Parent-infant psychotherapy

1. Introduction

Version followed: Selma Fraiberg's infant-parent psychotherapy (Ann Arbor Child Development Project) as set out in Fraiberg, Adelson & Shapiro, "Ghosts in the nursery" (1975) and Fraiberg (ed.), Clinical Studies in Infant Mental Health (1980). It is the core procedure throughout. Two descendants are named as variants and tagged where they add or differ: [CPP] Child-Parent Psychotherapy (Lieberman, Ghosh Ippen & Van Horn, Don't Hit My Mommy!, 2nd ed. 2015), the manualised, trauma-focused, 0–5 descendant; [AFC-PIP] UK psychoanalytic parent-infant psychotherapy (Baradon et al., The Practice of Psychoanalytic Parent-Infant Psychotherapy: Claiming the Baby, 2005; 2nd ed. 2016, Anna Freud Centre).

Fraiberg's original method is a clinical method, not a manual. It is described through case studies, with no session-by-session protocol. CPP is the manualised form, with fidelity strands and phase-specific procedures. Where this guide gives step-by-step detail for Fraiberg's method, the steps are distilled from case descriptions and marked [synthesis] where they go beyond what the authors state. [source: Fraiberg et al. 1975; Fraiberg 1980; Weatherston, Ribaudo & Michigan Collaborative 2020]

What it is. It is psychotherapy of the infant-parent relationship. The parent(s) and baby (pregnancy to about age 3; CPP 0–5) are seen together, classically in the family home ("kitchen table therapy"). Psychodynamic work on the parent's past is combined with concrete help, emotional support and developmental guidance. [source: Weatherston et al. 2020; Shirilla & Weatherston 2002 intro]

Core idea of change. "In every nursery there are ghosts" (Fraiberg et al. 1975). Unremembered, unfelt pain from the parent's own childhood intrudes into the present. The parent then misreads the baby, for example hearing the baby's cry as an attack, or not hearing it at all, and repeats what was done to them. The authors argue that parents who can remember and feel their childhood suffering are protected from repeating it. Parents who have kept the events but cut off the feelings, and so become identified with the aggressor, are at risk of repeating it. Change comes when, with a trusted therapist and the baby physically present, the parent recovers the old affect and links it to the present. The baby can then be seen as a separate, real baby who needs protection. [source: Fraiberg et al. 1975, via secondary summaries; exact wording beyond the opening line is [uncertain]]. CPP adds a trauma frame: the relationship is the vehicle for restoring the child's sense of safety, and the parent and child together build a shared, regulated narrative of traumatic events. [source: CYFD NM CPP manual; GV Health CPP slides]. Lieberman et al. (2005) added "angels in the nursery": benevolent early experiences that the therapist also brings forward as protective resources. [source: supportingchildcaregivers.com; Lieberman et al. 2005 [uncertain]]

2. Framework

Format (Fraiberg original). Joint sessions with parent(s) and baby, usually at home, weekly, at least an hour, more often in crisis. Duration is open-ended and was often a year or more in the published cases [uncertain: no fixed length in primary sources]. The work was done by a multidisciplinary team (social workers, psychologists, nurses, psychiatrists) with close case consultation. [source: Weatherston et al. 2020; Shirilla & Weatherston 2002]

Fraiberg's three treatment modalities (1980 Clinical Studies, treatment-modalities chapter). The modality is chosen after assessment, can change over time, and the three can be combined. [source: Fraiberg 1980, reconstructed from standard secondary accounts [uncertain on exact selection criteria]]

Modality	Used when	Typical length
Brief crisis intervention	An acute, circumscribed crisis in a family whose relationship is basically sound (e.g. a reaction to a sudden event)	A few sessions [uncertain]
Developmental guidance / supportive treatment	Parents who cannot use, or do not need, exploration of their past: severe personal limitations, or a sound relationship needing information and support	Months; open-ended
Infant-parent psychotherapy	Parental conflicts or ghosts are distorting perception of and care for the baby, and the parent can engage reflectively	Usually ≥1 year in the published cases [uncertain]

Phases (Fraiberg; the phase labels are [synthesis] from case accounts).

Assessment and engagement (roughly 3–6 home visits [uncertain]). Observe the baby's development and the interaction; take the parent's story; meet the urgent material needs; judge the danger to the baby. Move on when there is enough alliance for the parent to let you return, and enough of a formulation to choose a modality.
Working phase. Alongside guidance and support, explore the parent's past as it shows up in the present with the baby. The aims are recovered affect and parental empathy for the baby. Signs of progress: the parent begins to see and respond to the baby's signals, and the baby's symptoms (feeding, avoidance, developmental lags) improve.
Ending. Begin when the baby is developmentally on track, the parent protects and responds to the baby without the therapist's scaffolding, and gains have held through some stressor. Taper and review. [synthesis]

[CPP] phases (manual-defined; each phase has its own fidelity criteria). [source: CYFD NM CPP manual; GV Health CPP slides; NHS Scotland Early Intervention Framework]

Foundational phase: assessment and engagement. Intake with the caregiver alone; dyadic observation; child and caregiver trauma histories and symptoms. Common instruments in implementations include the TESI or THS and the LSC (Life Stressor Checklist). Assess safety; discuss cultural child-rearing values. Close with a feedback session that co-constructs a formulation and the "triangle of explanations" (experience → behaviour/feelings → treatment, plus protective steps and hope). The sample schedule is about 4 sessions (intake; dyadic observation; caregiver trauma history; feedback), with more as needed. Move on when a working partnership exists, the caregiver can acknowledge and talk about the child's traumatic experiences, and there is an agreed plan for how trauma will be spoken about with the child.
Core intervention phase. Weekly dyadic (or triadic) sessions of about 60 minutes at home, clinic or community, with parent-only collateral sessions as needed. The first dyadic session explains to the child why they are coming.
Recapitulation and termination. Taper where possible; count down the sessions; review the family story and gains; anticipate trauma reminders; plan for the future; say goodbye explicitly to the child.

CPP length: NHS Scotland gives "20 to 32 weeks or more". Many US implementations run about a year [uncertain: sources differ]. Weekly reflective supervision; a formal learning collaborative of about 18 months is needed to be rostered.

[AFC-PIP] format. Weekly clinic-based sessions, usually about 50–60 minutes, open-ended, with the baby present and fathers included where possible. The text is organised as engagement and beginning, a middle phase of elaboration and consolidation, then endings, with a dedicated chapter on risk. Group PIP is also described. [source: Routledge 2nd-ed contents; session length [uncertain]]

3. Guiding principles

[source: Fraiberg et al. 1975; Weatherston et al. 2020; CPP manual and slides; Baradon 2016 contents. Practical glosses are [synthesis]]

The relationship is the patient. Formulate and intervene on the parent-baby system, not on the parent or baby alone. → Ask "what is happening between them?" before "what is wrong with her/him?"
The baby is present and is the catalyst. → Keep the baby in the room. Let the baby's actual behaviour cue what you explore, and return attention to the baby after every excursion into the past.
The baby cannot wait. Developmental time is short, so the baby's safety and development take priority over the pace of the parent's therapy. → Act on feeding, safety and neglect now, and explore later.
Go to the family. Home-based, "kitchen table" outreach. → Accept chaos, TV and visitors as the clinical field, not as obstacles; your reliability is part of the treatment.
Meet concrete needs as part of therapy, not instead of it. → Housing, food and medical appointments are legitimate session content and build trust.
Listen for the past in the present. → Note when the parent's reaction to the baby is disproportionate or strangely absent; that is where a ghost may be.
Affect, not just memory, is what protects. → Do not settle for a factual account of abuse; gently seek what it felt like to be that child.
Empathy for the parent-as-child before demands on the parent-as-parent. → The parent must feel heard before they can hear the baby.
Developmental guidance is non-didactic. The parent is the expert on their baby. → Observe together and wonder aloud; avoid lecturing or handouts as the main mode.
Strengths and vulnerabilities both. → Name the loving moments and gently name the harmful ones; do not praise around problems.
Angels as well as ghosts [CPP/Lieberman]. → Actively look for experiences of being loved and protected, and use them as resources.
Safety first [CPP]. → Restoring physical and psychological safety for child and caregiver comes before trauma processing.
Speak directly about trauma [CPP]. → Name what happened, in words the child can understand; silence is not protective.
Translate meanings between parent and child [CPP]. → Turn the child's behaviour into understandable communication for the parent, and the parent's intentions into words for the child.
Look beneath anger for suffering; seek positive intent within conflict [CPP]. → Respond to the fear or grief under a hostile act.
Cultural humility [CPP]. → Ask about the family's child-rearing values before judging practices.
The therapist as a new object for parent and baby [AFC-PIP]. → Your way of attending to the baby is itself a model and an intervention.
Claiming the baby [AFC-PIP, subtitle]. → Help the parent emotionally own this baby as theirs and as a person with a mind.
Use your own reactions; seek reflective supervision. → Note your discomfort, reflect, take it to supervision, then decide whether and how to use it. "How you are is as important as what you do" (Pawl & St. John 1998, cited in the Michigan model) [uncertain on exact attribution].
Parallel process / the platinum rule. Treat the parent as you hope the parent will treat the baby. [source: Weatherston et al. 2020]

4. Intervention inventory

All example language is illustrative wording written for this guide, not text from the manuals. Part A covers Fraiberg's original method; Part B adds CPP; Part C adds AFC-PIP; Part D covers safeguarding.

Part A: Fraiberg infant-parent psychotherapy

A1. Home-based joint session ("kitchen table" frame)

Purpose / when: The default setting. It reaches families who would not attend a clinic and puts the real baby and real life in view. [source: Weatherston et al. 2020; Shirilla & Weatherston 2002]
Steps: (1) Agree a regular weekly time when the baby is usually awake; this lets you see feeding and play. (2) Sit where the family places you: kitchen table, floor or sofa. (3) Spend the first minutes watching and listening, including to the baby. (4) Let the session follow what is alive: the baby's behaviour, the parent's preoccupation or a practical crisis. (5) Before leaving, return to the baby and confirm the next visit. [steps: synthesis]
Example language (illustrative): "I'll just sit here with you both. Tell me how this week has been, for you and for Kayla."
Watch for: missed or "not home" visits as communication rather than mere non-compliance; who else is in the home; the baby's whereabouts and state when you arrive. Working: the parent begins to keep the baby in the room and to start sessions with news about the baby.

A2. Engagement and alliance building with reluctant or unreferred parents

Purpose / when: From the first contact onward. Many families are referred by others and did not ask for help; trust may build agonizingly slowly. [source: Weatherston et al. 2020; Fraiberg et al. 1975 cases began with unwilling or avoidant mothers [uncertain on detail]]
Steps: (1) Be steady, reliable and predictable: same day, same time, phone if late. (2) Begin from the parent's stated concern, even if it is not the baby. (3) Offer something concrete early (A3). (4) Tolerate cancellations and keep showing up; leave a note. (5) Do not confront the parenting until the parent feels you are on their side.
Example language (illustrative): "I'm not here to judge how you're doing it. I'm here because the first months with a baby can be very hard, and you shouldn't have to do it alone."
Watch for: fear that you will remove the baby; shame; the parent "performing" good parenting. Working: the parent tells you something difficult unprompted.

A3. Concrete assistance and advocacy

Purpose / when: When material need (food, housing, medical care, childcare, benefits) threatens the baby or swamps the parent. It also demonstrates care in action. [source: Weatherston et al. 2020]
Steps: (1) Ask about basic needs directly. (2) Help with the task itself (calls, forms, accompanying to appointments) rather than only referring. (3) Coordinate with health visitors or public health nurses, paediatricians and social services. (4) Talk afterwards about what it was like to be helped.
Example language (illustrative): "Before we talk about anything else, is there enough food in the house this week? Shall we make that call together now?"
Watch for: the therapist becoming only a caseworker; dependency issues; the parent's surprise at being helped, which is often a doorway to their history of not being cared for. Working: the parent's stress drops enough for reflective conversation.

A4. Emotional support

Purpose / when: Acute distress (premature birth, a death, abandonment, a depressive collapse) or as a steady background. [source: Weatherston et al. 2020]
Steps: (1) Listen without interrupting. (2) Reflect the feeling. (3) Help the parent tolerate the distress rather than fix it immediately. (4) Link it to their capacity to care for the baby only when they are calmer.
Example language (illustrative): "You've been carrying all of this on your own since he was born. No wonder you're exhausted."
Watch for: depression or risk signs (see D1); a parent who can only receive support and never turn to the baby. In that case consider a supportive or developmental-guidance modality rather than insight work.

A5. Brief crisis intervention

Purpose / when: A circumscribed crisis in a family whose relationship is basically sound. Also emergency intervention when a baby is in peril, for example non-organic failure to thrive. [source: Fraiberg 1980 modalities; Fraiberg, Shapiro & Adelson 1976, a case of infant-parent psychotherapy on behalf of a child in a critical nutritional state [uncertain]]
Steps: (1) Increase visit frequency, several times a week if needed. (2) Clarify the precipitant and its meaning to the parent. (3) Secure the baby's immediate physical needs, liaising with medical services (weight checks, admission if indicated). (4) Offer focused support and guidance. (5) Reassess whether longer infant-parent psychotherapy is needed once the crisis settles.
Example language (illustrative): "Let's get Leo weighed tomorrow with the nurse. I'll come back on Thursday too, so you're not waiting a whole week."
Watch for: a crisis masking a chronic ghost-driven pattern; medical deterioration. Working: the acute symptom resolves and the parent re-engages with the baby.

A6. Developmental guidance (non-didactic)

Purpose / when: Throughout, and as the main modality for parents who cannot or need not explore their past. The aim is to help the parent see the baby's developmental needs and signals. [source: Weatherston et al. 2020; Fraiberg 1980 [uncertain on detail]]
Steps: (1) Watch the baby together. (2) Wonder aloud about what the baby is doing and why. (3) Ask for the parent's reading first and treat them as the expert. (4) Add small pieces of developmental information in the context of what you are both seeing. (5) Notice and name the parent's attuned responses.
Example language (illustrative): "Look, she keeps turning to the sound of your voice. What do you think she's after?" / "At this age babies often start to get upset when Mum leaves the room. It can feel like she's being difficult, but it's a sign she knows who you are."
Watch for: lecturing; information delivered when the parent is too distressed to take it in; advice that clashes with cultural practice. Working: the parent spontaneously reads the baby's cues and tells you new things the baby does.

A7. Eliciting the parent's own childhood experience

Purpose / when: When the parent's response to the baby seems driven by something other than the baby: indifference, rage, misreading. This opens the path to linking past and present. [source: Fraiberg et al. 1975; question form from Weatherston et al. 2020]
Steps: (1) Begin from a present moment with the baby. (2) Ask a gentle, specific question about the parent's own early care. (3) Follow the story, listening for what is missing, especially feelings. (4) Do not push for disclosure. Let it surface over many sessions.
Example language: "Who would have soothed you when you were sick or tired?" (Michigan IMH model wording, Weatherston et al. 2020). Illustrative follow-up: "When you were little and you cried, what happened?"
Watch for: flat factual accounts ("Yeah, he hit us, it was normal"); sudden shifts of topic; the baby's reactions while the parent talks. Working: the parent begins to bring memories spontaneously.

A8. Linking past and present (interpreting the ghosts)

Purpose / when: When a repeated pattern with the baby (not hearing the cry, avoiding the baby, punitive handling) can be connected to the parent's past. This is the signature intervention. [source: Fraiberg et al. 1975]
Steps: (1) Build a shared, detailed picture of both the present pattern and the past experience. (2) Wait until the parent feels understood and has some access to the old feeling (A9). (3) Offer the link tentatively, as a question. (4) Bring it back to the baby: what would this baby need that the parent did not get? (5) Repeat the link as it recurs in new forms.
Example language (illustrative): "I wonder if when Mary cries, it's hard to hear her because for so long no one heard you when you cried." → "What do you think Mary needs from you right now?"
Watch for: intellectual agreement without feeling, which means the link is premature; blame or shame ("So I'm a bad mother like her"). Working: changes in the specific behaviour follow, for example the parent picks up the crying baby, often within days or weeks of an affect-laden session (as in the March case) [uncertain on timescale].

A9. Recovering the affect (working against identification with the aggressor)

Purpose / when: The parent remembers childhood abuse or abandonment but without the fear, helplessness or grief. They are aligned with the aggressor and so may repeat. [source: Fraiberg et al. 1975; Annie and Greg case as summarised in secondary sources [uncertain on detail]]
Steps: (1) Listen for affect-less accounts of frightening events. (2) Gently invite the child's-eye experience: what it felt like, not just what happened. (3) Stay with the emerging fear or grief and hold it. Do not rush to the baby. (4) When the parent can feel for their child-self, invite empathy for the baby: "what might your baby feel when…". (5) Expect anger, possibly at you (A10).
Example language (illustrative): "You tell this as if it were nothing, but you were six, alone in that room. What was that like for the little girl you were?" / "No child should be that frightened."
Watch for: overwhelm or dissociation, so titrate and ground (see section 5); this is not cathartic reliving. Working: the parent cries or is angry about their childhood, then becomes more protective and tender with the baby rather than identifying the baby as the aggressor.

A10. Using the transference (the therapist as a new, trustworthy object)

Purpose / when: The parent's expectations of being judged, abandoned or attacked show up with the therapist. Fraiberg's team used the positive transference to make painful material bearable and addressed negative transference when it threatened the work. [source: Fraiberg et al. 1975 [uncertain: detail drawn from standard accounts]]
Steps: (1) Notice repetitions with you: lateness, avoidance, hostility, idealisation. (2) Name them in the here and now when they block the work. (3) Link them to past figures only when the parent can use it. (4) Be reliably different from the feared figure.
Example language (illustrative): "I wonder if you were expecting me to tell you off today, the way your dad would have."
Watch for: your own urge to rescue or punish (see A13). Working: the parent can tell you they are angry with you and the alliance survives.

A11. Using the baby's presence in the moment

Purpose / when: Whenever the baby's behaviour in session, such as crying, seeking, avoiding or feeding, is a live example of the pattern. [source: Shirilla & Weatherston 2002 (the infant as an energising focus); Fraiberg et al. 1975]
Steps: (1) Draw attention to what the baby is doing now. (2) Ask what the parent sees and feels. (3) If something important is happening, such as the baby's distress being ignored, name it gently before moving on. (4) Link the moment to the themes being explored.
Example language (illustrative): "He's crying now and you just looked away. What happened inside just then?"
Watch for: using the baby as a mere prop for adult therapy; the baby's distress going on too long while you talk. In that case prioritise comfort, and do so through the parent where possible. Working: the parent responds to the baby's signal in session.

A12. Eliciting "angels in the nursery" (benevolent memories)

Purpose / when: When the parent's history seems wholly bleak, or as a counterweight to ghost work. Even one remembered moment of being loved, protected or understood is a resource for the parent's own parenting. [source: Lieberman, Padrón, Van Horn & Harris 2005 [uncertain]; supportingchildcaregivers.com]
Steps: (1) Ask about anyone who made the parent feel safe, special or understood. (2) Elaborate the memory's sensory and emotional detail. (3) Link it to what the parent can offer this baby.
Example language (illustrative): "Was there anyone, a grandmother, a teacher, a neighbour, who made you feel you mattered?" → "What did she do that made you feel that? Do you see yourself doing any of that with Ana?"
Watch for: idealisation used to deny harm. Working: the parent draws on the remembered figure in their behaviour with the baby.

A13. Self-observation and reflective supervision

Purpose / when: Always. Home visiting with traumatised families evokes strong reactions: rescuing, anger at the parent, loneliness that mirrors the parent's. [source: Weatherston et al. 2020]
Steps: (1) After each visit, note your feelings and urges. (2) Bring them to regular reflective supervision. (3) Consider them as possible information (parallel process) before acting. (4) Decide with the supervisor whether to address anything with the parent.
Example language (supervision, illustrative): "I left feeling furious with her for ignoring the baby, and then completely alone in the car."
Watch for: avoiding visits, overstaying, taking sides with the baby against the parent. Working: your interventions become less reactive and more timely.

Part B: [CPP] additions (manualised variant)

[source for Part B: CYFD NM CPP manual; GV Health CPP slides; NHS Scotland Early Intervention Framework; Lieberman, Ghosh Ippen & Van Horn 2015. Steps are paraphrased from these implementation documents; the full manual's wording was not reviewed [uncertain on fine detail]]

B1. Foundational assessment with separate caregiver sessions

Purpose / when: Phase 1. Gathers child and caregiver trauma histories, symptoms and safety information, and builds the partnership before dyadic work.
Steps: (1) Intake with the caregiver alone: referral reason, feelings about coming, developmental history. (2) Dyadic observation. (3) Child trauma history and symptoms (e.g. TESI or THS; YCPC or CPSS). (4) Caregiver trauma history and symptoms, alone (e.g. LSC, PCL-5, depression screen). Explain why you ask. (5) Assess danger and safety: current violence, contact with the perpetrator, the caregiver's own risk. (6) Ask about cultural child-rearing values. (7) Address resistance openly, including mandated attendance.
Example language (illustrative): "I'm going to ask about hard things that may have happened to you and to Jayden. I ask everyone, because what parents have been through often shapes how they and their children cope."
Watch for: caregiver dysregulation during history-taking, so pace it and ground; disclosures that trigger safeguarding duties (D1). Working: the caregiver can say what the child has been through.

B2. Feedback session and the triangle of explanations

Purpose / when: End of phase 1. Co-creates a shared formulation and the rationale for joint sessions.
Steps: (1) Meet the caregiver alone. (2) Share the assessment in plain language. (3) Build the triangle together: what happened (experience) → how it shows now (behaviour and feelings) → how treatment will help. Add the caregiver's protective steps and hope. (4) Explain why play and the child's presence matter. (5) Agree weekly sessions and how trauma will be named with the child.
Example language (illustrative): "When Jayden saw his dad hurt you, he was terrified. Now when people shout, his body remembers and he hits or hides. You got him out of there, and that mattered. Here, we'll help him understand what happened and feel safe with you again."
Watch for: the caregiver feeling blamed; disagreement about whether the child "remembers" (address the belief that a baby is too young to know). Working: the caregiver can tell the triangle in their own words.

B3. Introducing treatment to the child

Purpose / when: The first dyadic session. It breaks the silence and gives the child a reason for coming.
Steps: (1) With the caregiver present and prepared, tell the child in simple words what happened, what they have been showing, and that this is a place to play, talk and feel safer together. (2) Use the caregiver's agreed words. (3) Watch the child's response in play.
Example language (illustrative): "You saw Daddy hit Mummy and you heard lots of yelling. Now sometimes you feel scared and you hit. Mummy and I are going to play and talk with you here so you can feel safe again."
Watch for: caregiver flinching or contradicting you (prepare better next time); the child's play enacting the event, which is meaningful, not a failure. Working: the child returns to the theme in play over sessions.

B4. Choosing ports of entry

Purpose / when: Every session. The "port of entry" is the clinical moment and the unit of intervention that you choose: child behaviour, caregiver behaviour, caregiver representation, the interaction, or the family's circumstances. (The concept comes from Stern 1995 [uncertain on CPP's citation].)
Steps: (1) Observe the moment-to-moment interaction. (2) Pick the entry point most likely to move the relationship and least likely to shame: sometimes the child's play, sometimes the parent's memory, sometimes a housing crisis. (3) Shift ports if one is closed.
Example language (illustrative): to the child, "The baby doll is crying and nobody's coming." Or to the parent: "It's been so hard this week. Is that why you looked so far away just now?"
Watch for: always defaulting to the same port. Working: the chosen entry opens conversation rather than defensiveness.

B5. Promoting developmental progress through play, physical contact and language

Purpose / when: Throughout. Supports regulation, reciprocity and the developmental trajectory.
Steps: (1) Provide age-appropriate toys, including trauma-relevant figures (families, ambulances, police, doctor kits). (2) Encourage the caregiver to join the child's play and follow the child's lead. (3) Support comforting touch where the child accepts it. (4) Put words to the child's feelings and actions.
Example language (illustrative): "You built the house so strong. Mummy, can you help him keep the people safe inside?"
Watch for: a caregiver who is intrusive or withdrawn in play; touch that frightens a child whose trauma involved bodies. Working: longer shared play, and the child seeking the caregiver for comfort.

B6. Unstructured reflective developmental guidance

Purpose / when: When the caregiver misreads age-appropriate behaviour as bad, defiant or a sign of the abuser. CPP's form of Fraiberg's guidance (A6).
Steps: (1) Wait for a live example. (2) Ask the caregiver's understanding. (3) Offer developmental information tied to the moment. (4) Reflect together on what the child needs.
Example language (illustrative): "Two-year-olds often say 'no' to everything. It's how they learn they're their own person. It doesn't mean he's turning into his father."
Watch for: information that feels like criticism. Working: fewer negative attributions to the child.

B7. Modelling and encouraging appropriate protective behaviour

Purpose / when: When the child is unsafe in the session (climbing, hitting, running out), or the caregiver is passive or overly punitive.
Steps: (1) Act first if the danger is immediate. (2) Name the safety rule. (3) Hand protection back to the caregiver as quickly as possible, and support them to do it. (4) Afterwards, reflect on what made it hard.
Example language (illustrative): "I won't let you hit Mummy. Mummy, can you help him? Hold his hands gently and tell him you'll keep everyone safe."
Watch for: taking over as the "better parent"; harsh physical restraint. Working: the caregiver steps in sooner and more calmly.

B8. Interpreting feelings and actions (incl. linking past and present, translating between parent and child)

Purpose / when: When behaviour carries an unspoken meaning, whether from the child's trauma or the caregiver's ghosts. CPP's form of A8.
Steps: (1) Notice the behaviour or reaction. (2) Translate it into its likely meaning for the other partner. (3) Where useful, link it to past experience, the child's or the caregiver's. (4) Frame it with compassion. Look for suffering beneath anger and positive intent within conflict.
Example language (illustrative): to the caregiver, "When he hits you and then hides, I think he's scared you'll be angry like his dad was. He's checking whether you'll still keep him safe." To the child: "Mummy's voice got loud because she was scared you'd get hurt, not because she's angry with you."
Watch for: interpretations that blame either partner. Working: softer responses follow.

B9. Co-constructing a trauma narrative; differentiating then and now

Purpose / when: The core phase, once safety and the alliance are in place. The goals include distinguishing reliving from remembering, normalising the traumatic response and putting the trauma in perspective.
Steps: (1) Follow the child's trauma play and give it words. (2) Help the caregiver acknowledge what happened in front of the child. (3) Emphasise protective steps and what is different now. (4) Build, over sessions, a shared story with a beginning, middle and safe now. (5) Respond to reminders (B10).
Example language (illustrative): "That was when Daddy was hurting Mummy. That was scary. Now you live in a new house and Daddy isn't there. Mummy is keeping you safe."
Watch for: child or caregiver dysregulation, so slow down and return to regulating play; a caregiver who is too triggered to tolerate the child's play (move to collateral sessions, B12). Working: the play becomes less driven, more varied and resolves more often.

B10. Addressing traumatic reminders

Purpose / when: When the child or caregiver reacts to a cue: a voice, a smell, a man's shout, sirens, the anniversary of the event.
Steps: (1) Identify the reminder together. (2) Name the link aloud. (3) Help the caregiver comfort the child, and themselves. (4) Plan for predictable reminders, including at termination.
Example language (illustrative): "When the man downstairs shouted, you both jumped. That sound reminds you of before. You're safe here."
Watch for: reminders that come from the caregiver themselves, such as the child resembling the perpetrator. Working: faster recovery from reminders.

B11. Emotional support, crisis intervention, case management and concrete assistance

Purpose / when: As in A3–A5. CPP explicitly keeps these within the therapist's role.
Steps / language / watch for: as A3–A5. Also coordinate with courts, child welfare, shelters and the child's other carers, and observe the child in care settings where indicated.

B12. Collateral (caregiver-only) sessions

Purpose / when: When the caregiver needs to process their own trauma or reactions, or when material is not suitable to discuss in front of the child (sexual detail, custody conflict, the caregiver's suicidality).
Steps: (1) Agree the purpose. (2) Keep the child's experience as the reference point. (3) Plan how insights will return to dyadic sessions.
Watch for: collateral sessions drifting into individual therapy that replaces dyadic work. Refer for individual therapy if needed.

B13. Recapitulation and termination

Purpose / when: Final phase.
Steps: (1) Plan the ending with the caregiver and agree a countdown. (2) Tell the child, and count down the sessions visibly (calendar, paper chain). (3) Review the family story: what happened, what changed. (4) Anticipate future reminders and developmental stresses. (5) Plan supports. (6) Mark a final session with an explicit goodbye.
Example language (illustrative): "We have three more times together. Then you and Mummy will keep doing the brave things you've learned."
Watch for: a resurgence of symptoms around loss, which is common; abrupt endings forced by court or placement decisions. In that case still do a goodbye session if at all possible. Working: the dyad can narrate their story and gains.

Part C: [AFC-PIP] additions (UK psychoanalytic parent-infant psychotherapy)

[source for Part C: Baradon et al. 2016, chapter list (Routledge); Pennicott-Banks 2020 thesis abstract (UCL); Miltz, Pennicott-Banks, Avdi & Baradon 2023 citation. Technique detail from book chapters is [uncertain]]

C1. Addressing the baby directly

Purpose / when: Throughout. Treats the infant as a subject and participant whose experience counts. The parent overhears the baby being thought about. A study of the AFC model found that the therapist talks directly to the baby for a significant part of the session (Pennicott-Banks 2020).
Steps: (1) Turn your body and gaze to the baby. (2) Describe what the baby seems to be doing or feeling. (3) Include the parent: "your mum…". (4) Speak about the relationship as well as the baby's state. (5) Then check the parent's reaction.
Example language (illustrative): "You're watching Mummy very carefully today, aren't you? You're wondering where she's gone, because she seems so sad."
Watch for: the parent feeling criticised through the baby, so keep it non-blaming; use with care when the parent's behaviour towards the baby is atypical or frightening (the topic of Miltz et al. 2023). Working: the parent starts to talk to and about the baby as a person with a mind.

C2. Attending to embodied and non-verbal communication; the therapist as regulator

Purpose / when: With pre-verbal babies and dysregulated dyads. Adds a focus on gaze, touch, rhythm and bodily states (the 2nd edition adds material on embodied communication).
Steps: (1) Track the micro-interaction: gaze aversion, stilling, arching. (2) Regulate your own tone and pace to calm the dyad. (3) Describe what you see. (4) Invite the parent to try small adjustments and notice the baby's response.
Example language (illustrative): "When you came close to her face just then she looked away. Shall we see what happens if you give her a moment?"
Watch for: frozen or disorganised infant behaviour, which is a risk indicator (see D1). Working: smoother contingent turn-taking.

C3. Including fathers and working triadically

Purpose / when: Whenever a father or co-parent is involved. Addresses each parent's representations and the parental couple's impact on the baby. (Dedicated chapters in 2nd ed.)
Steps: (1) Invite both parents explicitly. (2) Give each a voice about the baby. (3) Notice alliances and exclusions in the triangle. (4) Address couple conflict as it affects the baby.
Example language (illustrative): "Dad, what do you see when he does that?"
Watch for: domestic abuse (D1); one parent using sessions to attack the other. Working: both parents can hold the baby in mind together.

C4. Group parent-infant psychotherapy

Purpose / when: Isolated parents who can benefit from peers, e.g. in perinatal or community settings.
Steps: [uncertain] Only the chapter title (James) was seen. Facilitation detail was not obtained; consult the book before use.

Part D: Safeguarding

D1. Risk assessment and child protection within the dyadic frame

Purpose / when: At assessment and continuously after. The baby's safety comes before the alliance. CPP builds safety assessment into the foundational phase, AFC-PIP has a dedicated chapter on risk in the parent-infant relationship, and the Michigan model coordinates with child protective services. [source: CYFD NM CPP manual; Baradon 2016 contents; Weatherston et al. 2020. Steps are [synthesis] grounded in standard child-protection practice]
Steps: (1) At the outset, explain the limits of confidentiality: you must share information if a child is at risk of significant harm. (2) Screen routinely for domestic abuse, substance use, parental mental illness (including postpartum psychosis and severe depression), thoughts of harming self or the baby, unsafe sleep, and the baby's growth and missed health appointments. (3) Observe for infant indicators: bruising in a non-mobile baby, faltering growth, frozen watchfulness, avoidance, frightening or frightened parental behaviour. (4) If concerned, use your service's standard risk assessment and consult your supervisor or safeguarding lead the same day. (5) Refer per local procedures: UK statutory guidance such as Working Together to Safeguard Children; US state mandated-reporting law. Where safe and appropriate, tell the parent you are doing so. (6) For parental suicidality or thoughts of infanticide, use standard suicide and homicide risk assessment and urgent perinatal or crisis psychiatric pathways. (7) Continue therapy alongside statutory processes where possible; the therapist's role is distinct from the investigator's. (8) Document carefully.
Example language (illustrative): "I'm worried about the bruise on Sam's arm. Because he can't crawl yet, I need to talk to my safeguarding lead today and probably to social services. I'd rather do that with you than behind your back. I'm still here to work with you both."
Watch for: your own reluctance to "damage the alliance" (take it to supervision; do not delay); collusion with an abusive partner present in the home; your own safety on home visits (lone-working policy). Working: the baby is safe, and in many cases the parent stays engaged.

5. Handling problems

Sources address engagement, resistance, mandated attendance and safety. Most other responses here are [synthesis], built from the principles above and marked accordingly. [source: Weatherston et al. 2020; CYFD NM CPP manual; Fraiberg et al. 1975]

Missed visits, "not home", door not answered [source: Weatherston et al. 2020 (slow trust); response is synthesis]. Keep coming at the same time and leave a warm note. Text the day before. Treat the absence as communication: fear of judgement, shame, or chaos at home. Explore it gently when you next meet: "Last week it felt hard to let me in. I wonder what was going on." If the baby is unseen for a long stretch, this becomes a safeguarding question (D1). Do not just close the case.
Mandated or court-referred parents [source: CYFD NM CPP manual addresses resistance including mandated treatment; wording synthesis]. Name the mandate openly and separate your role from the court's. Find the parent's own goal for the child, such as "get her back" or "stop the tantrums", and work from it. Be transparent about what you will report.
The parent wants help only for themselves and ignores the baby [synthesis]. Accept their need first (A4); a neglected parent cannot attend to the baby. Then build bridges through the baby's actions in the room (A11) and through speaking to the baby (C1). If insight work is not possible, shift to the supportive/developmental-guidance modality (Fraiberg's modality choice).
The parent is hostile to or frightened of the baby ("he's just like his father") [source: Fraiberg et al. 1975; Weatherston et al. 2020 (crying misread as aggression); response is synthesis]. Do not argue. Get curious about who the baby reminds them of (A7) and acknowledge the parent's fear. Over time, separate the real baby from the projected figure: "He has his father's eyes. I wonder what else you see in him that's just his own." Monitor safety closely.
Intellectual insight without change [source: Fraiberg et al. 1975 (affect, not memory, protects); response is synthesis]. The link has probably been made without the feeling. Slow down and return to the child's-eye experience (A9). Stop offering explanations.
Overwhelm or dissociation when the past is opened [synthesis]. Stop exploring. Orient to the room and the baby: "Look, Mia's here, she's fine, you're here with me." Ground through the senses, and offer concrete calming such as tea or a walk. Next session, agree a pace and a stop signal. Consider collateral sessions without the baby (B12). If the parent has PTSD or a severe mood disorder, refer for adjunctive individual or psychiatric care. A baby left alone with a dissociating parent is a safety issue.
The child dysregulates during trauma play [source: CPP goals of regulated arousal and remembering vs reliving; response is synthesis]. Shift from narrative to regulation. Have the caregiver comfort the child, slow the play, and use a calming activity. Name it: "That got too big. Let's help your body feel calm." Return to the theme in later sessions at lower intensity.
Rupture: the parent is angry at you, or feels judged [source: Weatherston et al. 2020 (therapist reflects on own reactions); response is synthesis]. Acknowledge your part without defensiveness: "I think what I said about the bath came across as criticism. I'm sorry; that's not how I meant it." Link to the transference only when it is safe (A10). Ruptures you survive together are reparative experiences for parents whose carers punished them.
Rupture after a safeguarding referral [synthesis]. Expect anger and grief. Stay available, explain your role again, and be honest about what happens next. Many families re-engage if the therapist remains steady (D1). Use supervision for your own guilt.
The therapist feels pulled to rescue the baby or to side against the parent [source: Weatherston et al. 2020 (parallel process); response is synthesis]. Take it to reflective supervision (A13). Keep both partners in mind: "Who in this family is nobody thinking about right now?"
The therapist feels useless or bored, or the sessions drift into chat [synthesis]. This may mirror a depressed parent's deadness. Re-centre on the baby with a fresh observation (A6/A11). Review the formulation in supervision.
Chaotic home: TV, visitors, no privacy [synthesis]. Treat it as clinical data first. Ask for what you need ("Could we turn the TV down so I can hear Sam?"). If an abusive partner or someone else's presence makes safe talk impossible, arrange another venue.
Domestic abuse present or ongoing [source: CPP origins in domestic violence work (UCSF publication list); response is synthesis]. Prioritise safety planning and liaison with specialist DV services before trauma narrative work. Never interpret in front of the perpetrator in a way that endangers the victim. Joint sessions with an abusive parent require specialist assessment.
Parental substance misuse or severe mental illness [synthesis]. Coordinate with adult services. Keep the dyadic focus but adjust expectations, often towards developmental guidance and support. Hold a low threshold for safeguarding consultation.
The baby is not developing or not growing (failure to thrive) [source: Fraiberg, Shapiro & Adelson 1976, cited; response is synthesis]. This is an emergency frame. Arrange medical review the same week and increase visit frequency (A5). Explore what feeding means to the parent while the medical risk is managed.
Cultural mismatch about sleep, feeding, discipline or carrying [source: CPP cultural values discussion; response is synthesis]. Ask before advising. Distinguish practices that differ from your norm from practices that harm. Adapt guidance accordingly.
Non-attendance at the clinic (AFC-PIP model) [synthesis]. Consider outreach or home visits, as in the Fraiberg frame. Offer transport help. Review timing around feeds and naps.
Premature or forced endings (placement change, court decision, family moves away) [source: CYFD NM CPP manual (termination triggered by permanency decisions); response is synthesis]. Hold at least one goodbye session, with a simple story for the child of why it is ending. Pass on to the new carers what helps the child, with consent or as legally permitted.
Relapse near the ending [source: CPP termination steps; response is synthesis]. Normalise it as a reaction to loss. Do not extend automatically; review whether the gains are holding.

Sources

Sources

Further reading (full text not drawn on unless listed above)

Fraiberg, S., Adelson, E. & Shapiro, V. (1975). Ghosts in the nursery: a psychoanalytic approach to the problems of impaired infant-mother relationships. J. Am. Acad. Child Psychiatry, 14, 387–421. [Content is taken from secondary accounts and is marked [uncertain] where detailed.]
Fraiberg, S., Shapiro, V. & Adelson, E. (1976). Infant-parent psychotherapy on behalf of a child in a critical nutritional state. Psychoanalytic Study of the Child, 31.
Fraiberg, S. & Adelson, E. (1977). An abandoned mother, an abandoned baby. Bulletin of the Menninger Clinic, 41.
Fraiberg, S. (ed.) (1980). Clinical Studies in Infant Mental Health: The First Year of Life. Basic Books / Tavistock.
Lieberman, A. F., Padrón, E., Van Horn, P. & Harris, W. W. (2005). Angels in the nursery. Infant Mental Health Journal, 26, 504–520.
Lieberman, A. F., Ghosh Ippen, C. & Van Horn, P. (2015). Don't Hit My Mommy! A Manual for Child-Parent Psychotherapy with Young Children Exposed to Violence and Other Trauma (2nd ed.). Zero to Three.
Baradon, T. et al. (2005; 2nd ed. 2016). The Practice of Psychoanalytic Parent-Infant Psychotherapy: Claiming the Baby. Routledge.
Stern, D. N. (1995). The Motherhood Constellation. Basic Books.
Pawl, J. H. & St. John, M. (1998). How You Are Is as Important as What You Do. Zero to Three.

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