. The therapists need to feel safe enough to maintain an empathic and reflective stance and provide a holding environment in therapy, the caregivers need to feel safe enough to trust the therapist to experience new relational experiences and provide a holding environment for the babies, and the babies need to feel safe enough to develop and thrive. While not surprising, this has implications for our understanding of the importance of providing holding and reflecting environments for therapists working with generational adversities in perinatal psychotherapy.

The therapists also direct our attention to the unmet needs of caregivers requiring more than outpatient clinical treatment, now attended to by Child Protection Services. This paper suggests that due to intergenerational adversities affecting the lives of families on many levels, flexible use of a wide range of services, including intensive ambulatory work and family units, is required to fight generations of adversities.