by Götz Egloff
Early Mental Health Intervention in Pregnancy: Three Approaches in Germany
Pills are not key to everything. Psychic trauma in pregnancy is best avoided by early non-pharmaceutical intervention. Although some progress has been accomplished, mothers-to-be and their offspring still seem to lack structured interventions that can prepare them for parenthood and childhood respectively. Recently, in Germany different yet similar interventional programs for mothers-to-be and their partners were developed. These programs more or less focus on bonding, relational issues and educational practices in parents-to-be. In the following survey an outline of three major programs in Germany is given so that the approaches´ objectives become accountable. Much of the knowledge available from prenatal psychology and medicine may be of relevance for secondary school education. Prenatal and perinatal educational tasks especially for teenagers in school can be derived from the programs depicted.
First of all, a quick retrospect of history is to recall the modes of infant health evaluation in time: in Philippe Ariès´ birth vignette (Ariès & Duby 1999) on Héroard and Ludwig XIII, who was born to Maria von Medici and Heinrich IV in 1601, he reports on the observations of Héroard, their private physician from 1601 to 1610. Héroard meticulously reports on his evaluating of newborn Ludwig´s bodily functioning. In Héroard´s diary, he notes: „kräftiger Körper, kräftiger Knochenbau, sehr muskulös, wohlgenährt, blank und glänzend, von rötlicher Farbe, robust [strong physique, strong-structured, well-built, well-nourished, shiny, of ruddy color, solid].” Over quite a long time span, Héroard would evaluate the infant, again and again: pulse beat, temperature, excretion, hygiene, fare. Interestingly, in his description of Ludwig´s head and face visible only, he attests to the infant not to be too inviting to be looked at or be touched. Ludwig´s body would show bruises, lichens, and oozing marks. It has not taken 400 years to employ evaluation beyond mere physical issues, yet today´s mental health care is still far from being an integrated pre-, peri-, and postnatal psychology and medicine. Moreover, only recently structured programs reaching out to prenatal aspects of mental health were developed in Germany although professional experiences had existed for decades. Social psychiatry and social pediatrics after World War II had still been in its infancy when the foundations of psychoanalysis and mother-infant-mental health research began to be recognized and be processed more and more. A whole new culture of birth-giving would have to be employed first.
Although all knowledge of the beginnings of life must be incomplete (Gouni 2011), by now there is quite an amount of evaluation of the influences of early communication on development and learning processes in children (Rakonjac & Dobrijevic 2013), of interaction, of interconnectedness, and of processes of symbolic communication (Mead 1973, Nelson & Fivush 2004, Habermas 2007). Even the overall phylogenetic human developmental process has been depicted extensively (Janus 2008a, cf. Egloff 2004). The ontogenetic aspects of pre- and perinatal development have largely augmented the concepts of postnatal development (Krüll 2009, Egloff 2010), yet there will have to be further augmentations (cf. Djordjevic & Egloff 2011). Early interventional programs for pediatricians and primary care practitioners (Papoušek et al. 2005) have been developed, and the knowledge on parent-infant-interaction has increased a great deal in a relatively short time span.
Infant mental health observations such as slight but distinct negative influences of infant crying and sleeping problems on the child´s subsequent social development (Sidor et al. 2013a), and infants´ regulatory problems which will contribute substantially to external and internal psychic problems in early childhood (Sidor et al. 2013b) are the results of international research efforts. In Germany, these have continually been conducted by teams under the auspices of M. Papoušek (parent-infant policlinic, Munich) beginning as early as in the 1970s, of M. Cierpka (parent-infant policlinic, Heidelberg), and C. Ludwig-Körner (parent-infant policlinic, Potsdam near Berlin) from the 1990s on. The structured programs depicted below have partially evolved from these; the programs aim at the accessing of pregnancy, of the unborn, and of the newborn, yet with different emphases. The programs are not supposed to be therapy for pregnant women, though.
1.”Das Baby verstehen” (Understanding Your Baby) (Gregor & Cierpka 2004)
“Das Baby verstehen” is a structured program for expectant mothers and their partners. Couples are supported through a midwife who will focus on the overall life situation of the family-to-be. Everyday communication between parents and their babies is depicted in the instructions. The “reading“ of the baby is at the center of most of the course lessons. Live video tapes will support the instructions. Playful exercises will focus on the personal well-being of the parents-to-be as well as on how to remain a couple when there will be three of them. In 2003 and 2004 the program was developed at the University of Heidelberg, followed by a revision in 2005, with accompanying evaluation in a German county district. The strengths and shortcomings of the expert trainings as well as of the courses for parents were explored, aiming at an integrative package of counseling for parents with infants up to the age of three. By that, developing of dysfunctional interaction in families can be cut early in order to prevent bodily and mental disorders in infants.
2.”Safe” (Brisch 2010)
The structured program “Safe” aims at what is best for mothers in their pregnancy, in birth, and in parenting issues. The well-examined program addresses real-life issues like, “do parents have to be always present?” or, “what to do when parents are having different needs from those the baby does,” and “when does pampering start, and which limits does an infant need, and when?” Another main issue of the program is how to avoid transferring of traumatic childhood experiences toward the baby. “Safe“ helps parents-to-be develop confidence in dealings with their baby. As early as in pregnancy they learn to react appropriately to the signals the baby shows. This is helpful for infants in developing a secure mode of attachment since securely-attached infants show more capability of empathy, are more creative, and are more capable of cognitive processing. The program is for parents-to-be up to the seventh month of pregnancy, and it will be continued after birth until baby´s first birthday. Parents may continue up to the second or third birthday of their baby. Within a group in whole days of class there is a training of sensitivity toward the baby. In combining of these elements group therapeutic and individual therapeutic effects are aimed at. Stabilization and imagination exercises in stressful situations are conducted, especially in adaptation phase after birth. A parental sensitivity training video is to support the reading of signals and needs of the baby. There is an attachment interview with parents, and diagnostic questionnaires (Erhardt & Brisch 2010, Brisch 2014).
3.“Mutter-Kind-Bindungsanalyse“ (Mother-Infant Bonding Analysis) (Hidas & Raffai 2006)
Mother-infant bonding analysis is a modality of accompanying women in pregnancy enabling them to get in contact with their unborn. It is not a structured program in the narrow sense of the word but a fairly structured interventional sequence of individual sessions. By these, early before birth first steps of building a relation between mothers-to-be and their unborn is aimed at. Through relaxation on a couch, women focus on their perception of signals from the unborn. These will show in the shape of emotions, images, thoughts, and phantasies on an “inner screen” which both baby and mother are related to. This communicative channel can be seen as “umbilical cord” of the soul, enabling a dialog that is to promote the intrauterine development of the unborn. The bonding analyst will support mothers-to-be get in contact with the unborn by encouraging them, by interpreting and by helping to overcome blocking, if necessary. Twenty to thirty sessions during the second half of pregnancy, that is around 20th through 38th gestational week, are usually taken; it is the time frame in which there would be the unborn´s highest brain sensitivity (cf. Djordjevic et al. 2007). The history of mother-infant bonding analysis started in the early 1990s when Budapest-based Jenö Raffai in his working with patients recognized the pertinence of the prenatal mother-unborn-relation for the infant´s further development. Together with the Hungarian psychoanalyst György Hidas, he conceptualized a method which developed into bonding analysis. In around 2200 analyses by Raffai and 800 analyses by Hidas (plus some of their followers) impressive effects were reported (Raffai 1997, Schroth 2009) on children´s personality development and on the well-being of mothers in pregnancy and birth-giving.
Addendum: Developmental Pathology Aspects
Findings on subjective violence and aggressive behavior hint at an early lack of empathy in children, of impulse control, and at a lack of anger management in connection with early deprivation phenomena (Cierpka et al. 2004, Cierpka & Schick 2006). Deviant behavior in the shape of criminal behavior can be viewed as developmental pathology. The lack of reflective functioning in offenders that has been observed regularly (Taubner 2008a, 2008b) requires not only early intervening in individuals but also proves the demand of a catalog of thrust of policy in order to influence future societal trajectories (Egloff 2015). On an individual level, kindergarten educational programs like Faustlos (Second Step/German version) have successfully been employed in many educational institutions in Germany (Egloff et al. 2015), yet there is still a lack of offers that start earlier. The majority of programs available have mostly been adaptations from the US. Moreover, any comparison between US and German programs has proven to be difficult due to structural differences in health services (Benz & Sidor 2013). Interestingly, in an international perspective, recent meta-analyses could show that programs already starting during pregnancy were evaluated best when they had a high frequency of home visits (Taubner et al. 2015). This hints at advantages of close and personal relating to one another which comes close to a therapeutic setting. Moreover, maternal symptom burden was relieved the most in a setting with psychotherapeutic elements from a premature birth coping program (Jotzo & Poets 2005, qtd. in Taubner et al. 2015). Generally, maternal symptom burden relief has been the most observed effect in programs while there have only been small effects in maternal competencies. Also, only small effects on child development have been observed, and these have been lower and more heterogeneous than effects on the mothers-to-be. Then again, having more than twenty sessions has proven helpful for the infant´s physical development (cf. Taubner et al. 2015). Since dealings with preterm newborns are highly problematic new approaches to perinatal medicine have been developed (Djordjevic 2015). Even early eating disorders in connection with preterm delivery have been examined (Erb et al. 2014), and future cooperation options have been explored (Ziegenhain & Künster 2012). Still there is room for extending to further surroundings: especially teenagers in secondary school education will benefit from introductory classes in pre- and perinatal psychology. Not only in females there usually is high interest in these issues.
While the first two programs introduced above, “Das Baby verstehen” and “Safe”, are not only quite similar in content but are well-structured and tend to aim at important everyday dealings with the baby such as reading of signals in a closed or half-open group setting, the last one (“Mutter-Kind-Bindungsanalyse”) is conceptualized as a rather open approach of an individually-shaped setting in which emotionality and empathic dealing with the unborn are in focus. By and large, it is obvious that there are recommendations of bonding analysis in particular from insiders (Linderkamp 2014) due to the approach being not so familiar to many yet. Studies would be helpful here, as would be to combinations of either approach since one of the rather structured programs combined with bonding analysis might be most promising. Apart from individual necessities of strengthening parental competencies (Janus 2008b), some kind of new UN Marshall Plan would be helpful in order to emphasize the pertinence of parental competencies worldwide (deMause 2005).
Ariès, P., Duby, G. (1999). Geschichte des privaten Lebens, Bd. 3. Augsburg: Bechtermünz, 360-364.
Benz, M., Sidor, A. (2013). Early intervention in Germany and in the USA: a comparison of supporting health services. An overview article. Mental Health & Prevention 1, 1, 44-50.
Brisch, K.H. (2010). Safe – Sichere Ausbildung von Eltern. Stuttgart: Klett-Cotta.
Brisch, K.H. (2014). Prävention durch prä- und postnatale Psychotherapie. In: Evertz, K., Janus, L.,
Linder, R. (Hg.). Lehrbuch der Pränatalen Psychologie. Heidelberg: Mattes, 571-596.
Cierpka, M., Schick, A., Egloff, G. (2004). Evaluation des Faustlos-Curriculums für den Kindergarten. Heidelberg: Universität Heidelberg.
Cierpka, M., Schick, A. (2006). Die Evaluation des Faustlos-Curriculums für den Kindergarten. Prax Kinderpsychol Kinderpsychiatr 55, 459-474.
deMause, L. (2005). Das emotionale Leben der Nationen. Klagenfurt: Drava, 43.
Djordjevic, D. (2015). Minimizing Prenatal and Perinatal Psychic Trauma in Premature Newborns – Current Interventions in Germany. Lecture at the 1st Intl. Congress on Psychic Trauma: Prenatal, Perinatal and Postnatal Aspects, May 15-16, 2015, Belgrade.
Djordjevic, D., Linderkamp, O., Brüssau, J., Cierpka, M. (2007). Zusammenhänge zwischen dem Wohlbefinden der Mutter und der Herzfrequenzvariabilität von Frühgeborenen. Prax Kinderpsychol Kinderpsychiatr 56, 10, 852-869.
Djordjevic, D., Egloff, G.(2011). Zur Bedeutung intuitiver Elternkompetenzen für die Entstehung von Bezogenheit. In: Langendorf, U., Kurth, W., Reiss, H., Egloff, G. (Hg.). Wurzeln und Barrieren von Bezogenheit. Heidelberg: Mattes, 117-123.
Egloff, G. (2004). Die psychogenetische Geschichtstheorie von Lloyd deMause. Konferenzpräsentation an der Abt. Psychosomatische Kooperationsforschung und Familientherapie, Psychosomatische Klinik am Universitätsklinikum Heidelberg, Juni 2004.
Egloff, G. (2010). The Unknown in Our Biography. Int J Prenat Perinat Psychol Medicine 22, 1/2, 164-166.
Egloff, G. (2015). Violence Prevention and Beyond – Theses on the Spirit of Terrorism. Egypt J Forensic Sci 5, 3, 75-81.
Egloff, G., Djordjevic, D., Cierpka, M. (2015). Socio-Emotional Learning through Faustlos in Germany. Proceedings of the 1st Intl. Congress on Psychic Trauma PTPPPA 2015, 1, 340-345.
Erb, L., Thiel-Bonney, C., Cierpka, M. (2014). Zum Zusammenhang von Frühgeburtlichkeit und frühkindlichen Fütterstörungen. Ärztl Psychother Psychosom Med 9, 1, 19-25.
Erhardt, I., Brisch, K.H. (2010). Safe – Sichere Ausbildung für Eltern. Ein bindungstheoretisch basiertes Präventionsprogramm für werdende Eltern. Familiendynamik 35, 1, 84-85.
Gregor, A., Cierpka, M. (2004). Das Baby verstehen. Bensheim: Karl Kübel.
Gouni, O. (2011). The Roots that Sprout Wings. Conference Presentation at the International Annual Conference of the ISPPM, Oct. 21-23, 2011, Frankfurt.
Habermas, T. (2007). How to Tell a Life: The Development of the Cultural Concept of Biography across the Lifespan. J Cognition Development 8, 1-31.
Hidas, G., Raffai J. (2006). Nabelschnur der Seele. Gießen: Psychosozial.
Janus, L. (2008a). Menschheitsgeschichte als psychologischer Entwicklungsprozess. Heidelberg: Mattes.
Janus, L. (2008b). Über Grundlagen und Notwendigkeiten der Förderung der Elternkompetenz. Psychoanalyse im Widerspruch 20, 40, 25-38.
Jotzo, M., Poets, C.F. (2005). Helping parents cope with the trauma of premature birth: an evaluation of a trauma-preventive psychological intervention. Pediatrics 115, 4, 915-919.
Krüll, M. (2009). Die Geburt ist nicht der Anfang. Stuttgart: Klett-Cotta.
Linderkamp, O. (2014). Gehirnentwicklung und frühe Förderung. In: Evertz, K., Janus, L., Linder, R. (Hg.). Lehrbuch der Pränatalen Psychologie. Heidelberg: Mattes, 19-33.
Mead, G.H. (1973). Geist, Identität und Gesellschaft. Frankfurt: Suhrkamp.
Nelson, K., Fivush, R. (2004). The Emergence of Autobiographical Memory: A Social Cultural Developmental Theory. Psychological Review 111, 2, 486-511.
Papoušek, M., Rothenburg, S., von Hofacker, N., Cierpka, M. (2005). Regulationsstörungen der frühen Kindheit. CD-basierte Fortbildung. München: Stiftung Kindergesundheit.
Raffai, J. (1997). Mutter-Kind-Bindungsanalyse im pränatalen Bereich. Int J Prenat Perinat Psychol Medicine 9, 457-466.
Rakonjac, M., Dobrijevic, L. (2013). The Influence of Early Communication on Child Development and Learning. In: Sovilj, M., Subotic, M. (eds.). Proceedings of the 4th International Conference on Fundamental and Applied Aspects of Speech and Language, Belgrade, Oct. 25-26, 2013, 368-371.
Schroth, G. (2009). Die Bindungsanalyse nach Raffai und Hidas – eine Einführung. Int J Prenat Perinat Psychol Medicine 21, 3/4, 343-347.
Sidor, A., Fischer, C., Eickhorst, A., Cierpka, M. (2013(a)). Influence of early regulatory problems in infants on their development at 12 months: a longitudinal study in a high-risk sample. Child Adolesc Psychiatry Ment Health 7, 1, 35.
Sidor, A., Fischer, C., Cierpka, M. (2013(b)). Early regulatory problems in infancy and psychopathological symptoms at 24 months: a longitudinal study in a high-risk sample. J Child Adolesc Behav 1, 3, 10.
Taubner, S. (2008a). Gewalt als Symptom? Antisoziales Verhalten in der Adoleszenz zwischen Normalität und Pathologie. In: Willenberg, H. (Hg.). Seelische Krankheit und Verbrechen. Psychoanalytische Erkundungen in einem Grenzland. Psychosozial 31, 3, 101-117.
Taubner, S. (2008b). Einsicht in Gewalt. Gießen: Psychosozial.
Taubner, S., Wolter, S., Rabung, S. (2015). Effectiveness of early-intervention programs in German-speaking countries – a meta-analysis. Mental Health & Prevention 3, 3, 69-78.
Ziegenhain, U., Künster, A.K. (2012). Frühe elterliche Bindungsförderung in der interdisziplinären Zusammenarbeit. Familiendynamik 37, 2, 84-93.