Mothers, Infants and Young Children of September 11, 2001

A Primary Prevention Project

Beatrice Beebe, Phyllis Cohen, K. Mark Sossin, Sara Markese, Beatrice Beebe, Phyllis Cohen, K. Mark Sossin, Sara Markese

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135698799
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The group of papers presented in this volume represents ten years of involvement of a group of eight core therapists, working originally with approximately forty families who suffered the loss of husbands and fathers on September 11, 2001. The project focuses on the families of women who were pregnant and widowed in the disaster, or of women who were widowed with an infant born in the previous year.

This book maps the support and services provided without cost to the families by the primary prevention project – the 'September 11, 2001 Mothers, Infants and Young Children Project' – organised by a highly trained group of therapists specialising in adult, child, mother-infant and family treatment, as well as in nonverbal communication. The demands of the crisis led these therapists to expand on their psychoanalytic training, fostering new approaches to meeting the needs of these families. They sought out these families, offering support groups for mothers and their infants and young children in the mothers' own neighbourhoods. They also brought the families to mother-child videotaped play sessions at the New York State Psychiatric Institute at Columbia University, followed by video feedback and consultation sessions.

In 2011, marking the 10th anniversary of the World Trade Center tragedy, the Project continues to provide services without cost for these mothers who lost their husbands, for their infants who are now approximately ten years old, and for the siblings of these children.

This book was originally published as a special issue of the Journal of Infant, Child, and Adolescent Psychotherapy.

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THE PROJECT

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Description of the Project: A Longitudinal Primary Prevention Project for Mothers Pregnant and Widowed in the World Trade Center Tragedy of September 11, 2001, and Their Young Children

Beatrice Beebe, Ph.D.
Joseph Jaffe, M.D.

Since spring 2002, the Project for Mothers, Infants, and Young Children of September 11, 2001, has been providing diverse pro bono therapeutic services for women who were pregnant when widowed by the World Trade Center attacks of September 11, 2001. This primary prevention Project attempted to facilitate grieving in the families and to promote optimal relationships between the mothers and their infants and their older children. This article describes the components of the Project.

INTRODUCTION

We began the Project with approximately 40 participating widowed mothers, their children born in the aftermath of the disaster (now in the spring of 2011 approximately 9 years old), and their older siblings, altogether approximately 80 children. Among these numbers were also several families where the infant was born in the year 2001 prior to the mother being widowed on September 11, 2001, and two families with infants who lived at the World Trade Center site and were traumatized by the tragedy but neither parent was lost. We are continuously involved in outreach, but we have been unable to find or to involve most of the approximately 60 additional families within this population. As time progressed, we have welcomed new families, as well as new fathers and new infants, as many of the mothers have found new partners or re-married. The original letter that we sent to the mothers in 2002 can be found at the end of this article.

Although there was a great deal of therapeutic intervention available in New York City for the bereaved adults of the World Trade Center disaster, their unborn infants and very young children were in danger of being forgotten (see Weinberg and Tronick, 1998; Gaensbauer, 2002). There were no specific programs available to provide services for these infants to be born amidst such traumatic circumstances. However, the value of mother-infant and mother-child therapy has been well documented (see, e. g., Brazelton, 1994; Cramer et al., 1990; Fraiberg, 1980; Hofacker and Papousek, 1998; McDonough, 1993; Murray and Cooper, 1997; Stern, 1995; van den Boom, 1995).

Most programs in New York City targeted traumatized adults, providing services to address their needs as individuals, but not specifically as parents. In contrast, our specialized training allowed us to identify and to respond to the maternal needs of these widowed pregnant women, their young children, and their infants once they were born. As far as we know, our Project has been the only one to provide a longitudinal primary prevention approach in an attempt to address the ongoing effect of this traumatic loss on these families. We address the parent-infant and parent-child relationship, and the ongoing and evolving needs of even the very youngest victims of this unprecedented disaster. In recent years, we have begun to address relationships in these families as they have evolved to include new partners for the mothers. Now in its tenth year, our Project is the longest-running ongoing clinical service, offered at no cost, to families with young children who were traumatized by the events of September 11, 2001.

RISK FACTORS FOR THESE FAMILIES

More than two decades of research on maternal distress, mother-infant interaction, and infant and child developmental outcomes have shown that infants suffer when a parent is distressed. Because of our backgrounds in mother-infant research and treatment, and child and family treatment, our Project operated on the assumption that all members of the family were at risk, not just the surviving parent. We thus focused on the effects of the trauma and loss in the motherinfant and mother-child relationships, as well as in the widowed mothers themselves (see Beebe and Markese, this issue; Moskowitz, this issue). However, we conceptualize any trauma effects as “normative” in a trauma of this kind, rather than as psychopathology. Moreover, we have no baseline of how these families were functioning prior to the trauma. We can infer family functioning from our understanding of their histories which have emerged, but it is impossible to determine what relational patterns might have emerged without this trauma.

Even highly competent parents can become destabilized in the wake of a loss as sudden and devastating as that experienced by the widows of September 11, 2001. As a group, the women who experienced this trauma were highly competent individuals and parents. However, parents who experience traumatic bereavement are often preoccupied with their own losses and may have difficulty being fully emotionally available to their infants and young children (Buxbaum and Brant, 2001; Brier, Kelsoe, Kirwin, Beller, Wolkowitz, & Pickar, 1988; Garber, 1997; Kranzler, Schaffer, Wasserman, & Davies, 1990; Moskowitz, this issue; Markese, this issue). Maternal depression and anxiety are associated with mother-infant communication disturbances (Beebe, Buck, Chen, Cohen, Feldstein, et al., 2008; Beebe, Steele, Jaffe, Buck, Chen, et al., 2011; Tronick, 1989; Feldman, 2006, 2007; Field, 1995, 2011; Murray and Cooper, 1997; see Markese, this issue). Inconsistent parental support or emotional unavailability can lead to insecure infant attachment and childhood social and emotional difficulties (Beebe et al., 2010; Carlson, 1998; Lyons-Ruth, Bronfman and Parsons, 1999; Main, Kaplan and Cassidy, 1985). In addition to maternal contributions, infants may also bring their own difficulties to the relationship based on constitutional or developmental factors or biological stresses suffered while they were still in utero (Monk, 2001; Monk et al., 2004). Ordinary variations in maternal caregiving are important even in low-risk populations. Infants who receive more tender and affectionate maternal caregiving show less fearfulness to novelty, more positive joint attention, less negative affect, and evidence a lower physiological index of negative affect (less right frontal electroencephalographic asymmetry), even when differences in infant temperament are taken into account (Hane and Fox, 2006; Feldman, 2006, 2007; Tronick, 1989).

Traumatic loss is often associated with depression, anxiety, and difficulty with mourning (Buxbaum and Brant, 2001; Worden, 1982). Traumatic loss also increases the risk of “complicated grief,” in which the person becomes stuck in the mourning process and has difficulty reestablishing a fulfilling life (Shear and Shair, 2005). In a study of 700 survivors of September 11, 2001, 50 percent of those who lost a spouse experienced complicated grief in the initial years following the trauma (Neria et al., 2007). Due to the intense and sudden nature of the trauma and the centrality of the loss, we anticipated that these mothers were likely to experience depression, anxiety, and possibly difficulties with unresolved grief following the traumatic loss of their spouses during their pregnancies.

The idea that a mother's emotional distress during pregnancy may influence the development of her fetus has existed since ancient times (Wadhwa, 2005). Recent research documents that, independent of other established obstetric and socio-demographic risk factors, pre- and perinatal stress, such as maternal distress, is a risk factor for fetal development (Wadhwa, 1998; Barker, 1998; Monk, 2001; Monk et al., 2004). Animal models show that prenatal stress predicts decreased infant learning, increased anxiety, and increased withdrawal (see Lange, this issue). The mother's own subjective experience of the stress appears to exert a larger effect on the fetus than the exposure to stress per se (Wadhwa, 2005). Yehuda et al. (2005) studied women who were pregnant on September 11, 2001, but did not lose their husbands. Infants of these mothers showed altered amounts of the stress hormone, cortisol, at one year of age. Cortisol passes through the placental wall and can be directly transmitted from mother to fetus, potentially altering the infant's physiologically based regulation capacities (Wadhwa, 2005; Dozier et al., 2008).

Loss of a parent in early childhood presents unique and profound difficulties for a child's development (Lieberman et al., 2005). Any child who has experienced the loss of a parent directly, as in the case of the toddlers, or indirectly, as in the case of the unborn infants in our Project, will be affected by this loss, whether or not symptoms are present at a particular moment. Opportunity to deal with this loss through play or talk is therapeutic. Interventions earlier on will help prevent later difficulties. With children, much goes underground, and delayed reactions are common (Bergman, 1999). The interventions of our Project have aimed to give children the chance to express their feelings and to help parents understand the feelings of their children, as a means of preventing later difficulties as development proceeds.

We thus anticipated that a primary prevention project would facilitate the mother-infant and mother-child relationships, the development of the infants who were as yet unborn on September 11, 2001, the ongoing development of the toddlers who had lost their fathers, and the mothers' own recovery processes. Instead of “treating difficulties,” our goal was the promotion and safeguarding of ongoing development and, where possible, the prevention of difficulties. The siblings of these infants, often toddler age or older, were included as central to the Project as well. We aimed to assist the mothers themselves, to facilitate mother-infant and mother-child communication, to provide assistance to mothers in handling developmental questions, and to provide mother and child referrals as necessary.

COMPONENTS OF THE PROJECT

The Project's therapist team is composed of a diverse group of highly experienced clinicians, including those who specialize in the treatment of severe adult disturbance based on early childhood trauma, mother-child and child treatment, family and couples treatment, motherinfant research and treatment, and video microanalysis of nonverbal communication. The services we provide for the families are diverse as well. Mothers and their infants and young children have been involved in supportive parent-child therapy groups, individual child and adult therapy with project therapists or other therapists through referrals from the Project; children's groups (without mothers); mothers' groups (without children); and video communication consultations and feedback sessions (see Cohen, Video Feedback, this issue) focused on facilitating the parent-child relationship, explored with the mother and a team of Project therapists.

The Project began with the following components:

1. Ongoing support groups for mothers, and mothers and children together, to address family concerns related to the evolving nature of the disaster's effect and to facilitate maternal as well as child bereavement (see articles on Support Groups I and II in this issue).
2. Children's groups to promote resiliency among children of similar ages with a shared experience of parental loss and family crisis post-September 11, 2001.
3. A bi-annual (or annual) two-session mother-child video bonding and communication consultation. The first component of the consultation, the filming session, takes place at the Communication Sciences lab, Department of Child and Adolescent Psychiatry, New York State Psychiatric Institute. This session videotapes face-to-face interactions between mother and child and therapist and child. The second component, the video feedback session, is held in Dr. Beebe's clinical office. This is a two-hour consultation with the mother and several team therapists. More frequent consultations are available to any mother who wishes to have them.

These consultations are intended to identify and support the strengths of these mothers, and to address any communication difficulties, or emotional difficulties. Regardless of whether mothers or children participate in our support groups, all families are invited to participate in the twosession video consultation to provide ongoing follow-up.

There is also a research component to this Project, although the potential research value has not yet been tapped. We hope to assess the effect of the trauma on maternal levels of anxiety and depression, and on mother-child communication, and to chart the course of recovery of these families, identifying the strengths and protective factors that contributed to their resilience.

SUPPORT GROUPS

One initial goal of the maternal support groups was to promote healthy mourning, in which the loss of the husband and father of the family could be gradually worked through and accepted by the mothers, allowing them to move forward in their lives to form new, meaningful relationships. The promotion of healthy mourning is tied to the well-being of the children. Protracted, derailed, or overly intense mourning processes have been shown to lead to the clinical phenomenon of complicated grief (Shear and Shair, 2005). We considered it important to facilitate the normal process of mourning in these mothers because it has been shown that unresolved mourning in mothers affects their mood, functioning, and attachment to their children; reciprocally it affects the security of children's attachment to their mothers (Lyons-Ruth, Bronfman and Parsons, 1999; van Ijzendoorn, Juffer and Duyvesteyn, 1995). Mourning is facilitated by the presence of others who are supportive, nurturing, and able to accept the guilt, grief, anger, and helplessness which are part of normal mourning. We thus conceptualized the mourning as a group process which could be facilitated by the presence of other mothers, and our therapists.

A second focus of the support groups was the mother-infant and mother-child relationships. Mothers were encouraged to bring their infants and older children to the groups whenever they liked. The group leaders observed and facilitated discussions of mother-child bonding, the normal difficulties of parenting, and any reactions the children were having to the loss of their fathers (see articles on Groups I and II in this issue).

At the beginning of the Project, we formulated the mother-infant support groups as described below (description courtesy of Rita Reiswig):

The format is an hour and a half meeting, in which the first 15 minutes might be “unwrapping” the baby and getting settled, an hour for group interaction, and a final 15 minutes of “wrapping up” and departure. To begin, the mothers introduce themselves and their babies and say whatever they want about who they are. The group process evolves in a non-structured manner, with each group taking on its own individual style. The aim is for the mothers to coalesce as a group. The therapists are not the “experts. ” The mothers can learn ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Notes on Contributors
• Foreword
• Photographs
• Introduction
• Part I: The Project
• Part II: Mothers and Children in the Early Years of the Support Groups
• Part III: Themes Arising from the Support Groups
• Part IV: Mothers and Children in the Video Laboratory Context
• Part V: The Feedback Sessions
• Part VI: Mother-Child Treatment with a Team Approach
• Part VII: The Therapists' Process
• Part VIII: Perspectives on Early Trauma – Neuropsychological and Clinical Literature
• Part IX: Commentary
• Conclusion
• Index