Impact of Early Relational Trauma on Psychic Processes: Implications for Treatment of vulnerable Children and Families^*

Impacto do Trauma Relacional Precoce nos Processos Psíquicos em Famílias Vulneráveis: Implicações para o Tratamento de Crianças e Famílias

ABSTRACT

Numerous works and clinical research conducted in various institutions have cast fresh light on the notion of trauma and have contributed to the emergence of the concept of early relational trauma. Early relational trauma is a form of trauma rendered complex by the multiplicity of its sources and its modes of expression. Its main features are often attachment and acting-out disturbances. In families where such trauma occurs, links could sometimes be perverted and form a narcissistic configuration. This mode of functioning, organized around negativity, impacts the plurality of psychic processes and interferes with the treatment approaches of multidisciplinary teams. In order to promote a multifocal approach to care tailored to differences in situations, educational and socio-judicial practitioners.

KEYWORDS:
Early relational trauma; attachment; intersubjectivity; play model; mediation; mentalization

RESUMO

Inúmeros trabalhos e pesquisas clínicas realizados em diversas instituições trouxeram à luz a noção de trauma e contribuíram para o surgimento do conceito de trauma relacional precoce. O trauma relacional precoce é uma forma de trauma complexo pela multiplicidade de suas fontes e seus modos de expressão. Suas principais características são frequentemente distúrbios de apego e atuação. Nas famílias onde ocorre tal trauma que às vezes pode ser pervertido em configurações narcísicas, esse modo de funcionamento organizado em torno da negatividade impacta a pluralidade do psíquico e interfere nas abordagens de tratamento das equipes multidisciplinares. Para promover uma abordagem multifocal de cuidados adaptados às diferenças de situações, profissionais de educação e sócio judiciais.

PALAVRAS-CHAVE:
trauma relacional precoce; apego; intersubjetividade; modelo do jogo; mediação; mentalização

Early relational trauma (ERT) is at the root of many disorders in the pathways of children and adolescents in the care of child protection services (see, for example, Ford and al, 2009).

In this article, we will begin by examining how the notion of ERT can help us gain a better understanding of the problems underlying the difficulties of vulnerable families. Then, we will discuss the consequences of ERT in the implementation of psychic processes, both in the development of children and in the family. Finally, the way ERT impacts mentalization will allow us to reconsider how we support and treat these children and their families.

How the notion of ERT can help us gain a better understanding of the issues at play in vulnerable families?

In patriarchal societies, clinical practice for treating trauma suffered within the family sphere has long remained poorly identified for two main reasons that have contributed to the silence of victims, namely, children and women. The first reason is cultural and social: The model of patriarchal society is still based on a power hierarchy, assigning to the pater families the mission of upholding order and respect within both the nuclear family and the community.

As of the 1990s, a plurality of family models and a culture of family pluralism began to take hold. According to de Singly (1991), these new conceptions were linked primarily to the liberal and individualistic ideal, but also to cultural considerations and changes in social mores (e.g., the quest for equality between men and women). At the same time, the family became a melting pot where its members forged their identity, and this stoked multiple tensions within vulnerable families. Violence broke out mainly when a balance between the desire to belong and the need for individuation was hard to find.

The second reason has to do with the approach to trauma, particularly its economy. This was at the root of the original conflicts between Freud and Ferenczi regarding the causes at the root of trauma. For a long time, these conflicts prevented a more contextual and metapsychological approach to trauma. In 1897, Freud abandoned his notion of neurotica based on actual traumatic events to focus more tightly on the psychic phenomenon of fantasy. Ferenczi opposed this change in direction and revived instead his theory of the early seduction of children by adults in his work on "the confusion of tongues", which long remained in the shadows of his approach to incestual and incestuous abuse (Ferenczi, 1932).

Whether trauma is related to fantasy or derives from an actual shock, the idea gradually took root in psychoanalysis that the story of a trauma and especially its impact on the individual very often covers several representations and even several origins. In this regard, Bokanowski (2002) referred to three types of trauma that can overlap: traumatism, the traumatic and trauma. The last of these is often associated with early damage to the ego, which generates fears of collapse that leave a lasting imprint on the individual in the form of vulnerability or negative attachment (Winnicott, 1974).

The clinical approach of family psychoanalysis has made it possible to specify the sources of this trauma. Guyotat (2005, p. 17) pointed to a traumatic filiation tie (e.g., psychiatric history, unelaborated losses, incest, shame in previous generations) and defined filiation as "that by which an individual connects and is connected, by the group to which they belong, to their real and imaginary ancestors and descendants" [free translation]. Filiation can refer to the origins of the individual in the relationship and the family they fall within. In this case, it is an instituted and symbolic filiation. But he also addresses the importance of narcissistic filiation through which trauma is transmitted. This type of filiation suggests a sort of fatalism about reproducing trauma.

The transmission occurs through coded objects incorporated in descendants that cannot be part of the register of identifications or an intergenerational relationship. These mechanisms will potentiate the narcissistic economy in connection with an incestual and interactive functioning in the family, at the expense of the symbolic and instituted dimension of filiation.

This narcissistic economy renders any process of subjective appropriation very precarious in childhood and causes traumatophilic functioning in adolescence. Traumatic filiation can be redoubled when it occurs on the scale of a group, a community, or a country in the face of migration, being uprooted, or trans-subjective violence in wars or in the tensions experienced by minorities. The traumatic is then transmitted from generation to generation, causing an economy of survival on the scale of a community or a family. In other words, we find ways in which suffering, and evil are trivialized that prevent revisiting the traumatic pockets of the origins. Therefore, faced with these very deep forms of malaise that contaminate several psychic spaces, Kaës (2015) insisted greatly on the need to recognize the various traumatic source by rewiring what can operate in the trans-, inter- and the intra-psychic registers (Drieu, 2020). A clinical vignette will be used to illustrate the authors' statements throughout the article.

Clinical illustration. Ahmed, 16 years old, was hospitalized in an adult psychiatry ward when we met him within the framework of a research-intervention on the situations of so-called difficult adolescents. Placed in a foster family at the age of 7 with his younger brother aged 4, he was described as very agitated, seeking an exclusive relationship with his family assistant, wandering around the farm, and alternating between rage and withdrawal, which made it very difficult to support his schooling.

Origins of the notion of ERT

In families in which his traumatic vulnerability is present, the children will very early in their lives be confronted with forms of overlapping trauma the roots of which can be found in what may have been transmitted in the filiation in the way of negativity, as well as in modes of psychic and emotional attunement where narcissistic paradoxicality and dominance rule (Racamier, 1995). These phenomena result from a distorted narcissistic seduction between a mother and her child, which is to say a seduction with a pathological bent. From the birth of the infant, the narcissistic seduction between the mother and her baby is reciprocal and is organized in response to a proto-fantasy of unison and omnipotence. It is a normal processual phenomenon that contributes to forming the ego and eventually wanes. In vulnerable families with boundary issues, it can persist, become interminable, and trap the developing child because the parent's narcissistic expectation will remain inexhaustible and unattainable (Bonneville-Baruchel, 2015; Racamier, 1995).

Consequently, regarding a particular configuration of "traumatic" or narcissistic filiation, what we see is a genuine telescoping of roles and generations. These representations, who are often the subject of family secrets, impose impossible missions on these children, such as dealing with wounds suffered indirectly by their ancestors. Family members often react to various traumatic experiences such as psychiatric antecedents, unelaborated stories of loss, or experiences of shame linked to identity relegation or being uprooted, for example. These symbolistic events and the family's traumatic history are known to everyone, but the negative impact of the resulting functions cannot be recognized because they are unspeakable. They reverberate throughout the generations in subjugation phenomena. These traumatic circumstances act as veritable black holes in the transmission. In other words, we can observe an inclination towards negativity with interactive defenses leading to modes of denial-based alliances and paradoxical functioning that continue to grow the pathological narcissistic seduction at the expense of the symbolic path between parents and children.

When these narcissistic issues dominate the construction of bonds, parental figures cannot become protective shields or detoxifying figures in the face of their children's needs for emotional regulation. On the contrary, very young children will often be taken to task by the emotional-regulation needs of their parents who enact numerous tensions or violence in their intimacy. Children with parents who present severe psychic wounds and who need narcissistic confirmation from them become the guarantee of their identity, the witness, proof and guarantor of their existence (Racamier, 1995).

We can begin to see emerge from complex trauma mobilizing multiple figures and multiple scenes the representation of ERT in children overwhelmed by the traumatic and the influx of disorganizing stimuli. Bonneville-Baruchel (2015) noted that these children very early on had to live in "an environment offering interactions characterized by unpredictability and the chaos of cathexis and exchange modes" (Bonneville-Baruchel, 2015, p.101; free translation). These early parent-child bonds will generate very insecure attachment modes for these children, sometimes of the avoidant style, but more often of the disorganized-disoriented style. These children will then develop "a singular form of attachment pathology that would hinder and considerably affect the development of their psychic, emotional and relational life […] and have deleterious effects on their cognitive abilities" (Bonneville-Barouchel, 2015, p.101).

Clinical illustration

Ahmed seemed permanently in prey to dissociation and had to forge very archaic forms of defensive strategies in order to survive in the face of fear elicited by the primitive violence caused by parental figures, who themselves were confronted with their own traumatic history (his father and mother were uprooted and exposed to the trauma of war in Algeria, and they had histories of disaffiliation and filicidal fantasies), to which we shall return.

Ahmed and his younger brother are the children of a second union for both their parents. His father, a survivor of the Algerian War, was 67 when Ahmed was born, and his mother was a marginalized woman victim of domestic violence in her first marriage in Algeria. After fighting as a "fellagha" early in the war, his father joined the French side to protect himself from his former brothers in arms, a secret he kept until his death. He then lived alone in France for years and, in time, lost his parents.

Trans-subjective violence was at work in Ahmed's family, and we could clearly see the traumatic incorporation that irradiated any shared experience of transmission. This phenomenon generated dominance in the form of a deadly pact of denial within the two-family groups. Thus, there were active conflicts, including reciprocal disqualification of the parents, denial of a violent reality such as the mother's abortion carried out alone at home, and repeated uprooting of each of them. These conflicts produced a form of paradoxicality in the bonds that reduces sharing and creativity within this family.

It was highly likely that the traumatic incorporations in the history of both parents (previous rapes and crimes, wartime violence in the case of the father, domestic violence and alcoholism in the case of the mother) had a negative impact on the constitution of a space of transmission allowing them to leave their respective families in relationships of creative ambiguity.

How the notion of ERT sheds light on the problems of children and their families

While the sources and, therefore, the situations at the root of ERT in children can differ (e.g., violence, sexual abuse, exposure to spousal or family violence, involvement in parental madness or in perverse relationships, pathological narcissistic seduction which represents narcissistic abuse), the traumatic process is often the same. In all cases, these are distressing situations where the child is regularly overwhelmed in their emotional regulation capacities, their defensive capacities and, therefore, their potential for transforming excitation. It is then no longer possible for the child to cope with the influx of disorganizing stimuli, both in their internal reality and in their relationship to the insecure environment (Bonneville-Baruchel, 2015).

This leads them to rigidify their defense system in order to mobilize archaic defenses such as splitting of the ego and dissociation. Their development is undermined, especially since they are immersed in an environment where the unpredictability of interactions and of unbounded incestual functioning reign. ERT also impact the cognitive abilities of children, who may present developmental delays and difficulties concentrating and learning. Relational modalities are undermined as well: Entering interaction with others awakens major anxieties and excitation in the child (Bonneville-Baruchel, 2015).

Clinical illustration

Unlike his younger brother, Ahmed functioned primarily in a disorganized-disoriented attachment mode. He had difficulty developing adequate defensive strategies to manage the stress of attunement and the stress of separation alike.

The disorders induced by ERT can present similarities with autistic functioning. Indeed, some of these children tend to get stuck on sensory stimuli, which translates into difficulty identifying and, therefore, regulating their emotions and which generates attitudes of withdrawal and isolation. They will react to the stress and insecurity aroused in group situations with agitation and logorrhea, which allows them to compensate for the lack of a containing psychic envelope. Therefore, we can observe traces of autistic functioning in their defective grasp of the limits of the body and of the psyche and, notably, a defective containment function.

However, the comparison stops there since we do not necessarily find the dynamics of self-stimming that we find in autistic children who use autistic objects and exhibit adhesive identification. On the contrary, children who have suffered ERT focus on their own body and sensory experiences. They display forms of clinginess that are reminiscent of adhesive identification but that relate, instead, to an attachment insecurity problem and to prementalizing modes of functioning that push these children to cling to their care figures. Therefore, the conduct disorders that they exhibit often resonate with the early trauma that they may have experienced (Bonneville-Baruchel, 2015).

Clinical illustration

When Ahmed arrived in his foster family at the age of 7, he manifested wandering behaviors and a sort of rhythmic anarchy in his relationship to the world that evidently related to disorganized-insecure attachment and to the numerous trauma that he suffered in the course of early bonding and attunement.

Bonneville-Baruchel (2015) warned that it is difficult to grasp the functioning of these children. They often present a certain heterogeneity of clinical pictures, with very wide differences in attitudes, reactions, modes of cathexis, and defense mechanisms. They can give the impression of having several personalities, which can be disconcerting for professionals. However, depending on the degree of subjugation/dominance, interactivity in the family, and the impact of the ERT, these children will have difficulty identifying, recognizing, or regulating their emotions. Changes in their foster setting will then generate stress that may lead them to shift from an evolved mode of functioning to an archaic mode of functioning marked by autistic or psychotic features.

Impact of ERT on Subjectivation Processes

Paradoxicality in the family and the unraveling of psychic envelopes

In a context of transmission of undisclosed and, therefore, unsymbolized trauma from forebears, the family bonds between parents and children that will be forged will be impacted by pathological modes of narcissistic seduction that will prevent the first games of subjective appropriation from being set up.

This very particular form of narcissistic seduction that imposes itself in the child's life creates a lot of subjugation/dominance and interactivity in the family bonds. In this type of context, the fact of being in a group gives rise to a deadly dominance and to conflicts of dependence, but there are also threats regarding any separation or attempt at individuation where separation can result in death. Dominance can escalate to very particular forms, including mafia collusions, which serve as a paradoxical defense against catastrophic separation anxiety. In addition, they signify the impossibility of constituting a protective psychic family skin. Paradoxicality protects everyone from primitive catastrophic sensations and anxieties (claustrophobic or agoraphobic) but it also prevents any experience of autonomy. Thus, it will lead to antagonistic fantasies of an idealized common envelope and an inadequate common envelope. The envelope is sometimes felt to be too tight (relative to the process of dominance/subjugation) and sometimes too loose, if not broken (relative to fears of breakdown).

Clinical illustration

Having witnessed great tensions between his father and mother and confronted with his mother's trivialized abortions, Ahmed was absorbed by his parents’ problems concerning traumatic filiation. The only logic he could be in was that of adhesive identification or functioning in psychic equivalence mode, which forced him into forms of dependence lest he lose himself in fantasies of being snatched away, which would provoke forms of unraveling of psychic envelopes experienced as imposed representations.

At the trans-subjective level, at the level of cultural and group incorporations, Ahmed inherited the violence suffered by his father during the Algerian War and by his mother as a woman stigmatized by spousal violence. In this regard, his father, faced with the violence against his family during the Algerian War (rape and genocide of members of his clan), went from being a fellagha (member of the National Liberation Front) to being a harkis (auxiliary in the French army). In addition to the need to flee his country, these betrayals at several levels operated like a dismantling of values (social meta-framework) on the psychic organization of the family envelopes, causing a sort of inversion of the guideposts within the taboos and the rules of common sense regarding the differences between the sexes and the generations.

Accused by his clan of being an informer, his father had to flee by embracing the cause of those who saved him, the French soldiers, leaving the family clan to answer for his actions to his former brothers in arms. For some thirty years, he felt condemned to exile and could not return to his native country. Because of a sort of detransitionalization of reality that he faced, returning to the country of his ancestors, be it only symbolically, was impossible, as was attuning to the meta-framework of his host country. Indeed, France at first did not recognize his brothers in arms and then confined them in camps, turning them into wandering souls.

In this regard, Kaës (1989, p.15) stated: "What is erased as not having taken place has no place to be part of, where it can be reflected upon, where the course of individual histories can be articulated with the course of collective history" (free translation).

So, after living reclusively for 20 years, Ahmed’s father wished at his retirement to reconstitute a family. A marriage was arranged at a distance in Algeria with the secret hope of being reunited with the land of his ancestors.

However, traumatic and cultural incorporations-such as the impossibility of mourning lost objects, the ineffectiveness of the fundamental prohibition on murder, and deculturation in exile-seriously undermined this secret hope of retransitionalizing reality and mending envelopes. In this case, the fantasy of returning no longer sounded like an experience of continuity but rather like a debt of death.

This is how Ahmed’s father came to marry a woman he did not know, already the mother of two children, secluded in an interior exile by her family clan, and some thirty years his junior. After unifying the two families, two children were born, Ahmed and his brother, in a state of great destitution and tremendous social and psychological precariousness.

However, those who barely survive the terrifying scenes of a mass annihilation can rarely cathect objects for themselves. They cathect them essentially as witnesses or proof of their miraculous and anguished survival or, by a brutal reversal of identification, as object-dumpsters, garbage that they feel themselves to be for having been the abjection of the world (Drieu & al, 2012).

Thus, a form of deep insecurity reigned in Ahmed’s family, a generational deflagration with incestuous effects that discredits any space of exchange.

Lack of attunement and impaired primary and secondary symbolization

"What does the baby see when he or she looks at the mother's face? […] ordinarily, what the baby sees is himself or herself" (Winnicott, 1971, p. 112). In other words, the baby of a family engaged in survival risks feeling a blocking of sorts of the maternal gaze, the impossibility of opening up to the world of the other. This leads to disturbed sensory attunement modes as well, which explains the parallels with autism discussed earlier. Later on, suffering can occur in connection with a narcissistic identity wound related to a state of primary distress. If the state of distress and lack of object is overly prolonged, the child cannot symbolize the absence and this absence then degenerates into a primary traumatic state. The suffering can subsequently produce a state of agony or nameless terror. According to Roussillon (2012), this state of terror generates an existential despair affecting the subjectivity and the psychic organization of the individual.

Clinical illustration

Ahmed was an adolescent in this state when we met him in the psychiatric department. His symptoms bore witness to his ERT: severe deficiencies in his early sensory attunements and excessive fear of annihilation linked to traumatic scenes. These scenes, several years later, regularly plunged him into psychotic experiences that referred to his mother’s abortions and also to his father’s scenes of war.

At the beginning of life, the baby's sensory envelope is poorly delimited and inextricably tied to the maternal figure whose contours are fuzzy. When the first instances of attunement take place without too many hitches, the child experiences through this co-sensoriality a feeling of extension of themself in the body of their mother in an undifferentiated manner. Body-to-body contact is undifferentiated and sensory zones are at times excited. However, when separated from the mother, the baby is likely to experience a sense of internal rending, whereas in moments of excessive closeness (excess), the baby is likely to experience a feeling of persecutory adhesiveness.

Before elaborating a first experience of separation in connection with subject-object differentiation, the child is thus confronted with discontinuity, which will be a source of pain and suffering. The outcome of the fight against this archaic suffering will depend on how the different psychic spaces are linked, namely, the intersubjective space through relational attunement and the intrapsychic space through the process of subjectivation.

Relational attunement depends on the quality of the sharing of bodily sensations between the baby and their environment, in other words a sort of creative adjustment of gestures, mimics and postures, of the permanent interactional play between the baby and their environment. As Nguyen (2021, p. 44) put it, "a baby’s sensory manifestations are echoed by the people around them and this builds an attunement that constitutes the first forms of symbolization" (free translation). Where subjectivation or primary symbolization is concerned, there is a co-sensory experience to begin with, followed by an awareness of these sensory impressions, which provides the first seed of the Ego or rather an embryo of meaning, which is the basis of the formation of a parental figure.

What happens, then, when these co-sensory experiences do not work to detoxify or transform excitation?

Clinical illustration

In Ahmed, the perceptive traces of these first co-sensory experiences could not be transformed into images, let alone a story, but remained a terrible imago, that of a matricidal mother (a witch casting her embryos into the fire). They also gave rise to scenarios evoking forms of maternal claustrum, that is, a mother in the image of Gaia who suffocated or swallowed her children. Before leaving on a therapeutic trip to Morocco, Ahmed imagined his Algerian family’s homes as caves or earthen barns.

Where symbolization is concerned, because the destructiveness that circulated was not mediated or deflected by a detoxifying object, it risked turning into hatred against the ego (Drieu & Marty, 2005). In addition to this family context, because there were significant environmental deficiencies, as Winnicott (1953) put it, that is, the absence of sufficiently good care, the child remained stuck with an enormous aggressive charge.

The development of his personality in adolescence was tainted by this and the neutralization of anger and aggression was lacking, which led to acts of self- or hetero-aggression (Pine, 1986). In constructing their autonomy, Ahmed and his brother were mobilized by traumatic tensions linked to an early experience of emptiness and excess in their interactions and in their emotional regulation.

They then repeated traumatic scenarios in an attempt to overcome or master them, which often led to deception. However, in an ambiguous way, this repetition contributed to shed light on certain facets of non-psychotic events that remained in the shadows, including relational modes with parents, authority figures, and inherited family secrets. Above all, these scenarios shed light on how phenomena of dependence and dominance were progressively put in place. Indeed, in their bonds, because of a traumatic filiation and a family environment where the generations are not differentiated, everything contributes to an escalation in their interactivity (Guyotat, 2005).

The psychic dimension of the conflicts of dependence could not be addressed as narcissistic expectations prevailed over differentiation and psychosexual development.

Incestuous abuse is one of the biggest risks in these anti-oedipal pathological family configurations. However, often, interactivity and tensions are linked to incest equivalents, discreet, trivialized substitutes. All these feeds acting out at the expense of fantasies belonging to the oedipal sphere. Paradoxicality counteracts ambivalence that integrates the absence. These family configurations insist especially on deep forms of psychic disattunement between generations. In the face of various traumatic events that intruded the psychic envelopes, each member of the family had to resort to primitive defenses.

Clinical illustration

So, is this the case for Ahmed's parents? Because of the Algerian War, his father had to forge a double identity. Because of her subjugation to her family, his mother had to lock herself into a logic of survival. In other words, the distress felt at the time of the various intrusions drove one and the other to forms of despair. They both functioned in damaged archaic dynamics in that, after these traumatic experiences, they could no longer rely on the basic narcissistic contract (solidarity, taking the other into consideration), to cite Aulagnier (1975).

Clinical illustration

Very early on, Ahmed and his younger brother had to learn to cope alone with excess and emptiness when visiting their parents. Their foster family informed us that they went out of their way to make it happen, even going so far as to bring firewood to heat the house, which went against instructions imparted by Child Protection Services. Ahmed especially returned from his visits in a state of anxiety that strongly recalled the state he was in when first placed in a foster family. This state of utter insecurity was reflected in his agitated and provocative behavior and a sort of wandering in the face of his needs for reassurance, which led him at times to reject all contact with certain degree of violence and at other times to follow his "auntie" (his main caregiving figure) in a sort of adhesiveness.

Mentalization in child development and impact of ERT on reflective potentialities

ERT was "coupled" with a disorganized insecure attachment in Ahmed but with an anxious insecure attachment in his little brother. How each brother evolved in his pathway could be tied to their mentalizing capacity.

The capacity for mentalization develops harmoniously in children when they are in a secure attachment relationship. It depends on how the care figures are able to respond to the children's needs with congruence (internal experience reflected in a bond of adjustment), contingency (attunement over time) and proximity, while the differentiation of self and non-self to emerge (need for emotions and experiences to be represented). It also depends on how parents who live in a situation of survival respect their children's needs but above all regulate the alternation between cycles of engagement (children's need to reconfirm their bond) and disengagement (children's need to explore the environment).

Fonagy and Target (1996) hypothesized that children gradually developed their mentalizing capacity in the first 5 or 6 years of life when their development was based on stable cues of presence/absence of care figures and no ERT was present. They identified the existence of three pre-mentalizing modes characterizing the psychic functioning of children.

The first one, the teleological mode, is characterized by a mechanistic interpretation of action (concrete observations) based on its consequences, with inferences on the intentions of others. It concerns children's psychic functioning between birth and the middle of the second year of life. During this period, children are unable to consider the motivations underlying behaviors.

In other words, since children do not yet have access to the mental world, they cannot understand the emotional reactions of others, let alone their intentions, which explains the existence of misunderstandings and the importance for the child to feel secure in the relationship.

The second pre-mentalizing mode, psychic equivalence, develops between one and a half and three years of age. The imagination gains the upper hand on external reality. Because children cannot yet perceive their experiences as mental representations of reality, their mental states are confused with external reality. They cannot understand that their mental states are related to their emotions and, as they have not made the distinction between self and others, they have the impression that what they know is shared by the other. They are often intolerant of any other alternative perspective and risk projecting their internal reality onto others (Fonagy & Target, 1996). These are things that children who have experienced ERT cannot do (Terradas et al., 2020).

Children exposed to ERT remain stalled in their development and risk getting stuck in a pre-mentalizing mode that causes cognitive and relational distortions. When this occurs, they exhibit severe problems in their ability to relate both to their internal reality and to others. Studies have shown that they are also more vulnerable to stress. In addition, they are at risk of losing their already weakened ability to think and regulate themselves (Allen, 2013).

Drawing on the ideas of Fonagy et al. (2002), we believe that trauma causes significant mentalizing deficiencies that result in children remaining stuck in one or other of the pre-mentalizing modes beyond age 5 (Terradas et al., 2020). In a context of extreme neglect or paradoxical tensions between excess and rejection, these children are not able to find regulation in their parents, who could have helped them feel secure about their needs to explore their mental states and to get feedback on them. They then risk remaining in a world of sensations without being able to develop representations of their internal experiences and, even less so, having the opportunity to experience the world and others. They may then lock themselves into a survival mode of functioning, masking their distress behind a shell that protects them from their mental states and those of others perceived as terrifying and threatening. In this context, children functions predominantly in the teleological mode and their affective, emotional, cognitive and social regulation is centered on the body, motor skills and overexcitement.

Clinical illustration

In Ahmed’s case, this functioning came through in the observations made after the fact by the family assistant and the careers to describe his behavior. When he was taken in by the family assistant at age 7, Ahmed ran away from the outset and continued to do so regularly or wander around the farm and the surroundings. Later, in adolescence and when isolated to receive psychiatric inpatient services, he repeatedly harmed others and himself and ran away (Drieu et al., 2010).

In this context, it was difficult to contain him and to undertake to reflect with him upon his behavior and, even less so, its impact on the environment. It was impossible in the immediate future to attempt to elaborate these conduct disorders to gain an understanding of himself, others and the world around him. His experiences could be approached only by focusing on what was observable and tangible. Any approach focused on conflicts and transgressions was doomed to failure since he could not make the connection between his mental states and his behavior and his mental states and those of others.

When Ahmed was in a particular position caught in paradoxical loyalty conflicts with his family, he could function predominantly in psychic equivalence mode. This often bore witness to an experience of undifferentiation between one or both parents and himself (Fonagy et al., 2002). The parents might be able to identify the sources and reasons of their son’s emotional state or even understand what was going on inside him but, because they were caught up in their own identity wounds, they could not mirror marked emotions distinct from their own. The parents could then impose themselves in a relationship of dominance given the great deal of distress and frustration that they experienced and reflected. Ahmed felt at times that his own distress was contaminating his parents.

This difficulty differentiating mental states hindered the development of a feeling of security within the bond between parent/adult and child. This was the reason that educators were concerned when accompanying the brothers to supervised visits. The child ran the risk of perceiving himself as potentially bad and with contagious, if not dangerous, experiences or mental states, because the reflections of his experience that resonated within him were as if permanently undigested (Leroux & Terradas, 2013). This functioning is illustrated by children who are convinced that they know what others think of them, who attribute their own emotions to others, and who make strong projections with the conviction that what is inside them is harmful to others. They often self-sabotage their cathexis or creativity and struggle to make believe because play is likely to be all too real for them (Domon-Archambault & Terradas, 2015).

The child will tend to dissociate themself from their emotional experiences and develop an alien self, going so far as to think that they are possessed by alienating representations that prevent them from having a coherent self-image (Slade, 2005). Therefore, the child’s emotional regulation will occur outside the intimate relationship with themself or others through a game of false pretense and a discourse disconnected from their internal reality, with the potential for false-self functioning. A narcissistic fault may then be created and cause them to drift towards a permanent vulnerability with an obvious lack of security and internal reliability that they will try to compensate for by denying depressive feelings and by reacting with poise.

Clinical illustrations

In the context of tensions related to the impact of traumatic injuries on children in child protection care and on the family environment, the shift towards an educational and care practice integrating the mentalization approach affords several advantages.

Resolutely focused on considering developmental processes and their impediments, these interventions can be applied to the entire population of children, adolescents and families in child protection care without the need to specify diagnoses. Taking into consideration the various stages of development, we are sure to obtain a positive impact on the acting-out, behaviors and violent interactional spirals of young people in child protection care. Finally, since the children and adolescents in foster care evolve in a context close to that of an ordinary family environment, projects generate positive investments at first. Often, after a certain honeymoon period, conflicts can shed light on the mentalizing modes of functioning of children, adolescents and parents. Once incorporated in institutional practices, the mentalization approach will help educators and psychologists to make choices about educational and care projects. This approach, which can be operationalized in daily life as well as in educational activities (mediation), does not require that practitioners learn completely new skills, only that they update their observation skills in view of an approach that we are already familiar with intuitively in order to enrich practices.

Educators and psychologists must communicate and cooperate to support children and families engaged in mentalization-based therapy

Since the 1990s, we have faced a sort of deinstitutionalization with new norms dictated not only by the progressive idea of developing projects centered more on integrating child and adolescents in school and working in alliance and cooperation with their families, but also by a model of educational intervention very often based primarily on the delivery of social services.

Under this model, social support work risks being considered from a competitive or even preferential perspective with respect to other care components or approaches. This can have the effect of obscuring the importance of the collective work of other teams focused on historicizing the pathways of young people and their families, not to mention the importance of foster parents, who make it possible to elaborate "negative resonances" in the foster care delivered to children and their family (Pinel, 2016). In other words, here too, if we are not careful, practitioners (e.g., educators, psychologists) may have to deal with several sources of bad feelings, including guardianships and organizations intent on delivering benefits and following protocols, but also uncertainty about the foundation of the project, or bad feelings regarding the provision of care and its professionalization. This plurality of bad feelings that professionals have to face risks provoking even more despair in teams or even more cleavages in how they function.

Clinical illustration

Thus, we can hear what played out around Ahmed's care with the sacrificial posture of child protection services (end of placement in the foster family) and Ahmed's comings and goings between psychiatric services, child psychiatry and temporary foster care that progressively dislodged him from all care projects and we can understand how he ended up being tagged as an “unplaceable” adolescent. In such a situation, we run the risk of creating a sort of perverse articulation of services, where different teams working at cross purposes and taking paradoxical measures. For example, the psychology team might request that the foster family attend consultation sessions with Ahmed after child protection services have decided to withdraw the foster family’s mandate.

Consequently, first of all, we must work on the foundations of the organizational meta-framework (organizational potential, bases of interventions) in order to give some thought to what we contribute and how (training, action research, supervision). In this regard, it is necessary to help our partners return to the guiding principle of historicizing educational and care practices in institutions.

Indeed, institutions nowadays are buffeted every which way, caught in numerous paradoxical injunctions, summoned to change their practices without taking account of the projects and the commitment of their teams. These processes of change initiate a form of mistrust that is not conducive to collective thinking about change. Before embarking upon any training or action research project, it is necessary to agree on and analyze how the expectations of the managers of these institutions will be shared, because it is clear that in order to cope with and survive the violence within the context of providing care to youths and the people around them, it is necessary to take care of the team(s) in these institutions and their spaces for mediation and elaboration. It is a matter of reasserting the dimension of care through collective training and supervision centered on the functions of the teams or groups in the provision of care and the elaboration of violence in institutions. Second, reflecting on these matters will put into perspective the more or less latent processes that bear witness to how young people and their families function-processes masked by the acting-out of the subjects receiving care and the counter-acting-out of teams.

The challenge for educators is, first and foremost, to withstand, survive, and deal with experiences of destructiveness, which necessarily arise during consultations with young people and their families. In other words, proposed training in the mentalization approach and in mediation does not aim to revamp accompaniment practices but rather to complete them to give fresh meaning to their capacity to reconnect with creativity and to increase the capacity of young people in this regard and, when possible, that of their parents or of the people around them. This approach is built first and foremost on the bond of trust that can be established between a team of educators, a psychologist and a young person with their environment. It is therefore understandable that it should be the subject of an institutional project that supports the idea that educational teams can propose restorative emotional experiences. These can allow children and adolescents, and when possible, their families, to experience sharing through relational play in a safe space to support their potential to be reflective about how they function and what they are suffering. Therefore, the training courses and the tools and mechanisms that come with them are organized as an intervention program specifically targeting the work of educators whose functions are akin to providing parental accompaniment.

The central objective of these interventions is to support children and adolescents in developing the ability to mentalize in emotionally impactful situations close to those of daily life so that they be able to express and regulate their emotions without being overwhelmed (Terradas et al., 2020).

In a context of tension in the face of the ever-present reactivation of the traumatic, openness towards an educational and care practice integrating the mentalization approach has several advantages. Resolutely focused on taking account of developmental processes and barriers, these interventions can be applied to the entire population of children, adolescents and families in care without needing to be specific about diagnoses. By taking account of the various stages of development, we are sure to obtain a positive impact on acting-out and behavioral problems, as well as on the spirals of violent interaction between young people in care.

Finally, as the children and adolescents in residential care evolve in a context close to that of an ordinary family, the educators and more often the family assistants will elicit cathexis at first and then conflict, which will serve to update the ambiguity regarding both the capacity (or incapacity) for mentalization and individuation/separation problems. Integrated into institutional practices, the mentalization approach will help educators and psychologists make choices about educational and care projects. This approach, which can be operationalized in daily life as well as in educational activities (mediation), does not require practitioners to learn completely new things in order to enrich their practice, only to update their observation skills, given that the approach is one that practitioners are already familiar with intuitively (Domon-Archambault & Terradas, 2015).

Like parents sensitive to their children's needs, they will be more interested in what motivates the children's or adolescent's behaviors (inner world or mental states) and use the environment to explore their dynamics. In other words, while trying to adapt to how youths function, they must give themselves the chance to actively question the children’s or adolescent's comments, confront them when they make non-mentalizing verbalizations or irrational assumptions about the mental states of the people around them, and offer them an alternative perspective on how they think about their own mental states (Allen et al., 2008; Terradas et al., 2020).

To restore a climate of trust in the educational work, they must, however, assume an ignorance stance, which means choosing to explore the underpinnings of behavior, that is, its underlying processes, rather than evaluating behavior at face value. Supported by the team and the various authorities of the institution, they will not stop exploring these scenarios together with the youths and, when possible, the people around them, in order to better explain the psychic processes and, in the background, the difficulties relative to their mentalizing capacity (Allen et al., 2008).

To this end, they must focus on what is happening in the here and now. On the one hand, they will invite the youths to consider what is presently happening in the relationship, given that the past is actualized in the present and access to past conflicted representations is thwarted.

On the other hand, depending on the circumstances and situations, they can invite youths to focus on themselves or on others, which favors a balance between mentalization of the self and that of others. Consequently, when the youths are excessively self-focused, educators invite them to consider the mental states of others. Conversely, when youths are fundamentally focused on others, educators encourage them to consider their own mental states (Domon-Archambault & Terradas, 2015).

Clinical illustration

When Ahmed appeared to dissociate his intimate experience but was quick to rationalize, his mental functioning was predominately in pretend mode. This functioning was because very often the primary caregiving parent was unable to attune to the child's experiences. These situations are common when parents protect themselves from a traumatic episode (shame, incest, family secret, bereavement).

They end up mirroring completely dissociated experiences at odds with their child’s subjective experiences because they are stuck on their own mental states rather than being sensitive and attentive to those of their child. Gradually, the child may no longer be able to connect their emotions and their internal reality to the outside world and may come to believe that others cannot understand them because they refuse to or because they are powerless to do so.

A process of educational and therapeutic support to be rebuilt through play

If the reception needs to be rethought, so does the caring provided daily and in the course of activities and workshops proposed to young people. In this regard, as is the case for mental health care, there is a need to rethink caring by working more on the modalities of change by providing educational and care strategy guidelines centered on a weave of interventions in different spaces and on play. In response to the acting-out and behavior problems of the young people in their care, teams must first of all maintain a framework for daily life that allows dealing with and containing outbreaks and excesses. Investment proposals for activities based on play work can be made only once such containment has been ensured. While it is important to diffract the different spaces of investment to help young people in care to better tolerate their functioning, the work of psychic elaboration or mentalization will not be able to occur in a sort of sharing as long as the processes of symbolization or the capacity for mentalization remain impacted by traumatic experiences. To track the resources of these young people as closely as possible, it is important to include play activities in the approaches used.

Accordingly, in therapeutic approaches with individuals with borderline functioning (childhood borderline personality features and borderline personality disorder), therapists have progressively shifted their work methods from the dream model (e.g., verbal exchanges, free association) to the play model (e.g., work on malleability, narration), from interpretation to construction, and from a method of transference based on abstinence and neutrality to one based on presence/absence and transitional analysis.

In other words, mediation or the mediating object, like play dough, are expected to serve the functions of a malleable medium characterized by the livelihood, indestructibility, sensitivity, flexibility, "indefinite transformation", "unconditional availability" and, finally, "self-animation" of sorts that emerge from mediating objects. Of course, the "malleable medium" functions will be exercised at once in the different spaces mobilized by practitioners and through the proposed mediating objects.

A therapeutic process to be underpinned by mediating objects

While mediation has existed in mental health care since Antiquity, mediating objects have long been used more in an occupational dimension in psychiatric care or in an abreactive approach in early corporeal and psychodramatic therapies. Used more and more in therapeutic groups under different forms, in the 1990s mediating objects became the subject of more sophisticated theorization inspired by works on the processes of symbolization and their vagaries.

In medico-social institutions, mediation and games serve as a pretext or support for communication and sharing. In both fields of experience, those of psychiatry and those of the medico-social world, mediation has long been used to compensate for the lack of sharing or exchange. More recently, play and games have been used for their malleability to support resources, processes and skills yet to come.

The malleability of mediating objects plays out differently depending on the type of mediating object chosen. Chouvier (2011) describes these objects according to two characteristics. On the one hand, they can be objects to be created, such as artistic mediation (e.g., drawing, writing, music), acting (e.g., psychodrama), or puppets to identify and regulate emotions. On the other, they can be found already created or existing, including such tools as Photolangage (thematic sets of 48 color or black-and-white photographs) and the Chemin de parents game used in mediated visits.

With objects to be created, the important thing is not esthetics but rather the quality of the creativity expressed. A puppet making workshop set up to broach emotions more easily in child protection residential centers can bring young children to engage in infra-verbal exchanges and a certain type of body language. This reinforces the experience of self and others when reliving experiences, often at the corporeal level, which have not been symbolized, as it does the corporeal grounding of symbolization and mentalization processes. Indeed, the group experience of making puppets can ground the therapeutic work in the mentalization process, and children can then use the puppet object to qualify emotions both in their daily exchanges and in mediated visits with their parents. They will then gradually gain access to more nuanced modes of emotional regulation and broaden their capacity for mentalizing and even for symbolizing issues of alliance that create the phenomena of subjugation often observed in situations of placement. It will then be a question of engaging in therapeutic work with children or adolescents when they are below the level of figurability, of helping to make unsymbolized sensory, affective and motor experiences figurable, as for example in the case of children who have been forced to migrate because of war or extreme violence.

Conclusion

In response to ERT, young children block their development at a pre-mentalizing mode of functioning. This later renders them more vulnerable when they experience stress or changes in their environment. This vulnerability has to do with both the preconditions for bonding (e.g., attachment insecurity) and the conditions for subjectivation (e.g., object survival and subjective appropriation). In other words, it will be necessary to accompany these children in both therapeutic work and educational work with a focus on their modes of functioning regarding mentalization.

Therefore, depending on the situation, it is necessary to develop projects in a concerted manner or at least in pairs (e.g., educator and psychologist), by developing, for example, special arrangements for mediated visits likely to broaden the range of experiences of parents and children through games that shed light on mentalizing activities.

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  This paper is a part of the Project entitled "Psicologia clínica e cultura: intervenções e treinamento profissional" supported by CAPES PrInt Program.

Publication Dates

• Publication in this collection
  05 June 2023
• Date of issue
  2023

History

• Received
  20 May 2022
• Accepted
  12 Aug 2022