Parent-infant Psychotherapy Research Articles

Within- and between-session changes of in-session reflective functioning of mothers in dyadic parent–infant psychotherapy

Objective: This study investigated if in-session reflective functioning (RF) of mothers improved between and within sessions of brief dyadic focused parent–infant psychotherapy (fPIP) for the treatment of regulatory disorders in infants. Method: In-session RF was coded for 44 therapy sessions from N = 11 mothers randomly selected from a RCT on the efficacy of fPIP as part of secondary analyses. A new rating system distinguished self-focused and child-focused in-session RF. Cumulative ordinal regression models were applied to analyze the dynamics of in-session RF within and across sessions, controlling for word count of each statement. Results: While in-session RF improved significantly within sessions, between-session RF improved significantly only in the second session compared to the first with a significant decrease observed in the last session. Child-focused in-session RF was significantly lower than self-focused in-session RF at the beginning of the sessions but improved significantly stronger than self-focused in-session RF during sessions. Conclusions: In-session RF (particularly in child-focused statements) can be regarded as a dynamic change process relevant within each session of dyadic fPIP. Improvements made on a session-by-session basis may not be maintained until the next session. Implications for practitioners and in-session RF research are discussed.

Virtual parent–infant psychotherapy is impactful and accessible for mothers and babies attending a community perinatal service

ABSTRACT Prior to the COVID-19 pandemic, parent–infant psychotherapy (PIP) was routinely offered face-to-face to mothers and babies attending a UK community perinatal mental health service. The pandemic necessitated the rapid transfer of PIP to a virtual platform to continue delivery at time of increased vulnerability for mothers and babies. This service evaluation sought to evaluate this novel method of delivery, of which, the processes and outcomes were unknown. The findings demonstrated that virtual PIP (vPIP) is impactful and accessible for mothers and their babies, with statistically significant improvements found in maternal mental health and postpartum bonding. Furthermore, interpretative phenomenological analysis (IPA) of interviews exploring the experience and meaning for mothers and babies engaging in vPIP, illuminated the complex therapeutic processes underlying the positive clinical outcomes. In conclusion, this small-scale service evaluation demonstrated that, despite the frustrations and anxieties of working online, mothers in our sample found the overall experience of vPIP to be positive, and to result in real-world differences for them and their babies.

On the State of Training in Parent-Infant/Toddler Psychotherapy in Germany

Regulation disorders in early childhood and postpartum mental disorders of parents can be effectively treated by interventions that involve parents and child (so-called parent-infant psychotherapy, PIP). Availability of PIP in routine care remains low, even though the intervention is in high demand. This study aims to map the current situation of psychotherapy training in PIP in Germany, to record existing obstacles from the perspective of the institutes, and to obtain indications for improving training. Contact persons of training institutes all over Germany were invited to participate in an online survey. N = 95 persons answered questions about possible training in PIP and related advantages and hurdles as well as conditions for a future implementation. Nineteen (22.4 %) of the institutions indicated that PIP was part of their training concept. In 84.2 % of the cases this was aimed at child and adolescent psychotherapists. In 63.6 % of the institutes PIP was treated comprehensively. On average, 2.55 barriers were perceived, most frequently of an organizational nature. 75.9 % of the institutes that did not yet offer PIP would be willing to do so in the future under at least one condition. Among those conditions, information on PIP curricula and specific training content was most frequent (40.7 %).The low implementation of PIP in training seems to be mainly due to barriers of an organizational nature that can be overcome by some simple means, such as the dissemination of model curricula.

Observing and interpreting clinical process: Methods and findings from 'Layered analysis' of parent-infant psychotherapy.

This paper describes a method for investigating clinical process, Layered Analysis, which combines therapist countertransference reports and multi-faceted microanalytic research approaches. Findings from the application of Layered Analysis to video-recorded micro-events of rupture and repair in four psychoanalytic parent-infant psychotherapy sessions are presented. Layered analysis showed that countertransference and observation are complementary perspectives, which enable concomitant study of interactive events, conscious internal experiences, as well as nonconscious and unconscious elements of therapeutic interaction.Interactional rupture and repair were found to constitute co-constructed micro-events that occurred fleetingly and often implicitly, and differed in the structure, coherence and flow of interactions and in the relationship between verbal and nonverbal communication. Furthermore, interactional ruptures were found to sometimes 'get into' the therapist and transiently disrupt their self-organization, such that the therapist became a locus of disruption for the patient(s), actively contributing to the rupture, which thus became embedded in the therapeutic system. Interactive repair was found to be most often initiated by the therapist and to be underpinned by the therapist re-establishing self-regulation, through metabolizing embodied and verbal aspects of the rupture. Studying such processes can enhance our understanding of clinical process, inform therapist training and clinical supervision, and contribute to clinical outcomes.

Mother-Infant Group Intervention on Maternal Depression and Bonding: A Quasi-Experimental Study.

Parent-Infant Psychotherapy (PIP) aims at improving the interaction between parents and their infants. Group intervention has advantages in facilitating universality, support, and social learning. However, the researches on PIP adoption in a group format are limited. This study aims to explore the outcome of a mother-infant group on bonding and maternal depression. Eighty-two infant mothers with subjective distress on parenting or depressed mood were recruited to participate in the intervention group (IG). Another sample of one hundred and ninety-four postpartum women was recruited as the control group (CG). Instruments for outcome measure were the Mother-Infant Bonding Scale, Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory-Second Edition (BDI-II), and Social Network Interaction System Questionnaire. Twelve courses of mother-infant groups were conducted for IG women. Each course consisted of twelve 90-min sessions. IG women joined the intervention with their infants and replied to the instruments at baseline, post-intervention, and follow-up. CG women replied to the instruments at similar intervals. Primary data analyses were performed by the intent-to-treat analysis, ANOVA, and GEE. Relative to CG participants, the IG women experienced significant benefits in most mother-infant bonding scores at both post-intervention and follow-up (ps = .000 - .026). IG women also experienced a greater reduction in follow-up depressive symptoms measured by EPDS (p = .023). However, no significant reduction was noted on BDI-II. Mother-infant group intervention has preliminary effects on improving bonding and reducing depressive symptoms for women with infants. Further studies are warranted to replicate the results.

Relationships reduce risks for child maltreatment: Results of an experimental trial of Infant Mental Health Home Visiting.

Research examining the effectiveness of home visiting programs that reduce child maltreatment or associated risks yield mixed findings; some find positive significant impacts on maltreatment, whereas others find small to no effects. The Michigan Model of Infant Mental Health Home Visiting (IMH-HV) is a manualized, needs-driven, relationship-focused, home-based intervention service that significantly impacts maternal and child outcomes; the effect of this intervention on child maltreatment has not been sufficiently evaluated. The current study examined associations between treatment and dosage of IMH-HV and child abuse potential in a longitudinal, randomized controlled trial (RCT). Participants included 66 mother-infant dyads (Mother M age = 31.93 years at baseline; child M age = 11.22 months at baseline) who received up to 1 year of IMH-HV treatment (Mdn = 32 visits) or no IMH-HV treatment during the study period. Mothers completed a battery of assessments including the Brief Child Abuse Potential Inventory (BCAP) at baseline and at the 12-month follow-up assessment. Regression analyses indicated that after controlling for baseline BCAP scores, those who received any IMH-HV treatment had lower 12-month BCAP scores compared to those who received no treatment. Additionally, participation in more visits was associated with lower child abuse potential at 12 months, and a reduced likelihood of scoring in the risk range. Findings suggest that greater participation in IMH-HV is associated with decreased risk for child maltreatment 1 year after initiating treatment. IMH-HV promotes parent-clinician therapeutic alliance and provides infant-parent psychotherapy which differentiate it from traditional home visiting programs.

Addressing the baby and atypical maternal behaviour in psychoanalytic parent-infant psychotherapy

ABSTRACT This paper aims to further our understanding of the process of therapy in psychoanalytic parent-infant psychotherapy (PPIP). Using a single-case study methodology, it examines the emergence of atypical maternal behaviours in the sessions and considers direct therapeutic work with the baby. The research material for this study consists of video tapes and verbatim transcripts of two sessions from different time points in one good outcome PPIP treatment. The Atypical Maternal Behaviour Instrument for Assessment and Classification (AMBIANCE) coding system is used as a basis for identifying atypical maternal behaviours, as they manifest in the sessions. In addition, the therapist’s intervention in moments of interactive disruption are analysed discursively, with a focus on the utterances that directly address the infant. Findings suggest that the mother exhibited a high frequency of disruptive behaviours, as coded in the AMBIANCE, in the beginning of therapy. These decreased considerably by the end of treatment. In addition, the therapist was seen to respond consistently and flexibly to maternal disruptive behaviours, employing different interventions. Furthermore, the therapist talked directly to the baby for a significant amount of the session time, especially early on in treatment, addressing several different issues. Disrupted maternal behaviours can be discerned and systematically observed in PPIP sessions; these may be addressed in psychoanalytic parent-infant psychotherapy through the therapist’s verbal and nonverbal interactions with the mother and baby. Using different coding systems to examine patterns of interaction in detail, it is possible to gain insight into the therapeutic process, furthering our understanding of change mechanisms in psychoanalytic work with infants and their parents.

Mixed heritage, mixed feelings: psychoanalytic parent infant psychotherapy during the coronavirus pandemic

ABSTRACT This paper is an account of Psychoanalytic Parent Infant Psychotherapy (PPIP) by a white therapist with a mixed heritage family during the coronavirus pandemic. It describes changes to the distant relationship between a mother and her infant son who appears at first to be developing an avoidant, dissociated defensive strategy to ward off painful projections from his traumatised parent. Necessary modifications in treatment due to working remotely contributed to several technical adjustments made. The paper attempts to consider the inclusion of race as a fully integrated aspect of working in a transcultural field, taking into account the ‘ghosts in society’. The specific trauma of racist abuse, with an emphasis on colourism that can be experienced by mixed heritage families is discussed. The key to the improved relationship between child and mother by the end of the Parent Infant Psychotherapy is postulated to have come from reflection on the therapist’s countertransference in regard to racism, that then enabled both therapist and patient/s to recognise and begin to work through experiences, thoughts and fantasies about belonging, heritage and racism.

Parent-infant psychoanalytic psychotherapy when child development is at risk: process assessment

The aim of this study is understanding the psychotherapeutic process in parent-infant psychoanalytic psychotherapy when child development is at risk, focusing on therapeutic interventions. Participants in the research were a 4-month-old baby at the beginning of psychotherapy, whose development was at risk – assessed from the Risk Indicators for Child Development (IRDI) - her parents and a psychotherapist. Thirty parent-infant psychotherapy sessions were carried out over nine months, being recorded in audio and video and subsequently described in detail for classification and intervention analysis by two independent judges. Frequency analysis and qualitative analysis of the collected data were performed. The results showed that there was a change in the types and number of therapeutic interventions used throughout the treatment. The interventions which occurred the most were those specific to parent-infant psychoanalytic psychotherapy when child development is at risk, referred to as prosody. It is known that there is still much to be explored, and further studies would be needed to understand how other interventions in parent-infant psychoanalytic psychotherapy when child development is at risk are characterized, considering that this case may have its specificities, taking into account the history of the family and also the background and personal characteristics of the psychotherapist.

Psychoanalysis with adults inspired by parent–infant psychotherapy: The analyst’s metaphoric function

ABSTRACT This paper investigates a phenomenon observed in parent–infant psychotherapy (PIP). Metaphors emerge in the analyst and, once voiced, they can become tools for understanding the present predicament of mother and/or child. The article contains vignettes from work with a mother and her son, four weeks old when PIP started. They are followed by a vignette of an adult analysand. In both settings, the analyst found himself in an impasse, until he came up with a metaphor expressed to the mother and the analysand, respectively. The paper investigates why PIP experiences might inspire an analyst to suggest metaphors to adult patients as well and thence to understand their suffering better. Aspects of linguistic theory underlining the infantile roots of metaphors are submitted as well as other analysts’ views of using metaphors at work. It describes how the validity of a metaphor – whether it expresses something essential about the patient’s internal world – should be assessed by following up his/her response to it. It defends the position that metaphor, if used with parsimony and sobriety, is a valuable tool in enabling the patient to map their internal world.

Psychodynamic Child and Adolescent Psychiatry and the Future of Our Field

The Accreditation Council for Graduate Medical Education (ACGME) requirements for child and adolescent psychiatry training require that child and adolescent psychiatry fellows demonstrate competence in psychodynamic psychotherapy.1 Child and adolescent psychiatry educators may turn to JAACAP to find up-to-date advances in psychodynamic psychotherapy to teach. However, the term psychodynamic appears to be hard to find, literally. A search on https://www.jaacap.org/ of past issues for psychodynamic2 resulted in 4 articles published in the past year, but none have the word psychodynamic in the title. Three articles describe newer evidence-based forms of psychotherapy: brief focused parent-infant psychotherapy, adolescent-focused therapy, and mentalization-based treatment. These are are described in their respective articles as "psychodynamic-based," as "psychodynamically informed," and having "historical roots in psychodynamic psychotherapy." As none are specifically titled psychodynamic therapy, it is unclear whether teaching these modalities would satisfy the ACGME requirement of competence in psychodynamic psychotherapy. Comparatively, this linguistic dilution does not seem to affect cognitive-behavioral therapy (CBT), another psychotherapy required by the ACGME1: specialized branches such as trauma-focused CBT, CBT for psychosis, and CBT for insomnia all retain the parent name of CBT. Therefore, it is important to define psychodynamic.

The Prevailing Emphasis on the Quality of the Parent-Infant Relationship for Early Intervention

Attachment theory is the buzzword in parenting guides and professional publications, and risk to the child's attachment development is widely used as the threshold for early intervention. Given the severe impact of inaccurately diagnosed attachment disturbances on the child's wellbeing (Granqvist et al., 2017), the valid assessment of the quality of the early parent-infant relationship is crucial.This is particularly relevant during the ongoing pandemic which specifically burdens young families. Based on the psychoanalytic understanding of the parent-infant relationship and its crucial importance for the infant's emerging self, this paper gives an introduction into the early relational development in infancy.The relevance of a psychodynamic diagnosis of relational disturbance in the first year is described using the Parent-Infant Relational Assessment Tool (PIRAT) Global Scales (Broughton, Hommel, the Parent-Infant Project, 2016; Hommel, 2018). Conceptualized at theAnna Freud Centre in London, the PIRAT was developed and validated, by the author.The prevailing emphasis on the importance of early intervention, and the evidence of the effectiveness of parent-infant psychotherapy in improving both parental functioning and fostering secure attachment relationships in young children (Barlow et al., 2013), support the clinical need to detect very early risks for parents and babies (Sleed, 2013).

Assessing therapist and clinician competency in parent-infant psychotherapy: The REARING coding system (RCS) for the group attachment based intervention (GABI).

The development of fidelity and quality measures for the dissemination of evidence-based practices is an often-neglected, vital step in the implementation of psychological interventions, especially within parent-infant mental health. The current study aims to address this gap by developing a competency-based measure for clinicians delivering the Group Attachment Based Intervention (GABI). GABI is an intervention aimed at supporting family preservation in parents who have experienced disparities across multiple systems of care. After observing over 100 hours of clinical video, the research team, comprised of clinicians and academic researchers, developed a competency coding system to measure clinician efficacy titled the REARING coding system (RCS). This paper outlines the development and structure of the measure, including a detailed discussion of the model of therapeutic action (i.e., REARING: reflective functioning, emotional attunement, affect regulation, reticence, intergenerational transmission of attachment, nurturance, and group therapy context), as well as provides a clinical case study to illustrate the utility, flexibility, and depth of the measure. The case study details a family session consisting of a mother, father, and two children (one infant, one toddler), and how RCS can be used in supervision to foster clinical competency and effectiveness in the GABI model. RCS seeks to address the dissemination gap in Evidence Based Practices (EBPs) by contributing to the limited number of existing fidelity and competency measures in infant mental health and psychodynamic dyadic psychotherapy. RCS is an important tool for monitoring clinical competency in the dissemination of GABI and gives supervisors the ability to provide fidelity-focused supervisions.

Learning from mothers who received focused parent–infant psychotherapy for the treatment of their child’s regulatory disorders

ABSTRACT Objective: Gaining a deeper understanding of how focused parent–infant psychotherapy (fPIP) works by asking mothers about their experiences. Method: Purposeful sampling was used to select participants who before had participated in an RCT on fPIP. Nine mothers of infants with early regulatory disorders who had received fPIP were interviewed. Eight cases received full-protocol treatment, one case was a treatment drop-out. Semi-structured interviews were audio-recorded, transcribed verbatim and analyzed applying grounded theory methodology. Results: Seven major categories evolved: (1) engaging in therapy while maintaining autonomy, (2) relating to an emotionally responsive therapist and resolving ruptures, (3) involvement of partners in therapy facilitates multiple perspectives, (4) understanding the meaning of the child’s signals and increasing acceptance of difficult behaviors, (5) feeling supported by advice that is attuned to the families’ needs, (6) insight into parental contributions to the child’s problems and (7) feeling strengthened as a mother and recognizing one’s own needs. Conclusion: Findings highlight which aspects of fPIP mothers find most helpful and most challenging. Aspects that compromised the change process seemed related to the specific needs of this population and therapeutic setting. The results may guide therapists and inspire future development in interventions for treating infant regulatory disorders.

Clinical studies on parent–infant psychotherapy pre- and post-COVID-19 pandemic ‘Making the best of a bad job’ (1)

ABSTRACT In his last writing in 1979, Bion, aged 81, described how ‘when two personalities meet, an emotional storm is created’ and the way that psychotherapy can only ever aim to ‘make the best of a bad job’ by turning that storm between the two people in the room to good account. This paper, whose title refers to Bion’s famous statement, complements a publication by Micotti and Pozzi, on a literature review regarding this topic. The paper describes clinical vignettes from psychoanalytic psychotherapy with parents, infants and children underfive seen in person, then online, in a Specialist National Health Service. Some technical issues in the move from in-person to online work as well as its impact on families and therapists are highlighted here.

Potential efficacy of parent-infant psychotherapy with mothers and their infants from a high-risk population: a randomized controlled pilot trial

BackgroundPsychotherapy of mother-child dyads is an intervention which was developed to prevent maltreatment and negative children’s development. There is a lack of good-quality research investigating psychotherapeutic interventions and social care for mothers at high-risk living in Mother-Child Facilities in Germany. The present randomized controlled pilot trial (RCT) aimed to evaluate the need for parent-infant psychotherapy (PIP) and to explore its impact on the mother-infant relationship. Primary feasibility objectives were recruitment and attrition, with potential efficacy defined as the secondary feasibility objective.MethodsThis pilot RCT focused on (young) mothers with cumulative risk factors and their infants under 7 months of age living in Mother-Child Facilities. N=32 mother-child dyads were randomly allocated to PIP or Care as usual (CAU). Outcomes were assessed at baseline, 3 months, and 6 months of intervention. The primary potential efficacy outcome was maternal sensitivity. Secondary outcomes were maternal mental health problems, reflective functioning, parenting stress, personality organization, infant’s development, and attachment.ResultsAt baseline, all mothers showed low levels of emotional availability, but results revealed improvements in sensitivity, mental health problems, stress, and depressive symptomatology favoring PIP after 6 months. Positive developments in maternal sensitivity, a healthy aspect of mother-child interaction, were only found in the PIP group. Overall attrition was high at 6 months. Some evidence of fewer depressive symptoms and lower maternal distress after 6 months of PIP-intervention exists that did not reach significance.ConclusionFindings revealed improvements in the mother’s well-being for both groups, but PIP had a higher impact on the mother-child dyad. In sum, there is some evidence that PIP may represent an effective intervention offer besides the social and pedagogical support in these facilities, but further research is demanded.Trial registrationDRKS00022485 (retrospectively registered).

Gaze avoidance in parent–infant psychotherapy: Manifestations and technical suggestions

ABSTRACT Infants express emotional distress through whining, crying, flailing, silence, etc., which can be viewed as communications that also afflict the caregiver(s). One expressive mode, subtle and often unnoticed except by the parents, is infant gaze avoidance. It often elicits parental feelings of rejection, shame and despair, and may be a reason for seeking parent–infant psychotherapy. In therapy, the symptom often discloses a disturbance in the dyad’s emotional interaction. Therapy can bring about relief in the symptom and the relational disorder. Sometimes, the therapist discovers that the infant is avoiding the therapist’s, rather than the parents’, eyes. This challenges the therapist’s expertise in establishing contact with the baby and in perceiving and processing emotional reactions to what may be experienced as the baby’s dismissal. Gaze avoidance elicits theoretical questions approached in a previous publication: what does the child seem to avoid in the adult’s eyes, and how can we conceptualize the psychodynamics behind the symptom? It also evokes technical questions: how can the therapist make contact with an infant who avoids the mother’s or the therapist’s eyes? How can the clinician exploit their emotional reactions, the countertransference, to understand and further the dyad’s emotional communication? Two case vignettes are provided.

The effect of the Newcastle Parent Infant Partnership approach: a qualitative evaluation

BackgroundAs a specialised intervention, the Newcastle Parent Infant Partnership (NEWPIP) service supports new parents and their babies experiencing issues affecting their relationship and development within the first 1001 critical days. NEWPIP is one of 34 specialised parent–infant psychotherapy teams across England. We aimed to gather in-depth data to understand parent's lived experiences and the effectiveness of the service, to provide recommendations for future practice. MethodsWith a qualitative approach, this study included ten semi-structured interviews. Guided by narrative methods and open-ended questions, interviews lasted between 30–90 min. Recruitment involved both purposive and convenience sampling. All parents received the service within the past 2 years between March, 2018, and April, 2020. Participants were provided with an information sheet before taking part. All participants electronically signed a consent form and provided verbal consent. Ethics was approved by Newcastle University, Newcastle, UK. Once interviews were complete, researchers transcribed the interviews and analysed the data thematically (NVivo 12), using a three-stage coding method, grounded in the data. Findings11 parents were involved in the study, including ten women and one man, due to the purpose of referrals being predominantly for mothers. Five overarching themes were discovered on the basis of the parent's own sense of empowerment, narratives of time, reflections on a unique approach, impact on relationships, and public awareness and partnerships. The findings illuminated an approach that supports parents to build a better bond with their baby by providing a safe space for parents to heal relationships, although with differences in expectations from parents around time and support required. Parents also felt there should be increased public awareness and improved partnerships with other health organisations to ensure a smooth transition to long-term support and improved outcomes for children after parents have ended their sessions with NEWPIP. InterpretationThe NEWPIP approach provides unique and flexible support, increasing a parent's confidence, autonomy, and deeply understanding the bond with their baby. There was also an emphasis from parents on how to strengthen the fluidity of the NEWPIP approach to incorporate wider service eligibility for parents and their infants within the 1001 critical days and beyond. Nonetheless, referral times were inconsistent and required more clarification. The service requires increased public awareness to highlight the success of the unique approach while also creating greater opportunities for self-referral to increase empowerment felt by parents. The timing and transition of the parents in receipt of the service is fluid and responsive to individual circumstances but could be improved to ensure that care is provided during the 1001 critical days and beyond. FundingNone.

Traumatized Refugee Parents and Infants Considered from Within and Without: The Iraq and Afghanistan Wars as Unexpected Legacies of the September 11th Attacks 20 Years Later

ABSTRACT This paper marks the 20th anniversary of the terrorist attacks of September 11, 2001. It makes the link between the author’s research, which explored the impact of those events on intergenerational trauma and traumatic stress, and the clinical dilemmas that the author encountered in treating Iraqi and Afghan refugees presently. Importantly, the refugee status of these patients was in part linked to the retaliatory actions of the United States in the wake of 9/11. The original hypotheses from the 2003 book, September 11: Trauma and Human Bonds are reviewed with previously unreported clinical vignettes that were a part of the author’s research. The impact of the author’s own experiences is highlighted as he approaches his psychotherapeutic work with Iraqi and Afghan postwar refugees in Switzerland. The author presents two case examples of patients in psychoanalytically oriented parent-infant psychotherapy. He demonstrates how trauma, attachment, development, and ruptures of intersubjectivity between parent and infant as well as between parent-infant dyad and analyst must be considered in the treatment of these complex cases.

Scaffolding the Brain: Key Areas of Evaluation in Infant Parent Psychotherapy

ABSTRACT Clinicians are often challenged by the complexity involved in early childhood infant/parent dyadic assessments and interventions. Working within a right hemisphere developmental period requires clinicians to have a good enough natural relational style that moves easily between the nonverbal implicit worlds of the infant and parent while attending to the parent’s verbal narrative. The author suggests using an evidence informed neurobiological scaffold called Integrative Regulation Therapy (iRT) with evidence based Infant Parent Psychotherapy (IPP) and introduces an iRT assessment that creates a Probable Map of the parent’s neurobiological organization to facilitate intervention by assessing clinical impressions in nine key areas: 1) attachment experience, 2) self-concept, 3) arousal organization, 4) soothing of dysregulated states, 5) use of defenses, 6) use of instinct, 7) use of reflection, 8) hopes and desires, and 9) current level of agency. A composite case will be presented illustrating the clinical use.