Introduction to the issue “Developments in perinatal psychoanalytic family therapy”

Introduction to the issue “Developments in perinatal psychoanalytic family therapy”

Élisabeth Darchis^*

Perinatal family psychoanalysis is a relatively new approach that has been slowly evolving and becoming more widespread over the past few decades. Professional practices in this field are advancing, demonstrating their effectiveness in mental health care and prevention. The resulting theoretical conceptualizations inform professionals and transform their therapeutic approaches when a child arrives in a family.

Majority of countries worldwide have legislated to protect motherhood, some as early as the late 19th century and others only a few years ago. Even today, a small number of countries do not have specific laws protecting women who, for example, work and give birth to their children. But, while practitioners are paying increasing attention to supporting the mother-baby bond, care for parents, babies and entire families is still far from ideal.

This 33rd issue of the AIPCF journal will address some of the latest advances in the specific field of perinatal family psychoanalysis. But, before presenting the articles that will illustrate this, let us first revisit the history of how these perinatal practices evolved.

Evolution of new approaches

Theories and approaches have progressed around childbirth, moving from individual care to support for dyadic and triadic bonds, and finally to care for the family group as a whole.

At a first level, practitioners focused on the individual subject in the field of psychic perinatality, echoing the models of medical consultation that treated the patient or that of Freudian individual psychoanalysis, listening to a closed monad on the couch. In this approach, the infant, gradually considered as a person, was observed and supported in their dysfunctions and various skills (“still face” experiences, separation and insecurity, infant depression etc.), a practice that was effective and rich in the framework it had already offered. Examples include the Lóczy Association (Budapest, 1946), the Tavistock Clinic (London, 1948), Esther Bick’s observation (London, 1948), the Centre de Soins Spécialisés de Myriam David (Paris, 1975) and the Maisons Vertes de Françoise Dolto (Paris, 1979). John Bowlby’s work on attachment (1960), verified by ethologists such as K. Lorentz and H.F. Harlow, had already shed light on the effects of separation in young children.

Psychoanalysts such as Sándor Ferenczi (1932), with his work on the unwelcome child or trauma in the original relationship with the mother, or René Spitz in his research in 1945 after the war, with his concepts of hospitalism and anaclitic depression, Wilfred Bion in 1962, with the maternal alpha function, Margaret Mahler and the symbiotic dyad  in 1973, and Donald Winnicott in 1958, with the concept of the good enough mother, had also contributed to our understanding of children’s suffering in relation to their environment. Winnicott, for example, placed great importance on the mother, with his concept of primary maternal preoccupation, a state that develops gradually during pregnancy and in the days following birth. Today, we know that parental preoccupation, but also anxious family preoccupation (Darchis, 1999 and 2016), prepares the family’s primary attention towards a baby and allows the construction of the psychic nest or family cradle. Winnicott speaks late in his work about the paternal function, but he emphasizes its importance ‘in the vicinity’ and in maternal reverie (Winnicott, 1958), but without yet considering the suffering of young fathers or the whole family.

At this level, interest focused on symptoms in children but, until the 1970s and 1980s, these were generally not detected earlier on and late treatment took place after the child was three-year-old, on an individual basis and over many years, before being followed up by a younger sibling. Vast majority of consultations for babies did not consider psychoanalytic therapeutic follow-up during the perinatal period, because ‘they couldn’t talk yet,’ it was said. There were also no partnership networks for perinatal mental health care. For example, in France, before the 1980s, child psychiatry departments and maternity hospitals did not generally treat early mental health disorders affecting the mother-baby bond.

The maternal and child health service (PMI), created in France in 1945, was primarily aimed at protecting the medical health of the mother and child as individuals. The suffering of the young mother and her symptoms were dealt with on an individual basis and, in this initial stage, the focus was on postpartum disorders in women, especially after the birth of the baby. This approach tended to lead to the hospitalization of young mothers suffering from severe depression or postpartum decompensation and they were separated from their infants.

Before the 1980s, support of mother-baby bond was not a very developed practice, even though pioneers such as Paul-Claude Racamier (1961) had already proposed mother-baby hospitalization, but still with the aim of treating the mother and supporting her ‘motherhood’ (1978). Racamier described the psychological and emotional process of maturation during this particular moment in the life of a woman who welcomes a baby, comparing the crisis of motherhood to the crisis of adolescence, arguing that these two periods are structuring transitions as stages of psycho-emotional development (Racamier, 1961). He added the terms ‘paternity’ and ‘parenthood’, but without really defining them. It was André Ruffiot who first proposed a specific definition of parenthood in family psychoanalysis upon the arrival of a baby: «Parentality seems to me to correspond, at its deepest level, to a connection, to a purely psychic communication between the paternal and maternal psychic apparatus on the one hand, and with that of their child on the other» (Ruffiot, 1981, p. 29).

On the other hand, if the father was experiencing decompensation or delirium at the time, he would find himself in adult psychiatric care, where no connection was necessarily made with his status as a young father. Paternal postnatal disorders and their origins were little explored. The couple went through the perinatal crisis without being listened to generationally and the risk was sometimes violence or the break-up of the family, which could not be born because of a painful legacy. Previously, however, Sándor Ferenczi had raised awareness in psychoanalysis about generational confusion and the incorporation of trauma, which Selma Fraiberg (1975) had taken up with ghosts in the nursery. Nicolas Abraham and Maria Torok (1978) also showed that the crypts of ancestors impacted the development of subjects in phantom effects that manifested themselves, particularly in enigmatic or delusional forms. But this generational psychic baggage was not yet understood by those caring for psychic perinatality.

At a second level, it was the space of early bonds that attracted the attention of perinatal professionals from the 1980s onwards, with the gradual introduction of joint mother-baby therapies, which became widespread in France and other countries. In this theoretical model, care accompanies interactions in the intermediate psychic space that links subjects to one another. Here, the practitioner listens to the subjectivity of the bonds established on the basis of mutual interests, agreements and conscious and unconscious alliances that allow for harmony and connection, but also distance and conflict. These measures, which are still in use today for prevention, refer to attachment theory and intersubjective psychoanalysis, taking into account, mainly in the postnatal period, the pathogenic interactions of the dyad. The main focus of care remains the baby suffering in his/her bonds, and the dyad may be hospitalized in mother-baby units. In this support, the child is considered in relation to his/her parents and fatherhood is gradually taken into account in the triad approach. However, the father is often considered in his role as a resource, a support and a third party around the birth. If he is fragile, depressed, incompetent or uninvolved, he is excluded from family interviews, isolated, even hospitalized on his own and forgotten in the parent-child bonds. Practitioners offer genuine joint parent-baby therapies at this level, but these family consultations or therapeutic family discussions are not yet truly psychoanalytic treatments for the family group. In healthcare settings and institutions, the family as a subject is not necessarily treated as a whole, with its origins, past suffering and generational, organizational and defensive group phenomena. This intersubjective approach to relationships may also be attentive to generational aspects that give meaning to the construction of the subject and its attachments, but it is not truly based on intergenerational and transgenerational psychoanalytic family listening or on the psychic heritage that organizes the new family.

Research and theorizing in subjective psychoanalysis concerning early bonds flourished in the 1990s. In France, the first perinatal psychiatry conference took place in Monaco in 1996, marking the birth of infant psychiatry with Serge Lebovici, Michel Soulé and René Diatkine. Together with several other practitioners, they would go on to further research into the mother-baby bond^[1]. More and more dyadic therapies, followed by mother-father-baby triadic therapies, began to accompany bonds and interactions. At this level, professionals in the field, even if they were not particularly oriented towards a psychoanalytic understanding of the generational family unit, left us with valuable references that often still enlighten family psychoanalysts today.

At a third level, new practices are being implemented in perinatal care, but differently depending on the country. The new approaches of perinatal psychoanalytic family therapy (PPFT) relate to a psychic space that is listened to on the theoretical basis of family psychoanalysis with its unconscious group and generational aspects. In this new approach, the family is accompanied in its three distinct but interdependent and interconnected psychic spaces: that of the individual subject, that of intersubjective links and also that of the family as a whole, which holds them together as a group in the unity they constitute according to the succession of generations. However, although these practices of listening to the family unconscious have been developing mainly since the 1980s and 1990s, these approaches to childbirth are still not very common in 2020 in the field of psychic perinatality.

The theories behind this approach have their origins in Sigmund Freud’s work on groups, transmission and collective psychology and in the research of psychoanalysts of the time and their successors^[2], who worked on myths and dreams, archetypes and the archaic, the confusion of languages, generational trauma, incorporations, crypts, ghosts, obsessions, grief disorders, necessary regression, resonances… or in more contemporary psychoanalysts of the group, but especially in psychoanalysts of couples and families^[3], generally members of family psychoanalysis societies^[4].

Today, however, perinatal psychoanalytic family therapies (PPFT) are beginning to develop thanks to therapists who are specialists in perinatal psychoanalysis^[5]. They support the entire suffering family, starting from the time of gestation. When care for future and new parents is sometimes necessary, this treatment allows them to rework the torments inherited from the family, to reshape and transform them. In this way, the family can take its place in the difference from this generational legacy resulting from a broken inheritance. TFPP addresses the family unit during times of perinatal crisis with its reorganizational and defensive group phenomena. The family’s present, past and future history is accompanied in its perinatal family novel and in its roots, which are anchored in the vagaries and accidents of life, in unresolved trauma and silent violence, difficult bereavements, torn filiations, family shame and secrets, painful migrations, or the unmanageable breeding ground of cultural differences, etc. We are not born into, but from, a family, and as André Ruffiot (1981) points out: ‘We are woven before we are born’.

It is in these third level practices that the articles in the AIPCF Review dealing with perinatal family psychoanalysis are situated.

In this issue 33, we therefore return to Today’s practices in perinatal psychoanalysis, in private practices, in early childhood and social welfare settings, in maternal and child protection, in neonatology, in maternity or paediatric hospitals, or even in child psychiatry etc. Reading these articles reveals the wealth of new theories and innovative approaches to families in distress. We can discover major advances in family care in perinatal mental health, based on group, family and couple psychoanalysis.

In the first part, entitled “The perinatal period: crisis, transformation and transmission”, the articles revisit the generalities of the process of building a family when a baby arrives. We will understand the vagaries of the perinatal psychological journey and how defensive family organizations emerge with the resulting symptoms. The implementation of perinatal family psychoanalytic therapies demonstrates effective approaches to supporting the birth of a family. We also understand that our conceptualizations have a history based on long-standing theoretical foundations proposed by pioneering psychoanalysts.

The article by Marie-Laure Royer and Paola Aburto: «La “trace-mission” en psychanalyse familiale périnatale» revisits the perinatal psychic crisis necessary to found a new family, with its indispensable group regression and its sometimes overwhelming but potentially creative disorganizations. Family psychoanalysts accompany the process of bringing to the surface traumatic content encysted in the transgenerational and participate in the representation of these archaic psychic fragments that have tested the containment capacities of the family group. Thus revisited, the family’s psychic heritage can be rewritten to open up to the future and make possible a transformation, an inscription and humanization of becoming a parent and a family.

Ludovica Grassi also returns to the period of pregnancy, which offers opportunities to deal with transgenerational trauma by questioning the psychic organization of individuals and the group when a child arrives. In her article, «Infant transgenerational trauma: An unconscious dialogue between Selma Fraiberg and Sándor Ferenczi», she reveals surprising similarities between Sándor Ferenczi’s relevant theories on trauma and the ghosts in Selma Fraiberg’s ghosts in the nursery. The author thus helps us to further understand the traumatic origin of transgenerational legacies and defense mechanisms in family, such as denial, repression, isolation, paralysis, fragmentation etc., moments around birth that are nevertheless potentially transformative.

The perinatal period, as a process of psychological transformation simultaneously, engages individual, group and family containers, which Pierre Benghozi calls “anamorphose”. In his article «Le natal, crise, en-crise et catastrophe. Une approche transcontenante en périnatalité», he theorizes around his concepts, with this transformation comparable to a chrysalis, to a ‘moulting of psychic containers’, whose clinical modalities are more or less solid depending on the mesh of genealogical links in the family. One case illustrates the clinical aspect of shame, where birth reactivates old, unresolved trauma, creating ‘ghost carriers’ that haunt generations.

Future and new parents place the newborn in the chain of generational transmission. Marthe Barraco De Pinto shows us in «Transmission et transformation des groupes au contact du bébé», how this process often impacts the entire functioning of the family group. Professionals also experience the perinatal period of trials and tribulations in this encounter with the nascent family, reactions that must be taken into account in ongoing collective reflection.

In the second part, “History of transgenerational clinical practice in perinatal family therapy”, we see that perinatal situations are varied because suffering does not only affect the mother and child. It can manifest itself in symptoms in the young father, grandparents, and family of pregnant teenagers, each of whom bears witness to the transgenerational suffering that hinders the transformation of the family’s psychological legacy.

The period of family crisis brings back old baggage that is sometimes encrypted, as Élisabeth Darchis points out in her article «À l’écoute des fantômes dans un délire puerpéral paternel». She shows us that the perinatal period is a propitious time to give free rein to the work of the ghost in the family, as conceptualized by N. Abraham and M. Torok. One of the group members may be the symptom-bearer of a history in which filiations have not been worked through and where the silence of family secrets freezes the processes of evolution. Perinatal psychoanalytic family therapy (TFPP), in the case of paternal postpartum delirium, illustrates the ventriloquistic listening to ghosts during this perinatal family cure.

Ellen Jadeau, in her article «Grand-parentalité et périnatalité: enjeux d’une prévention à tout âge», offers a clinical illustration of couples therapy in a perinatal crisis of grand-parenting. She highlights the important issues of the articulation of the conjugal and the parental in the perinatal psychic dynamic and the dimension of prevention in a space of psychoanalytic listening to the bond at the time of the birth of a grandchild. The emergence of transgenerational elements offers a dynamic for understanding archaic experiences of collapse. Their elaboration consolidates the foundation of the family with benefits for filial, conjugal, parental and grandparental bonds.

In a clinical vignette concerning teenage pregnancy, Ana Marques Lito, in Embarazo adolescente – Reinventar la maternidad», revisits her conceptualization of the Glass family typology, which here serves the purpose of incestuality. Teenage pregnancy is a reality check, filling the intra-fantasy void in the family, particularly in terms of conjugality and ancestral parenthood, which have not been represented in the transgenerational axis. Faced with the group’s psychic destiny, Class’s families present themselves with cyclical, closed and endogamous movements, in the quest for a mythopoetic (re)signification, a construction-deconstruction of the unconscious struggles between generations, but also in the search for new identities with a view to a transformation of family culture.

The third part of this dossier, “Attention to the suffering psychic body of the family in perinatality”, returns to the anxieties and upheavals that grip the family when a child arrives, accentuating its vulnerabilities. Old sufferings, reactivated during pregnancy, seem to mobilize the work of healthcare teams.

Life and death lurk around the family’s psychic cradles, which Denis Mellier explores in his article: «La vie et la mort autour de la naissance. Appareillage familial du berceau psychique et travail de l’attention». The upheaval experienced by the newborn also affects the identity of the group that welcomes it. The author observes the necessary psychological regression that sometimes affects very archaic levels of the family psyche by modifying its psychological apparatus. Following this gathering around the baby, a protective envelope and the work of the caregivers’ attention are consolidated. These processes are illustrated by observations from Esther Bick’s work on containment with interdisciplinary teams and adaptation to the social context.

In the same vein, Evelyne Cano Balcerzak, in her article «Cicatrices partagées d’un corps familial traumatique», also explores the perinatal period as a time of crisis when the family psyche, rendered transparent, sees transgenerational fragilities and trauma come to the surface. Based on a case of perinatal psychoanalytic family therapy, the author shows us how the suffering body of a baby reactivates a traumatic family body, mixing unresolved grief, fear of dismantling, silences and defensive collage. The therapeutic setting will allow the family to lay down part of this shared bodily memory, and the child’s body will move from being the ‘bearer of family trauma’ to a support for transformation, paving the way for a less deadly transmission.

When it comes to premature birth, Andrea Benlodi shows us, in «Une approche psychanalytique de la famille dans le service de Néonatologie et de Soins Intensifs Néonataux», how highly traumatic this situation is for the whole family. Through the presentation of a clinical case of extreme prematurity, we see how the family therapist adopts a psychoanalytic view of the baby’s parents and caregivers in order to promote the child’s favourable psychological and neurological development, the latter being influenced by the parents’ mental state. In particular, it highlights how the internal objects with which the family interacts have an impact on the role of caregivers.

We continue with the theme of teamwork in a hospital’s maternity, neonatology and paediatrics department and in family mental health centres. Gabriela Sbiglio, in «Un nacimiento», describes the work of a psychotherapist trained in group, couple and family psychoanalysis in the field of perinatal prevention. She shows us the potential of a group situation to promote multidisciplinarity within the team and the construction of a network between institutions. This learning environment is a privileged space for the production of new subjectivities, which can facilitate understanding of the complexity of couple and family relationships in perinatal. Working in groups avoids fragmentation in practices and promotes care.

The latest articles in the fourth part “Death of a baby and assisted reproductive technology: support for caregivers” will address the loss of a child, a tragic event in family history where support for the family is now known to be essential.

Ausilia Sparano, who works in a mother-child unit at a hospital, reiterates, in «Crossing the storm together: supporting couples in the perinatal mourning process in a hospital setting»,  that there are no words to describe the loss of a baby in utero or immediately after birth. This tragedy is often inconceivable and unspeakable, because outliving one’s child seems abnormal: the event leaves an indelible scar on the family history. Supporting perinatal bereavement and treating bereaved parents help to prevent pathological crystallization by containing the manic and massive defenses that could undermine the couple’s bond.

Erika Parzani and her colleagues revisit the issue of perinatal bereavement in their article «Padres que han perdido un hijo en el periodo perinatal: una mirada psicosocioanalítica sobre la experiencia de los grupos de intercambio». Psychoanalytic knowledge about the family helps to find spaces for listening, welcoming and caring for women, men, couples and families. The authors describe a non-profit psychological association: GenitoriAmente, which organizes various groups in Italy, based on the theoretical models of operative and psycho-socio-analytical groups, for couples who have experienced perinatal loss, such as intrauterine death following a therapeutic termination of pregnancy proposed by prenatal diagnosis.

Finally, to conclude this dossier, Christiane Joubert offers us a perinatal tale.

We continue with a “Research” section featuring a report by Joël Djatche Miafo and his colleagues entitled «Mental health care for adolescent mothers in Cameroon: psychoanalytically inspired tools, complementing the WHO’s IG-mhGAP protocol». In Cameroon, a quarter of teenage girls aged 15 to 19 are mothers, and the prevalence rate of mental illness among teenage mothers is 66.4%. A pilot project based on a World Health Organization guide was launched as part of a mental health care program for these young mothers. A total of 1,633 teenage mothers participated in the study, and 715 were supported until the end of their pregnancy. Psychoanalytically inspired tools deemed useful were introduced: free association, analytical listening, listening to transference and countertransference, elaboration of aspects of parenthood and perinatality, interpretation of family dynamics and work on transgenerational transmission etc. The results of this study reveal that psychoanalytically inspired tools are effective for mental health care for teenage mothers in Cameroon.

In the “Dictionary” section, Denis Mellier presents the concept of Psychic envelopes in perinatal and early childhood, in relation to the theme of the issue.

In the “Reading Notes” section, Pascal Nguyen reviews Alberto Eiguer’s book Un divan pour la famille, while Élisabeth Darchis and Véronique Lopez Minotti comment on Claude Nachin’s Mon abrégé de psychanalyse.

Finally, we pay tribute to the great figures of psychoanalysis who passed away in 2025: Claude Nachin, Judith Dupont and Claudio Neri.

We hope that this issue on perinatal psychoanalytic practices will encourage younger generations to explore this approach, which is so effective in preventing the risk of serious family suffering.

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Bibliographie

Abraham, A. et Torok, M. (1978). L’écorce et le noyau. Paris: Aubier Flammarion.

Bion, W.R. (1962). Aux sources de l’expérience. Paris: PUF, 1979.

Bowlby, J. (1960). Attachement et perte. Volume 1: L’attachement, Paris: PUF. 2002.

Bydlowski, M. (1991). La transparence psychique de la grossesse. Études freudiennes, 32, 135-142.

Darchis, É. (1999). Maison et parentalité, faire son nid. Le Divan familial, 3, 83-94.

Darchis, É. (2016). Clinique familiale de la périnatalité. Malakoff: Dunod

Ferenczi, S. (1932). Journal Clinique, Paris: Payot, 2014.

Fraiberg, S.; Edelson, E. et Shapiro, V. (1975). Fantômes dans la chambre d’enfants. Approche psychanalytique des problèmes liés aux relations nourrisson-mère altérées. Psychiatrie de l’enfant, XXVI(1), 57-98.

Mahler, M. (1973). Symbiose humaine et individuation: Psychose infantile. Volume 1. Paris: Payot.

Racamier, P.C. (1961). La mère et l’enfant dans les psychoses du post-partum. Évolution psychiatrique, 4, 525-570.

Racamier, P.-C. (1978). À propos des psychoses de la maternité. In M. Soulé (sous la dir.), Mère mortifère, mère meurtrière, mère mortifiée (p. 41-50). Paris: ESF.

Ruffiot, A. et al. (1981). La thérapie familiale psychanalytique, Malakoff: Dunod.

Spitz, A. (1945). De la naissance à la parole: la première année de la vie. Paris: PUF, 2002.

Winnicott, D.W. (1958). De la pédiatrie à la psychanalyse. trad. fr. J. Kalmanovitch. Paris: Payot, 1969.

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* Clinical psychologist, psychoanalyst, psychoanalytic group, family and couple therapist. President of the SIPFP (Family and Perinatal) and the AENAMT (Abraham and Torok). Member of STFPIF, SFTFP, SFPPG, AIPCF, APPCF, AFCCC, WAIHM, MARCE. Founder and head teacher at a university diploma course at Paris 7. darchiselisabeth@orange.fr

[1] In the 1980s and 1990s, these included: D. Houzel, P. Mazet, B. Cramer, D. Stern, S. Stoléru, F. Palacio, G. Haag, G. Appel, M. David,E. Pickler, M. Lamour, M. Bydlowski, D. Marcelli, M. Dugnat, B. Durand, B. Golse, A. Guedeney, A. Carel, S. Missonnier, É. Darchis, P. Benghozi, R. Sandry M. Barraco, D. Mellier, and many others who studied perinatal psychic.

[2] These include: O. Rank, K Abraham, C. Jung, S. Férenczi, S.H. Foulkes, M. Klein, A. Freud, M. Balint, D.W. Winnicott, S. Fraiberg, W.R. Bion, N. Abraham and M. Torok, J.-B. Pontalis, etc.

[3] From 1970-1980: D. Anzieu, A. Missenard, R. Kaës, E. Pichon Rivière, A. Ruffiot, G. Decherf, J.-P. Caillot, P.-C. Racamier, G. Haag, D. Meltzer, J.C. Rouchy, C. Pigott, O. Avron, E. Granjon, A. Eiguer, S. Tisseron, AM. Blanchard, F. Aubertel, F. Fustier, A. Loncan, C. Joubert, A. Ciccone, P. Robert, J.-G. Lemaire and many others theorized on group, family and couple psychoanalysis.

[4] For example: the AIPCF (International Association for Couples and Families), the SFTFP (French Society for Psychoanalytic Family Therapy), the CPGF (College of Group and Family Psychoanalysis), PSYFA (Psy et famille), etc.

[5] In France, for example: E. Darchis, A. Carel, D. Mellier, F. Maffre, M. Lemaitre, P. Benghozi, O. Rosenblum, F. Baruch, M. Barraco, and then the next generation: M.-L. Royer, P. Aburto, E. Balcerzak, as shown in several articles in this issue.