Mothers, Infants and Young Children of September 11, 2001: A Primary Prevention Project (Book Reviews)

Author:  Edited by Beatrice Beebe, Phyllis Cohen, K. Mark Sossin, and Sara Markese 
Publisher:  London: Routledge, 2012 
Reviewed By: Barbara Gerson

One hundred or so pregnant women lost their husbands during the 9/11 attacks on the World Trade Center, their lives forever transformed. These precipitously widowed mothers-to-be were faced with foreboding circumstances—grieving their husbands, their familiar selves, and their futures while delivering babies and sustaining new lives in a time of national chaos. It is upon this group of women that Beatrice Beebe immediately focused, as if drawn by an internal magnet, to help them grieve, heal, and attach to their (and our) next generation.

Together with a core group of seven colleagues—Anni Bergman, Phyllis Cohen, Donna Demetri Friedman, Sally Moskowitz, Rita Reiswig, Mark Sossin, and Suzi Tortora—Beebe initiated and still continues the Project for Mothers, Infants, and Young Children of September 11, 2001 (the Project, as it is referred to). It is conceptualized as a primary prevention project to “facilitate the mother-infant and mother-child relationships, the development of the infants . . . the ongoing development of the toddlers who had lost their fathers, and the mother's own recovery processes” (p. 13). I will be focusing in this review on the primary prevention work with the bereaved mothers/infants/children.

This multimodal project offered support groups for the widows and their children, and annual or semiannual mother-child “video bonding” filming and communication consultations, all provided without charge. Forty mothers and eighty children participated. Twenty therapists were involved along the way, running support groups with mothers; countless other students, researchers, and psychoanalysts contributed. The Project also established a research component, although those results are not yet available.

Before Routledge issued this book in 2012, the Project was presented on the tenth anniversary of 9/11 in a special issue of the Journal of Infant, Child, and Adolescent Psychotherapy , with Beatrice Beebe, Phyllis Cohen, and Sara Markese as guest editors. When I first read the special issue, I experienced a sense of professional pride in the response of these analysts to the traumas of the 9/11 attacks. At the time I was teaching a course in child psychotherapy to new doctoral students in clinical child psychology. Reading about the Project in their first psychodynamic course was inspiring to them. It offered a model of the relevance of contemporary psychoanalytic thinking and a picture of psychoanalysts themselves as committed and active professionals.

The Project is psychoanalytic activism at its best, with professionals immediately recognizing the long-term consequences of a crisis, locating and recruiting those in need, devising and flexibly changing the services offered, and staying available for the long term. It stands as an exemplar of the application of psychoanalytic research to a social crisis, the “event trauma” of the terrorist attacks. Beebe's decades-long microanalytic frame-by-frame studies of mother-infant interaction were tailored to provide the bereaved mothers with video-based consultations to help with attachment to their babies in the midst of destabilizing and numbing grief.

In addition to admiring the Project, I have been considering where this Project stands in current work on primary prevention. Our typical clinical practices, in hospitals, clinics, schools, or private offices, are largely involved with secondary or tertiary prevention—that is, on aiding recovery or decreasing limitations from already existing difficulties (Caplan, 1974). But within both the psychoanalytic and the psychological communities, there is increasing interest now in prevention, which offers hope for improving the mental health of children and families.

Theories and research on prevention have expanded since the community mental health movement of the 1960s and 1970s, when the goal of primary prevention was to reach a nonreferred but at-risk population. Following a recommendation from the Institute of Medicine in 1994, this is often referred to as “selective prevention” (Fonagy, 1998; Weisz, Sandler, Durlak, & Anton, 2005). Some current prevention programs have broader goals: to reduce future problems for all members of a population, not only for those at risk. These “universal prevention” programs may focus on, for example, all first-time mothers, or all children entering school. There has also been a growing recognition of the centrality of increasing protective factors and building resilience, so that people will be able to withstand negative events with less dire results. These prevention programs have been considered to be a “secondary transformation” in primary prevention programs (Durlak & Wells, 1997). Most recently, they are conceptualized as prevention programs for “health promotion/positive development” (Weisz et al., 2005). Researchers in the prevention field hope that the more precise differentiations of prevention programs will lead to clarity in our understanding of the relative effectiveness of specific programs for specific groups.

By now, prevention programs for children and adolescents are well established as ways of both reducing problems and increasing competencies; a meta-analysis of primary prevention programs found that those for first-time mothers were among the most effective of all interventions (Durlak & Wells, 1997). Many prevention projects occur in schools, early childhood or Head Start centers, or in community settings. There are a number of psychoanalytically informed selective prevention programs that target those with known risk factors, such as mothers living in poverty (Slade, 2006), or mothers with histories of interpersonal violence (Schechter et al., 2006). There are also psychoanalytic systems-oriented selective prevention programs; for example, Osofsky (2003) devised a program to train police officers in New Orleans to respond to children exposed to violence, in order to lessen the long-term impact of this exposure.

The Project is a “selective prevention” program, in that it targeted the high-risk group of pregnant mothers with traumatic bereavement and infants/young children sensitive to the transmission of trauma, focusing particularly on the at-risk attachment relationship. Two excellent chapters by Adrianne Lange and Sara Markese present strong empirical support for the belief that the infants and young children of the bereaved widows were at risk for attachment problems (predictive of later behavioral and emotional difficulties). Markese's chapter is particularly noteworthy for the extensiveness of its literature review; it could by itself become the text for a course on trauma in infancy and early childhood.

Other chapters discuss the psychoanalytic underpinnings for the Project. Beebe and Markese cite the influences of Bowlby, Mahler, Winnicott, and Ainsworth. Sossin discusses the centrality of affects in the mothers' groups—affect sharing, reflecting on affects from multiple points of view, increasing affect tolerance. Tortora presents her system of movement analysis, which focuses “on all aspects of body movement” (p. 99), such as gestures, postures, and the shapes people make with their bodies in interactions. This analysis supplemented the microanalysis of gaze patterns and facial and vocal dialogue developed by Beebe and colleagues in understanding mother-infant interactions. Cohen talks about the positive effects of having multiple therapists collaborate with the mothers in the video feedback sessions; mothers could see models of many people working together with different points of view about the child, and there was always a clinician sensitive to the mother's point of view, thus preserving a positive alliance. Throughout, there is psychoanalytic sensitivity to individual differences in reaction to trauma, loss, and the behaviors of the infants/toddlers.

I want to highlight several other basic clinical factors that seem to have been curative. The Project provided a holding environment in which grief-stricken mothers could gradually recover. The mothers received unconditional positive regard from the clinicians, who adopted a strength-based perspective from which to understand the mothers and their children. The goal was always to return to a parenting perspective. Mothers were helped to become more sensitive to their children's minds by a focus on the communicative and health-promoting qualities of child-directed play.

While reading the book under review, Fraiberg, Adelson, and Shapiro's (1975) classic work on traumatized mothers and infants kept coming to mind, with her famous quote, “When the mother's own cries are heard, she will hear her child's cries” (p. 396). This current team of therapists honors that work while updating it. Kitchen consultations are transformed to support groups, with a homey feel and food provided. Video is added to the human eye to sharpen the lens in understanding interactions, but human sensitivity remains basic and crucial.

It is interesting to note that the mothers' support groups embody three of the five “empirically supported intervention principles” for disasters—promoting a sense of self-efficacy and community efficacy, promoting connectedness, and instilling hope (Watson, Brymer, & Bonanno, 2011). The groups are truly models of “tend and befriend,” which Kaitz in her commentary describes as a response that “refers to the management of stress by caring for others, seeking or giving social support, and forming groups” (p. 230). We hear, for example (in a chapter by Sossin), about how the group of mothers helped another widow slowly confront her ongoing inability to tell her 5-year-old that the buildings had fallen. A year after 9/11, the group helps her piece together her husband's claustrophobia, her own pain at picturing his death, and the ways her coping through activity and keeping secrets have compromised her ability to grieve and help her child grieve. It is one of innumerable vignettes illustrating how the groups supported the widows' courage, their emergence from disorganization and numbness, and their gradual constructions of whole narratives for themselves and their children. Powerful chapters by Moskowitz and Reiswig deepen the picture of the groups as ongoing holding environments, with a focus on strength, resilience, and parenting.

In the Project's work with the young children, we are made particularly aware of the overlap between prevention and intervention (Weisz et al., 2005). Sossin and Cohen discuss “Carl,” aged 3 when his father was killed on 9/11 and his mother was pregnant. Carl would sit glued to his father's chair at home for long periods of time, not allowing anyone else to sit there. Nine months later, during his first video play session, he symbolically reenacted with the therapist a play scene of a cow going off to work and not returning home. The theme of disappearance and loss was elaborated in the play in various ways. When Carl's request to take a play figure home from the lab was turned down, he began to sob uncontrollably, the first time he had cried since 9/11. Following this, his mother reported that he no longer needed to sit in his father's chair.

A video session that was intended as part of the prevention, to help a mother focus on her implicit procedural communication with her child, became an intervention for a child whose behavior conveyed that he had not yet grieved. Carl began to process his enormous loss through his symbolic play and no longer needed to rigidly enact it by occupying his father's chair. Similarly, in Demetri Friedman's section about the children's play in the support groups, we meet preschool-aged siblings whose age-typical building and rebuilding of towers that stay up, fall down, or are knocked down is accompanied with intensified affect and bits of narrative of 9/11. We see how they are helped to recall and process their traumas in play, so that they can return to their developmental trajectories. Previously, in work with 4- to 7-year-old Israeli children directly exposed to terrorism, even a single play session intended as assessment was found to be a meaningful intervention (Cohen, 2006). Young traumatized children's responsiveness to such short-term therapeutic play argues for its routine inclusion in trauma treatment.

In fact, a separate section of the book presents the therapy of two mothers and toddlers seen by Anni Bergman and her colleague Andrea Remez; both mothers had been traumatized by proximity to Ground Zero rather than bereavement. These treatment dyads became affiliated with the Project by participating in the mother-child video bonding and consultations only. The interested reader is urged to read these fascinating chapters directly for more detail on this early intervention work.

The implications of this long-term project are important for two groups. The first is other parents and young children who suffer from event trauma (such as natural or man-made disaster, traumatic bereavement, or community violence) in which the parent's psychic state is altered, compromising the attachment relationship. This is a “selective prevention” group different from the other high-risk mother/infant/young children groups for whom psychoanalytic prevention programs are more typically developed, such as the mothers in poverty mentioned earlier, for whom a reflective parenting program was established (Slade, 2006). The provision of a group holding environment led by clinicians with a strength-based focus, who always return to helping parents learn more about their child's state of mind and who promote child-directed play, could serve other parents well in yet unforeseen event traumas.

The second group is the population of new mothers as a whole—that is, an entire group in a community for whom a “universal prevention program” could be directed. The video bonding and consultation format is particularly suited to develop greater reflective functioning and thus more secure parent-child attachment. One such experimental program with reflective video-based feedback has been initiated in the UK for low-income mothers (Svanberg, Mennet, & Spieker, 2010). In that program, mothers were divided into groups of high, medium, or low risk, based on ratings of 3- to 4-minute videos of mother-infant free play. They were then provided with video-based consultations for various lengths of time, depending on their levels of risk. Improvements in maternal sensitivity were found, as well as higher rates of secure infant attachment. Such a program could be delivered similarly, in conjunction with pediatric well-baby visits. The split-screen technology, moved from the lab to the community, and the follow-up consultations by clinicians would offer increased numbers of mothers help with their relationships with their infants. Improving attachment by such a prevention project would go a long way to improving the mental health of our youth.

In order for the impressive clinical results of the Project to reach a larger audience, we will need to turn to the empirical data collected. The stated research goal was to study “the effect of the trauma on maternal levels of anxiety and depression, and on mother-child communication . . . and . . . the course of recovery of these families, identifying the strengths and protective factors that contributed to their resilience” (p. 14). Mothers were given several questionnaires about mood, loss, parenting experience, and child's temperament. Children from preschool age and older were given the Steele Affect Task. At 12 months of age, the infants were given the “strange situation” task for attachment ratings. There are videos of mother-infant/child and therapist-infant/child play over a 10-year period. This is an impressive variety of data. Certainly the data would be expected to be typical of applied data obtained secondary to a clinical intervention, particularly an intervention in a crisis situation never previously encountered. Such real-life data, however, messy as it may be, offers the most meaningful picture of what happens in real life. And these interventions were certainly of the highest clinical caliber. We eagerly anticipate the data analysis—perhaps a Volume II of Mothers, Infants and Young Children of September 11, 2001: A Primary Prevention Project ?

Now, 11 years after 9/11, we know more about how to proceed in trauma situations than we did then (Watson et al., 2011) It can be hard to recall our professional inexperience and the altered states in which we, along with all other New Yorkers, lived and worked. Just prior to 9/11, the National Child Traumatic Stress Network was established; its funding greatly increased post-9/11 (Pynoos et al., 2008). Its website now offers detailed descriptions of clinical programs for helping the full range of trauma victims. This website presents a unique opportunity for the Project to be disseminated widely, beyond the psychoanalytic community, to reach an audience with diverse theoretical orientations.

In the meantime, we have this book available as a resource for consultation and reassurance in future trauma work. We are fortunate to have it to read, study, and inspire.

References

Caplan, G. (1974). Principles of preventive psychiatry. New York, NY: Basic Books.

Cohen, E. (2006). Play and adaptation in traumatized young children and their caregivers in Israel. In L. Barbanel & R. J. Sternberg (Eds.), Psychological interventions in times of crisis [pp. 151-179]. New York, NY: Springer.

Durlak, J. A., & Wells, A. M. (1997). Primary prevention mental health programs for children and adolescents: A meta-analytic review. American Journal of Community Psychology, 25 , 115–152.

Fonagy, P. (1998). Prevention, the appropriate target of infant psychotherapy. Infant Mental Health Journal, 19 , 124–150.

Fraiberg, S., Adelson, E., & Shapiro, V. (1974). Ghosts in the nursery. Journal of the American Academy of Child & Adolescent Psychiatry, 14 , 387–421.

Osofsky, J. (2003). Psychoanalytically based treatment for traumatized children and families. Psychoanalytic Inquiry, 23 , 530–543.

Pynoos, R. S., Steinberg, A. M., Fairbank, J. A., Amaya-Jackson, L., Gerrity, E., & Mount, M. L. (2008). The National Child Traumatic Stress Network: Collaborating to improve the standard of care. Professional Psychology: Research and Practice, 39 , 389–395.

Schechter, D. S., Myers, M. M., Brunelli, S. A., Coates, S. W., Zeanah, C. H., Davies, M., . . . Liebowitz, M. R. (2006). Traumatized mothers can change their minds about their toddlers: Understanding how a novel use of videofeedback supports positive change of maternal attributes. Infant Mental Health Journal, 27 , 429–447.

Slade, A. (2006). Reflective parenting programs: Theory and development. Psychoanalytic Inquiry, 26 , 640–657.

Svanberg, P. O., Mennet, L., & Spieker, S. (2010). Promoting a secure attachment: A primary prevention model. Clinical Child Psychology and Psychiatry, 15 , 363–378.

Watson, P. J., Brymer, M. J., & Bonanno, G. A. (2011). Postdisaster psychological intervention since 9/11. American Psychologist, 66 , 482–494.

Weisz, J. R., Sandler, I. N., Durlak, J. A., & Anton, B. S. (2005). Promoting and protecting youth mental health through evidence-based prevention and treatment. American Psychologist, 60 , 628–648.

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