Multiple adverse childhood experiences (ACEs) in one generation have been found to increase the risk of ACEs in the next generation, especially through exposure to parental domestic violence, mental illness, and substance abuse. The cost of suffering from abuse, violence, neglect, and trauma for individuals, families, communities, and society at large, has spurred research on the mechanisms of the transference and buffering of intergenerational ACEs, and the development of therapeutic programs addressing multiple and specific ACEs. However, despite the high risk and cost involved in intergenerational ACEs, research on treatment and therapy remains scarce. In particular, there is a significant knowledge gap regarding perinatal psychotherapeutic treatment aimed at preventing or buffering the intergenerational transmission of ACEs at the very beginning of a new generation.
The aim of this study was to explore therapists' and patients' experiences of working with intergenerational ACEs during perinatal therapy, to expand existing clinical and research knowledge. To achieve this objective, we conducted a qualitative study in which pregnant women with ACEs and their perinatal psychotherapists were interviewed about their therapy experiences in general (therapists) and specifically related to “The Angels in the Nursery Interview” (the Angels Interview” for short (patients).
In Paper I, we interviewed 7 therapists individually, and then in a follow-up focus group (FG). We asked them about their experiences with perinatal psychotherapy with families with high ACEs. We explored central therapeutic themes, alliance challenges, therapeutic dilemmas, and therapy outcomes. Our focus included theoretical assumptions, emotional experiences and clinical reflections. The individual interviews involved questions such as the following: What are your experiences with intergenerational ACEs perinatal psychotherapy? What do you find challenging/rewarding? Which themes emerge during therapy? What is unique to this patient group? In what directions would you like the work to develop? The follow-up FG discussed 5 key themes emerging from the individual interviews. Three themes were chosen by the research team, and two themes were chosen by the therapists. To analyze the data, we applied reflexive thematic analysis. Our main findings were the importance of a safe enough therapeutic alliance and advanced tailoring of treatment to meet the needs of a highly heterogeneous group of patients. A holding environment for the therapists was perceived as key to cultivating the much-needed reflective and empathic capacity required to tailor treatment, address therapeutic dilemmas and make therapeutic decisions. The need to feel safe enough to address intergenerational adversities was perceived as a shared need among therapists, patients, and their babies. The babies needed to feel safe enough to develop and thrive. The parents needed to feel safe enough to engage in therapy and experience new ways of being together, which could provide a contrast with their childhood experiences and provide opportunities for them to develop new ways of being with their babies. The therapists needed to feel safe enough to provide a safe place to ponder, try, fail, and try again without losing the empathy or reflection necessary to hold both parents and baby in mind, even when their needs conflicted.
In paper II, we performed a secondary reflexive thematic analysis of a specific therapeutic theme, unexpected changes in the mother-grandmother relationship among perinatal women with ACEs. The theme emerged during the individual interviews and was further discussed during the follow-up FG. Our main finding was that negotiating the mother-grandmother relationship in pregnancy and postpartum in families with high ACEs both resembled and differed from negotiating the motherhood constellation in dyads with fewer childhood adversities. The therapists experienced more abrupt relational changes and greater difficulty in articulating and reflecting upon the relational shifts. The ambivalence seemed stronger, picturing both confusing and conflicting needs of drawing close and distancing oneself from the grandmother. The therapists understood the abrupt relational shifts in light of complicated separation-individuation processes, unresolved trauma, defense mechanisms, and an elevated need for support during pregnancy, birth, and early parenting. Abrupt relational changes could challenge the empathic and reflective capacity. Of the therapists. This paper addressed the therapists` temptation to overlook the ambivalence in renegotiating relationships and lean into the hope of generational change in an early phase and identify too strongly with the “good grandmother transference”. This issue could result in a premature closing of the theme. It was perceived as important that the therapists could hold space for the patients’ ambivalent feelings and thoughts related to childhood memories and the present mother-grandmother relationship and, by doing so, signal the possibility of exploring the ambivalence of wanting and fearing, hoping and being disappointed, needing but not getting their mothers when they became mothers themselves.
In the third paper, we conducted the Angels Interview with 20 pregnant women with high ACEs and asked them about their experience of the interview 4 months postpartum. We wanted to explore the possible benefits and challenges of using the interview clinically. This interview was developed specifically for patients with ACEs and childhood trauma. The data were analyzed using ideal-type analysis. Four ideal types of patient experiences with the Angels Interview were constructed, ranging from very positive experiences to mixed, less significant and painful experiences. These findings suggest that a systematic emphasis on good childhood memories (“angel memories”) can be helpful when dealing with traumas from the past (“ghosts”) in perinatal psychotherapy with pregnant women with ACEs. The paper moreover suggests that the Angels Interview can provide a powerful doorway into the therapeutic work of integrating good and bad childhood memories during pregnancy and a helpful way of framing the work by providing structure and direction. However, the paper emphasized the need to tailor the interview to address alliance insecurities, “ghost memories” during and after the interview, and the lack of “angel memories” and to elicit more complex and mixed memories involving primary caregivers. Suggestions for tailoring involved introducing the interview as a potentially mixed experience, interviewing in a step-by-step manner, probing and validating, and offering a systematic follow-up to attend to the “angel” and “ghost memories” surfacing afterwards.
In summary, the papers presented in this thesis explore therapeutic experiences with perinatal psychotherapy addressing intergenerational adversities. Our findings suggest that it can be challenging to work with generational adversities through perinatal psychotherapy, for both the families involved and their therapists. The dual focus on addressing risk factors, childhood adversities and traumas as well as resilience factors, benevolent childhood memories and strengths suggests a need for highly qualified, empathic and reflective therapists who can address, receive, contain and work with contrasting, competing, ambivalent emotions, thoughts and experiences both within themselves and the patients and between the patients and the therapist. Our findings suggest that intergenerational adversities are inherently existential. The pain of one generation is passed to the next, closely linking the generations together in dysfunctional relational patterns of shame, fear, abuse, and neglect. To open the door to the past requires courage from all the parties involved. Taking a closer look at what happened and what was lacking and englobing both perspectives is challenging. The urge to turn away and avoid the pain instead of encouraging individuals to “speak the unspeakable” (Lieberman & Van Horn, 2005) and be prepared to “hear the unhearable” is a well-known impulse on both sides of the table (therapists and patients). This study recognizes the trickle-down effects of fear and shame, which impact babies, parents, and therapists. It also highlights the potential trickle-down effects of security and safety for all parties involved in therapy, starting with the holding environment for therapists.