In interaction with their mother, infants not only learn how human relationships work, but – on an even more basic level – the continuous bidirectional, interactive regulation between mother and infant shapes the infant’s socioemotional development. Coordinated interactions alternate with uncoordinated ones, the latter resulting in momentary ruptures during this dyadic exchange. Usually, these are quickly repaired. The mother’s capacity for engaging with her infant in a sensitive and appropriate manner is crucial for successful socioemotional development. On a transgenerational level, a mother will draw on her own relational experiences – embodied as implicit memory – when interacting with her baby. Thus, comprehensive and effective treatment of maternal postpartum disorders that often impair the mother’s interactive skills and capacity for maternal bonding is of great importance. One aim of modern mother-infant treatment is to target dysfunctional interactive patterns, often with the help of video feedback and microanalysis of behavioral observations. In this paper, after giving an overview of affective regulation in mother-infant dyads and the role of maternal factors and postpartum mental health, we describe relationship-focused approaches to mother-infant treatment. Our focus lies on video feedback and body-oriented interventions. We also explore classical as well as contemporary theoretical underpinnings in mother-infant research and how psychoanalytic concepts like containment and mentalization not only enrich approaches to mother-infant treatment but also adult treatment in general. We conclude that working with and expanding one’s own implicit relational knowledge is central for the therapeutic process and can be initiated by video-based interventions or by genuinely experiencing and reflecting on interactions in dyads and groups.

© 2022 S. Karger AG, Basel

Introduction

A primary focus in the research of infant development is on the interaction between mother and infant: not only is the mother most often the primary caregiver, but this dyad also begins earlier than all other social relationships and is characterized by the unique physicality during pregnancy, birth, and, where given, the breastfeeding phase (e.g., [1, 2]). In fact, maternal-fetal bonding has been shown to be an early predictor of the quality of later maternal bonding (e.g., [3]; see overview in [4]). While the importance of paternal influences is recognized in current research [5], this justifies focusing on the postpartum maternal experience.

Basically, every interaction in the first place is an interaction between bodies [2]. That is especially the case in earliest child development, where sensorimotor experiences predominate (e.g., [6]). As Donald Winnicott [7] pointed out, the way a mother holds her baby and how she interacts with her infant lays the groundwork for self-perception and for the lifelong sense of identity in one’s own body. Yet, the infant does not form explicit memories. Though the child is learning continuously, the infant brain does not yet process these experiences also as conscious (explicit) memories but only as implicit memories (e.g., [8]). Any experienced interaction is internalized, or as Geuter ([1], p. 210) put it, the “basic patterns of body awareness and self-experiencing, emotional experiencing, and affect regulation are acquired in early dialog as a child” [translated by the authors].

The concept of relational and every other experience being stored as implicit or procedural memory, and thus being “embodied,” was utilized in experiential and body-oriented psychotherapeutic approaches from early on, although not always being termed as such (e.g., [9]). Contemporary theorists and practitioners of body psychotherapy (e.g., [10, 11]), or body-oriented psychotherapy, as we prefer to call it, rely more explicitly on this concept. The term “embodiment” is borrowed from cognitive science, according to which cognition is shaped by the fact of having a physical body. In clinical psychology and especially in psychotherapy, embodiment in that sense refers to the fundamental inseparability of body and mind: not only are cognitions and affects reflected in physical events (“mindful body”) but also posture and behavior which in turn influence cognitions and affects (“embodied mind”) (see overview in [1, 11]).

Downing [10] was one of the first to combine concepts of body-focused psychotherapy with modern infant research. From interactive experiences in early development, a sort of individual “core repertoire” is formed, which was labeled differently by Downing over the years, e.g., as affect-motor schemas, body organizing, or bodily micropractices. These terms describe the abilities and strategies anchored in the body for regulating proximity and distance in interactions as well as for regulating and expressing affect [12]. A mother will draw on her own implicitly stored repertoire of bodily micropractices when interacting with her infant and this will influence the quality of the relationship. So, the “embodied” sensorimotor-affective experiences from mother-infant interaction (or “implicit relational knowing,” e.g., [13]) are significant for the transgenerational transmission of developmentally relevant interactional experiences. This notion of an implicit or procedurally formed level of “relational knowing” is not at odds with attachment theory and Bowlby’s description of internal working models but rather places more emphasis on bodily experiences (see [14], for a discussion of attachment theory and embodiment). From our point of view, it seems only logical to integrate relationship- and body-oriented interventions into approaches to caregiver-infant treatment in general and in the treatment of postpartum disorders in particular.

In the following, we present our point of view on how the results of infant research and experiences from clinical work with mothers and their infants not only strongly suggest a relationship-focused and body-oriented approach in mother-infant treatment but also might enrich adult treatment in general. We are not the first to do so, and we will draw on the seminal work of, among others, the Boston Change Process Study Group (e.g., [13, 15]), as well as Fonagy et al. [16] and Beebe and Lachmann [17]. After a short overview of affective regulation in the mother-infant dyad and the role of maternal factors and postpartum mental health, we give examples for relationship-focused approaches in mother-infant treatment, highlighting Downing’s Video Intervention Therapy and its body-oriented approach (e.g., [18]), and mentalization-based group approaches with high-risk mother-infant dyads (e.g., [19]). We conclude with summarizing how the interactive experiences from the mother-infant dyad serve as a template for later relationships, even in therapeutic settings.

Interactive Regulation in the Mother-Infant Dyad

A substantial number of both earlier and more recent studies (see overview in [20]) point to the significance of specific interactive patterns in the mother-infant dyad for infant affective regulation in the first months of life. These interactive patterns are shaped by the self-regulatory and interactive abilities of both interaction partners: Three-month-old infants already initiate a great part of their interactions on their own, as was found quite early in modern infant research (e.g., [21]). The infant’s innate ability for communication and intersubjectivity is met by the equally universal intuitive parental skills for simplified communication when engaging with an infant (see below), so that both sides can share a common experience and constantly reinforce each other [22]. For the neurobiological foundations of this shared intersubjectivity, see, e.g., Fuchs [2] (chapter 5).

Mutual Regulation and the Still-Face Paradigm

The bidirectional, interactive regulation between mother and infant has been described in detail by Edward Tronick’s research group (Mutual Regulation Model; [23]). During face-to-face interaction, both partners coordinate their behavior in an effort to maintain optimal levels of engagement, arousal, and affective regulation. These mutual behavioral adaptations largely take place outside of conscious perception – also on the mother’s side. Presumably, these experiences are internalized by both the infant and the mother, forming – or expanding in the mother’s case – the basis for implicit relational knowing, which is the “procedural knowledge of how to do things with others” ([13], p. 284). Basically, the infant expects contingent behavior from the mother and is irritated when this assumption is violated – or as Beebe and Lachmann ([17], p. 314) described it: “Infants are contingency-detectors from birth.”

This notion is impressively demonstrated by the so-called “face-to-face still-face” paradigm (FFSF; [24]). Most often conducted with infants aged between 3 and 9 months, the experimental paradigm consists of three consecutive episodes, each lasting 2 min, in which the infant is placed vis-à-vis of the mother, so they can look at each other. In the first phase (face-to-face), the mother interacts and plays with the infant as usual. For the second phase (still-face), the mother has been instructed to look over the infant’s head with a neutral facial expression without reacting to her infant. The infant experiences this interruption of maternal engagement as a stressor and shows less positive affect in general and various behaviors from fussing and trying to reengage the mother to gazing away and other forms of withdrawal (see overview in [25]). In the third and last phase of the experiment, the mother resumes the interaction (“reunion”). The successful return to a positive exchange reflects the affective regulation skills in the dyad, and thus also the general quality of the mother-infant relationship or the degree of maternal sensitivity, respectively [26].

According to the Mutual Regulation Model, the interactive partners continuously alternate between well-coordinated exchanges (“matches”) and less coordinated ones (“mismatches” or “interactive errors”). This oscillation between interactive states is the rule, and most interactive errors are quickly repaired [23]. Possibly, it is precisely these processes of interactive repair (i.e., the coordination of behavior, gaze, affect, vocalization, etc. of both interaction partners in order to transform an asynchronous state into a synchronous state) and the associated experience of self-efficacy and of acquiring effective interactive coping skills that are of particular developmental importance for fostering affect regulation competency and for attachment formation ([27], see also [28, 29]). For example, regarding affect regulation, Müller et al. [30] were able to show that lower latency in interactive repair (i.e., mismatches are resolved faster) is associated with lower cortisol reactivity (i.e., the infants aged between 3 and 8 months reacted with less distress during the still-face episode of the FFSF experiment). In this sample of mothers with either one or more diagnoses of anxiety disorders or no diagnosis (healthy controls), diagnostic status was not significantly related to infant cortisol reactivity. In a follow-up with infants aged between 12 and 24 months [31], attachment security was assessed via the Strange Situation paradigm [32]. While diagnostic status at 3–8 months postpartum predicted later child attachment status best, with children of clinically anxious mothers being more than five times more likely to be insecurely attached, increased latency to interactive repair measured during the FFSF paradigm at 3–8 months postpartum also predicted insecure attachment. Taken together, the quality of interactive regulation in mother-infant dyads – or caregiver-infant dyads in general – influences the infant’s socioemotional development, and it is important to examine which parental qualities foster successful interactive regulation.

Maternal Sensitivity and Maternal Bonding as Central Conditions for Infant Development

The intuitive parental skills mentioned above have been described in detail, e.g., in Papoušek and Papoušek [33]. These skills are biologically anchored and – to some extent – universally found across cultures [34] and they are called upon spontaneously during interaction with an infant. This genuine parental behavioral repertoire includes distinct modifications of speech (e.g., in pace and pitch), facial expressions, and body language (with simplified, prototypical forms of behavior, e.g., an exaggerated greeting response when the baby is looking); it is adapted to and guided by the infant’s receptive capacity [35]. In this way, the caregiver supports the infant’s affect regulation, arousal, and attention. Essentially, intuitive parenting results in an optimal support for the infant’s development within a well-designed reciprocal reward system [35]. However, despite being biologically anchored, this central parental equipment requires a certain responsiveness and is quite susceptible to faults. The extent to which the mother can attune to her baby is determined by individual as well as environmental factors (see, e.g., the dynamic model of postpartum development of parent-infant communication by Papoušek and von Hofacker [36] or Feldman’s [37] model of parenting behavior); as one example, postpartum depression might hamper her responsiveness (see below).

Infants depend on maternal regulatory support as their self-regulation skills are not yet sufficiently developed. This is why responsiveness or sensitivity – in the sense of Mary Ainsworth – on the part of the mother is so crucial, i.e., perceiving the infant’s signals, interpreting them appropriately, and responding to them in a contingent and appropriate manner. According to Ainsworth et al. [32], infants are more likely to develop a secure attachment to caregivers who are sensitive to their needs. In later attachment research, maternal sensitivity has been discussed as one of the pathways through which the mother’s attachment representation is passed on to the offspring (e.g., [38]). One precondition for being a sensitive mother is the capacity to perceive and (appropriately) interpret the infant’s behavior in terms of their inner mental states, that is, so-called parental mentalizing (e.g., [39]). A meta-analysis found that while both parental sensitivity and parental mentalizing were related to infant attachment (studies with mother-infant dyads as well as with father-infant dyads were included), mentalization additionally fostered infant attachment security via more parental sensitivity [40]. Also – as Shai and Belsky [41] pointed out and quite important in this context – while the assessment of parental mentalizing capacity often relies on parents’ verbal expressions, mentalizing is not solely limited to that channel. The authors coined the term “parental embodied mentalizing” to describe the parents’ implicit understanding and extrapolation of the infant’s mental states from the infant’s movements and body posture on the one hand and them adjusting their kinesthetic patterns accordingly on the other ([41]; p. 173).

Another crucial influence on the infant’s social and emotional development is maternal bonding, that is, the mother’s emotional attachment to her infant – as opposed to the infant’s attachment to the mother and other caregivers. Maternal bonding begins to develop during pregnancy: the mother anticipates her role as a mother and she directs her attention to the fetus, e.g., observing her belly when the baby moves [42]. Ideally, this bond increases as the pregnancy advances [43]. Maternal bonding predicts, e.g., health-promoting practices during pregnancy [44] but also the quality of later postpartum maternal bonding [3, 45] and maternal sensitivity [46, 47]. A sufficiently established postpartum bond is essential for adequate and constant care of the infant despite the toll taken by the efforts involved (e.g., sleep deprivation). Overall, higher maternal bonding is associated with more favorable developmental outcomes in infants, e.g., higher attachment quality and easier temperament [48].

Postpartum Depression, Anxiety Disorders, and Bonding Impairment

With the exception of a slightly increased risk for an episode of major depression, the risk for peri- or postpartum depressive and anxiety disorders for pregnant women or those who have recently delivered a baby is similar to other women of child-bearing age [49]. A meta-analysis found an average prevalence for depressive disorders according to DSM-5 of 11.9% for the peripartum period (onset up to 4 weeks after birth), with higher prevalences in low- and middle-income countries compared to high-income countries [50]. Regarding anxiety disorders, a meta-analysis found a prevalence of 8.5% for at least one anxiety disorder (including diagnoses of posttraumatic stress disorder and obsessive-compulsive disorder) in women up to 1 year postpartum [51]. This rate might be even higher (20.7%) as found by another meta-analysis choosing a different statistical approach [52]; however, in both meta-analyses, heterogeneity was high. In a representative German study, the prevalence rates for depressive disorders within the first 12 weeks after delivery were 6% and for anxiety disorders, 11%, with significant comorbidity [53]. Numerous studies attest to the negative long-term consequences of maternal mental illness around birth for the child’s development, both in the cognitive and social-emotional area and concerning behavioral problems (see overview in [54]). Hence, researching postpartum disorders and how they affect the mother-infant interaction is highly relevant [55-57].

From a clinical viewpoint, in addition to typical symptoms of the respective disorders as defined in international classification systems, mothers with postpartum depression or anxiety disorders experience specific dysfunctional cognitions and anxieties about their role as a mother and about the infant, e.g., exaggerated worries about the health of the baby, feelings of being overwhelmed and fear of being alone with the baby, or compulsive thoughts of harming the child ([58, 59], see also [60]). So, mothers experiencing postpartum disorders may feel or actually be impaired in their parenting behavior as well as in their bonding.

In fact, impaired bonding occurs more frequently in connection with depressive symptoms in the pre- or postpartum period, and it can persist even after remission of symptoms in mothers with postpartum depression [61]. There are fewer findings on postpartum anxiety disorders, but maternal bonding can be impaired, especially in the presence of depressive symptoms and pronounced avoidance behavior [62]. If maternal bonding is impaired, mothers may feel or express less affection toward the infant or think that they are not able to love their baby “properly.” Instead, they may show indifference or rejection, even up to the point of hostility and wishing the baby would die or somehow disappear [63].

Mothers with depressive symptoms generally tend to show less positive but more negative affect toward their infants and a lack of sensitivity and responsiveness. However, while some are rather withdrawn and disengaged, others show anger and intrusive behaviors [56, 64]. During the face-to-face still-face experiment, depressed mothers and their infants exhibited a lower degree of affective and behavioral “matching” and their interactive repair took longer, that is, to move from a “mismatch” to a resolution with a renewed “match” [65]. There is also evidence that infants of depressed mothers make significantly less effort to activate their mothers during the still-face episode of the experiment than infants of healthy mothers [56]. Moreover, they react specifically to the interactive behavior of their mothers: With more intrusively acting mothers, the infants usually averted their eyes; they cried little but showed angry affect. Infants of mothers who were withdrawn and emotionally unavailable, on the other hand, cried more often and seemed sad and disturbed.

Basically, the lower sensitivity and emotional availability of mothers with postpartum depression is one presumable path for transgenerational transmission of depressive affects (see [56]). However, such clinically relevant interactional deficits occur particularly in mothers with severe and chronic depressive symptoms [66]. Also, long-term consequences of maternal depression for child development were associated with more severe and chronic depressive symptoms in mothers [67]. Still, clinical interventions that directly address dysfunctional interactive patterns occurring in the mother-infant dyad might be of advantage in less severe cases as well.

Mother-Infant Psychotherapy: Focusing on the Relationship

While a wealth of studies attest to the overall efficacy of the treatment of pre- and postpartum depression (see [68, 69]), most of these studies exclusively focus on depressive symptoms as outcome [70]. However, Forman et al. [71] showed that despite successful treatment of maternal depression and some reduction of parenting stress, a primarily symptom-specific treatment that focused on the mother (interpersonal psychotherapy in this study’s case) did neither improve the quality of mother-infant relationship or maternal responsiveness, nor the child’s socioemotional development. Thus, inpatient as well as outpatient treatment should not only focus on maternal psychopathology but also on mother-infant interaction [72]. Ideally, symptom-specific and mother-infant-focused interventions complement each other; see Goodman [60] for a short overview of approaches. Most of these dyadic interventions refer to attachment theory or to psychodynamic theory in general. However, a meta-analysis with randomized controlled trials (RCTs) evaluating psychodynamic mother-infant psychotherapy for postpartum depression could not show substantial improvements regarding mother-infant interaction or infant attachment [73], so there is still a need for more refined interventions in this specific population. A meta-analysis focusing on RCTs with clinical samples in general (either a parent showed mental health problems or the infant showed attachment or dysregulation problems) found some evidence that psychodynamic parent-infant psychotherapy could improve infant attachment security [74]. One of the evaluated approaches was “Watch, Wait, and Wonder” ([75], see [76]), another was the “New Beginnings” program ([19]; see below).

Another promising approach might be video feedback (e.g., [77]; see a recent meta-analysis for an overview of evaluated video-feedback interventions [78]). According to Downing et al. [18], video feedback helps to explore the implicit, nonverbal processes in the mother-infant dyad and, in that way, stimulates changes in interactive behavior (see also [35, 79]). Video feedback is a technique that has been used in both behaviorally and psychodynamically informed dyadic approaches. A large meta-analysis on mostly preventive studies with nonclinical samples showed that interventions including video feedback were particularly helpful in improving maternal sensitivity [80]. A more recent meta-analysis focusing on video-feedback interventions in high-risk populations (defined as showing problems that might impact child attachment or parental sensitivity – also studies with fathers were included in the analyses) found evidence that these interventions increased parental sensitivity [78]. Evidence regarding attachment security was inconclusive. However, another recent meta-analysis exclusively focusing on a specific program (Video-feedback Intervention to Promote Positive Parenting and Sensitive Discipline, VIPP-SD; see [81]) found significant effects for sensitive parenting as well as for child attachment security but not for child externalizing behavior [82]. Below, we elaborate on three interventional approaches that incorporate important therapeutic elements and draw upon both contemporary and earlier research on the mother-child dyad.

George Downing’s Video Intervention Therapy

In light of all the above, treatment for postpartum disorders should never exclusively focus on the mother’s symptoms but also on the actual interaction between mother and child. Integrating body-oriented interventions and video feedback fosters the mother’s self-awareness and helps to explore the “remembering context” as Stern posed it, that is, the mother’s own experiences in infancy that are inevitably but not necessarily consciously evoked when caring for her baby ([83]; p. 180ff). We deem the Video Intervention Therapy (VIT) developed by Downing (e.g., [18]) as a particularly viable approach that smoothly integrates all these methods. VIT has not been evaluated in RCTs so far, but a first pilot study with a program comprising of VIT, psychological counseling, and developmental guidance showed favorable results regarding maternal sensitivity, as well as dyadic emotional regulation in adolescent mothers and their infants [84]. During VIT, individual dysfunctional interactive patterns (e.g., intrusive behavior of the mother and withdrawal behavior of the baby, e.g., by avoiding eye contact) are identified in video-analysis and then discussed with the mother using footage from typical everyday situations (e.g., playing, feeding, or changing diapers). The aim is to improve maternal contact and bonding skills as well as promote maternal sensitivity to infant stress signals. Watching the recordings together, first the mother’s attention is directed to positive aspects of the interaction in order to support her in her experience of self-efficacy as a mother. The dysfunctional interactive patterns are addressed by seeking a positive exception and encouraging the mother to show these positive behaviors more often. Nevertheless, in case of mothers with more severe postpartum depression, intensive video-based intervention should not start before the mother has stabilized sufficiently in the course of treatment of the acute symptoms of depression or anxiety. Clinicians should be cautious not to overwhelm the mother’s coping abilities and not to increase already existing fears of failure and feelings of guilt.

Taken together, VIT may help uncover the implicit nonverbal processes in the mother-infant dyad (as described in the Mutual Regulation Model) and stimulate changes in the interactive behavior patterns. In this process, the mother gets to know her personal, implicitly stored core repertoire of “body organizing” when relating to others, that is, her very own “bodily micropractices” for the regulation of proximity and distance in the mother-infant dyad, which she herself may have acquired in contact with her own mother [10, 12]. The exploration of her biographical background and of individual coping strategies and attachment style, stemming from early interactive experiences that may be triggered when caring for the infant, is therefore of great importance (see also [83]). By becoming aware of her implicitly stored embodied experiences, which often manifest themselves on a more procedural, nonverbal – in analytical terms, on an unconscious – level (e.g., in the rhythm of interactional exchange), the mother learns either to actively avoid previous dysfunctional interactive patterns, or to better repair interactive ruptures – and this not necessarily consciously so but by fostering her capacity for embodied mentalizing in the sense of Shai and Belsky [41]. Also, on a more cognitive level, the often negative perceptions a depressed mother has of herself, of her child, and of their relationship can be corrected. For example, giving the mother ample time to view a still image of how intensely her baby is watching her helps to correct previously stuck cognitions such as “My baby does not love me” (example taken from [85]). Another possible starting point is typical defense mechanisms of the body, such as shallow breathing or tensing the body, which usually serve the function of not having to experience unwanted feelings [1, 10]. For example, by watching a video excerpt where the mother seems to be disengaged, the mother’s physical posture – e.g., how she holds her baby – can be observed and discussed in the therapeutic session (“outer movie”; [86]); and, more importantly, the mother may reenact her own posture and put herself mentally in her own shoes (“inner movie”) in order to become more aware of her feelings like anger or disappointment. She may have learned as an infant, e.g., when being cared for by an intrusive mother, to withdraw into herself instead of protesting. For her own child, however, her withdrawal is like a still-face situation, and their connection is temporarily disrupted.

So, this kind of video feedback is also a body-oriented approach insofar as the mother is supported in developing an accepting and loving relationship with her own bodily experiences and is encouraged to test her new-found awareness in direct contact with her baby. To do so, she needs to be encouraged to perceive previously suppressed emotions (e.g., by being instructed to find out where in her body she has a certain sensation or to intensify this sensation through movement) but also to be able to express them in a safe environment.

Wilfred Bion’s Concept of Container/Contained

By encouraging a distressed mother to express her emotions and responding to her in a sensitive manner, the therapist addresses the patient’s need for affect regulation and fosters her self-regulation skills. Similar to the regulatory processes in the mother-infant dyad, successful mutual regulation strengthens the – therapeutic – relationship, thus preparing the basis for further development of the patient (see [15] and below).

These ideas match well with the classical analytical concept of “container and contained” by Bion [87]. According to Bion, the infant on its own would be overwhelmed by his or her strong sensations and affects, projecting these distressing states upon the mother instead. The mother receives and transforms these experiences into more “digestible” elements; the infant, in turn, is able to reintroject. To do so, the mother needs to empathize with her child, sensitively picking up his or her nonverbal cues with an open mind (a state coined “reverie” by Bion [87]). If she successfully contains the experiences of her infant, this shared reality is the foundation for the child’s experience of “being known by another” ([88], p. 264) – and thus for secure attachment (see [16]). However, due to the psychosocial stress or the inner states of the mother, the maternal containing function can be temporarily, repeatedly, or continuously impaired, which could in turn impair her infant’s development.

Taken together, the psychoanalytic concept of containment was originally conceptualized as a maternal function, which was adopted by therapists to support their patients in regulating their affects. Using case material from the classic paper by Fraiberg et al. [89], Malone and Dayton [88] describe how therapeutic containment is the prerequisite to help a severely distressed mother function as a container for her baby’s affects. By giving the mother the space to remember, explore, and, above all, express so far unprocessed experiences, and by containing them in the sense of Bion, the therapist helps the mother to actually perceive her baby instead of projecting early experiences of rejection or violence onto the child. That way she no longer uses her baby as involuntary container of her affective needs. The “ghosts in the nursery,” as Fraiberg et al. [89] called them, are banished – they are contained. In order to achieve this, the therapist must be sensitive – much like a mother or other primary caregiver. Just like in the mother-infant dyad, it is less important whether there is always a “match,” but rather if “interactive repair,” that is mutual understanding, is achieved again after disruption [90].

Drawing on both Bion’s concept of containment as well as the above-mentioned papers from the Boston Change Process Study Group, Bain et al. [90] describe the therapeutic processes in group treatment with mothers and their babies living in a shelter in Johannesburg. The authors demonstrate how the therapists’ minds as well as the “group mind” helped to contain the affective ruptures and intense emotions occurring during sessions. All seven mothers in this particular group were HIV-positive and reported experiences of early loss and abuse. Recurring themes were issues of shame and reluctance to trust and to form attachments. Especially trust was an important group issue where members were “socioeconomically deprived, marginalised black women, and the two therapists were white and middle-class” (p. 35). One major therapeutic aim was to break the cycle of intergenerational transmission of shame and mistrust by supporting the mothers to open up to the needs of their infants. In the words of the authors: “How do we make space for the minds of babies in the minds of mothers who need to believe their babies have no minds, thereby avoiding the pain of their own infantile experience of not being thought about or protected?” (p. 34).

Peter Fonagy, Mary Target, and Mentalization-Based Group Treatment

The therapeutic groups conducted by Bain and colleagues (see also [91]) were based on the “New Beginnings” program, a short-term mother-infant group format with the aim to improve attachment in high-risk mother-infant dyads, e.g., young mothers in prison, by fostering the mothers’ capacity for reflective functioning and mentalization [19]. The concept of mentalizing – that is, perceiving and interpreting behavior in terms of intentional mental states (e.g., [39]) – was developed by the research group around Peter Fonagy and Mary Hepworth (formerly M. Target): In order to further investigate intersubjective processes of affect regulation, Fonagy et al. [16] collected and reviewed a wide array of evidence from research on the early mother-child dyad. Their work of how processes of affect regulation and mirroring can either foster the development of the self or cause pathologies when failing led to a specific treatment approach, namely mentalization-based treatment [92]. Mentalization-based treatment has shown to be effective in individual as well as in group settings for diverse indications, borderline personality disorder in particular [93]. According to Bateman et al. [94], group therapy is a very suitable setting for patients to practice mentalizing within multiple relationships in a safer space than their regular social environment. Ruptures in group communications (among group members or between therapist and a group member) will certainly occur, with the opportunity to experience reparation, agency, and a “joint intentionality” (p. 7). In his pioneering work towards group-analytic therapy, Foulkes [95] coined the term “ego training in action,” describing therapeutic groups as a field of experiencing and reflecting multiple relations where the ego/the self can be developed and strengthened by this experience.

Conclusion: From the Mother-Infant Dyad to Therapeutic Dyads and Groups

The insights gained from infant research on the nature and importance of interactive regulation in the mother-infant dyad can be transferred to research on the therapeutic process as well as to clinical practice. Experiences from the mother-infant dyad function as a basic template for affective self-regulation and for how to relate to others – which means they also influence the therapeutic relationship not only in mother-infant therapy in particular but also in adult treatment in general, whether in individual or group settings. “Mentalizing the baby,” containing the infant’s otherwise overwhelming affects, repairing the inevitably recurring ruptures in interaction… all of these maternal functions (or functions of a primary caregiver, respectively) lay implicitly stored foundations for later relationships and the child’s own capacities for mentalizing, containment, and interactive reparation. These capacities become especially important when the child – many relational experiences later – becomes a caregiver, e.g., as a mother; or becomes a therapist who needs all these qualities as well. Most importantly, the early “dyadic dance” as some authors put it (e.g., [20]) is characterized not only by the meeting of two minds but above all by the meeting of two bodies – on the part of the infant the interaction is exclusively preverbal (e.g., [96]). This is one reason why mother-infant therapy should address nonverbal aspects of the mother’s interactive behavior and why we consider a body-oriented approach as an important avenue for intervention. To gain more insight in what is helpful in fostering the infant’s development, we need to look more closely to what is actually happening, which is why video feedback in treatment and microanalysis of interactive behavior in research is so valuable. Shai [97] developed a coding system that aims to capture parental mentalizing on a somatic and kinesthetic level, focusing on movement qualities and interactive movement patterns. Together with other methods for observing and rating parent-infant interaction, this kind of fine-grained analyses will shed even more light on interactive regulation. Additionally, the respective research methods might be transferable for analyzing interactive regulation in therapeutic dyads and groups as well.

In an extension of the Mutual Regulation Model, Tronick [15] argues that in both the mother-infant dyad and in therapy each partner can be viewed as a self-organizing system (in the sense of systems theory) that creates its own states of consciousness which can be expanded to higher levels of coherence and complexity when interacting with another. This process of shared intersubjectivity is a fulfilling experience and it drives further development. Just as the infant acquires implicit relational knowing through this exchange, i.e., knowledge about how “relating to each other” works, the patient as well as the therapist experience “something new, something expanded, and something singular” ([15], p. 298) during their intersubjective exchange and thus expand their implicit knowledge of relationships.

Finally, in this article, we concentrated on the mother-infant dyad as a prototypical constellation. While we do believe that the bigger part of the above-cited research transfers to primary caregivers in general, practically all of this research was actually done with biological mothers and their offspring. We do not want to be understood in a way that we say this can be generalized to all other caregiving constellations and cultural contexts. For example, it was argued that attachment theory is more specific for Western societies with a tendency towards individuality and autonomy of the individual whilst other cultural contexts might be different [98]. In clinical practice, we need to look as open-minded and deeply as possible into each presenting caregiver-child constellation, assessing and taking cultural background, economic disparity, and other sources of diversity into account. In research and healthcare policies, local context always needs to be considered before implementing intervention strategies.

Acknowledgments

We thank Star Dubber, Dipl.-Psych., for translating parts of the paper and final language-editing. Also, we thank the reviewers for their valuable suggestions, many of which have been included in the final version of this paper.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

None.

Author Contributions

C.R. and M.H. wrote the first draft. R.O. and A.-L.Z. edited the draft. All the authors contributed to and approved of the final manuscript.

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