Ghostbusters: Transpiration of Intergenerational Trauma

When I began my training in child psychiatry, my program had a focus on psychiatric issues of children 5 years of age and older. Shortly thereafter, I became aware of clinicians and researchers who were focusing on the mental health of infants. These very young children were being evaluated and treated as part of an infant-parent unit. During my training, I had the opportunity to participate in research that assessed infant-parent interactions and attachments and read voraciously about this age group, around this time I came across a paper, Ghosts in the Nursery by Selma Fraiberg that had a profound effect on my career.

These clinicians focused on infants (0-3 years) along with their parents who had been exposed to intergenerational trauma. Fraiberg and her team were contracted by Child Protective Services (CPS) to provide these families with guidance and therapy. They noted that oftentimes these parents interacted and behaved aggressively or neglected their child without awareness of their own history of childhood trauma and associated feelings (transference). This intergenerational trauma was coined by Selma Fraiberg as “ghosts in the nursery.”  Frequently, therapists felt overwhelmed with the challenge of working with these families, leaving them with thoughts of giving up, that is, abandoning the therapy with these families. A common finding was that many parents were abandoning their children to be cared for by others (extended family, CPS, etc.) because they were overwhelmed by the responsibility of taking care of these children.

Many parenting styles are transmitted and modeled from one generation to the next. This could be positive or negative in its impact. Many parents who have experienced trauma are conscious of the negative impact that it has had on their own development, so much so that they commit to themselves that they will not continue to perpetuate this approach in their parenting. Some adults even choose not to have children because they are concerned with the potential risks.

Parent-infant therapy consists of meeting with parents and infants together as a unit, usually at the family’s home. Babies cannot thrive on their own and require the parent to be a copilot in the first few years of their life to promote attachment and to reach developmental milestones—all essential factors for survival. The aim of this therapy is to get the parent to connect their own traumatic history with their emotional response at the time an event is occurring (for example, “I wonder how terrifying it must have been for you as a 5-year-old child to be whipped with a belt and placed in a dark room for spilling your milk”). The hope is for the parent to connect their memory with the emotional impact of that moment—this insight can create empathy for their own child.

Many individuals have been impacted by temporary or permanent residing “ghosts in their nursery,” which undoubtedly affect them throughout their lives. Over time, many layers of maladaptive behaviors—including addictions, eating disorders, depression and anxiety—cover the ghosts of trauma and prevent addressing the maltreatment. On many occasions individuals present with a wide range of emotional instability and disruptive behaviors that are challenging, leading clinicians to attempt a whole range of interventions including psychotropic medications to manage the presenting symptoms. These clinical approaches frequently benefit and ameliorate uncomfortable symptoms that impact everyday functioning but do not address the underlying causes of maladaptive behaviors.

One idea consistent with “Ghosts in the Nursery” is to put in place preventive and educational programs that focus on issues that happened to someone early on. Training programs in psychiatry could collaborate with other medical specialties (pediatrics, OB/GYN, family medicine, etc.) as well as social work, psychology and public health in screening high-risk children and parents and intervening early on.

Over the last few years, many psychiatric training programs have become more biologically focused, at the expense of more diverse training. I hope psychiatric training programs will revitalize psychotherapeutic skills as once emphasized to handle a wide range of diagnostic, therapeutic, and developmental understanding of patients of all ages, thus equipping one to approach them with compassion and the care necessary in building a therapeutic alliance. Unfortunately, the proliferation of rapid assessments and the current reimbursement models in medicine leads psychiatrists to practice more as a “prescriber,” mainly managing medications, which will not sufficiently address the needs of complex patients who require a more comprehensive approach and care. We lose important clinical skills when we do not cultivate them, thus emphasizing the urgency to bring back more psychotherapy training to psychiatry residency programs.

Selma Fraiberg and her team were mostly privileged, white, highly educated therapists, who took a unique approach, based on curiosity, to what was ailing these families. Their starting point was not an assumption but a question, a curiosity to understand, such as, “Why can’t these mothers hear their infants cry?” I think that if we go into our sessions with our patients with similar curiosity, we can use our expertise and experience to better understand and help them. I hope that using this classic article by Fraiberg et al. about hidden ghosts of intergenerational trauma can catapult us to seek more comprehensive interventions. We must insist that the new generation of psychiatrists, especially those that treat children, be trained in a way that they can obtain the necessary skills to address the needs of all patients, especially those impacted by a wide array of social determinants of health, intergenerational trauma and other complex factors.

A TRAINEE’S PERSPECTIVE

My passion for psychiatry has evolved over time. Initially, I was fascinated by psychopharmacology and its mechanics in treating patients. I would check off symptom lists and categorize them into a diagnosis which I can then treat with medications. However, with time and experience, I came to appreciate the many stories the patients brought that shaped who they are. Every trauma, every depression, every anxiety-whatever the patient presented with-had its own flavor and a unique story that required unpacking to get to the core of the issues. The past, when unspoken, turns into pathology, and I realized patients needed your presence to hear them out and process safely to heal. Psychiatric training programs have evolved from being psychoanalytically and dynamically oriented to biologically focused, with the intent to teach cutting-edge science, while inadvertently displacing past skills that we now realize to be crucial in one’s healing. As I near the end of my training, I have found humans to be complex beings with much depth in their lives. I hope to treat my patients as a whole considering the many layers of their lives in conjunction with modern medicine.