Psychoanalytic Approaches in Child Psychotherapy

When a child is struggling emotionally, the instinct is often to look at the child in isolation. But some of the most powerful approaches in child psychotherapy take a different view – they look at relationships. Psychoanalytic approaches, in particular, recognize that a child’s inner world is shaped from the very first days of life, through the bonds they form with their caregivers. Two key methods rooted in this tradition are Parent-Infant Psychotherapy (PIP) and Mentalization-Bevorderende Kinder Therapie (MBKT) – or Mentalization-Based Treatment for Children. Both draw from psychoanalytic foundations, yet each targets a distinct developmental window and therapeutic need.

The psychoanalytic foundation of child psychotherapy
Parent-Infant Psychotherapy: healing the earliest bond
Origins: Fraiberg and the “ghosts in the nursery”
What happens in a session
Why early intervention matters
Mentalization-Bevorderende Kinder Therapie (MBKT): building the capacity to understand minds
What does mentalizing look like – and when does it break down?
The structure of MBKT/MBT-C
Evidence for MBKT
How these two approaches complement each other

The psychoanalytic foundation of child psychotherapy

Psychoanalytic child psychotherapy operates on the premise that early experiences – including unconscious emotional processes – profoundly shape a child’s development. Child psychotherapy as a field recognizes that children rarely seek treatment themselves; it is their relationships, behaviors, and emotional symptoms that bring them to therapeutic attention. Unlike adult therapy, which is primarily verbal, work with children and infants demands creative adaptations – including play, observation, and active engagement with caregivers.

The psychoanalytic tradition gave birth to child therapy through the work of figures like Anna Freud and Melanie Klein in the 1920s. But it was the later contributions of Donald Winnicott – who focused on the mother-baby interplay – and crucially, Selma Fraiberg, that opened the door to working therapeutically with the very earliest relationships, including those involving infants.

Parent-Infant Psychotherapy: healing the earliest bond

Parent-Infant Psychotherapy (PIP) is a psychoanalytic approach specifically designed for cases where the normal course of secure attachment between a parent and infant has been disrupted. The goal is to restore this bond, or to work with vulnerable parents to overcome disruption and prevent its recurrence. It is sometimes described as a “catch-all” term for psychotherapies addressing the parent-infant relationship, but its psychoanalytic form has a specific theoretical depth and clinical structure.

Origins: Fraiberg and the “ghosts in the nursery”

PIP as a formal psychoanalytic intervention was introduced by Selma Fraiberg after World War II. Her landmark 1975 paper, “Ghosts in the Nursery,” laid out a concept that remains central to the field today: that unresolved conflicts from a parent’s own past can intrude into the nursery, preventing them from forming a warm and attuned relationship with their infant. These “ghosts” – the emotional residue of a parent’s own unmet needs or early trauma – operate largely unconsciously, yet they have a direct impact on how a parent perceives and responds to their baby.

Fraiberg’s infant-parent psychotherapy uses this metaphor to understand and prevent the intergenerational transmission of negative relationship patterns during the first three years of life. By helping parents access and reflect on their own emotional histories, the approach aims to free them to respond to their infant’s actual needs rather than to the distortions created by their past.

What happens in a session

PIP is not simply individual therapy conducted in the presence of a baby. The infant is treated as an active participant in the therapeutic process. At the Anna Freud Centre in London, PIP integrates Freudian metapsychology with infant research, attachment theory, and developmental psychology, with the therapist watching, waiting, and wondering about the interactions between parent and infant.

The therapist functions simultaneously as an observer and interpreter. They may share observations about the child’s behavior with the parent, offering an alternative way of experiencing the child. During sessions, the parent may explore their thoughts and feelings – shaped by their own history, expectations, and relationships – while the therapist tracks how these internal states influence live interactions with the infant. The baby’s cues, distress, or moments of connection become direct clinical material.

The overall aims of the approach, as articulated by practitioners at the Anna Freud Centre, include supporting the parent-infant relationship to facilitate infant development, reinforcing the baby’s attachment needs toward caregivers, and scaffolding the infant’s emerging capacity for emotional regulation and mentalization.

Why early intervention matters

Psychoanalysts have documented the long-lasting effects of early disruptions in the caregiver relationship, noting that such disruptions can orient a child’s psychological economy toward anxiety avoidance – leaving less energy available for healthy development. Early experiences exert powerful influences on the way that infants become integrated and form attachments, making the timing of intervention critically important.

Research covering 34 studies has provided tentative support for PIP and related mentalization-based approaches, with evidence showing psychoanalytic psychotherapy to be particularly effective for children with a range of conditions, and notably, that therapeutic gains often continue well beyond the end of treatment – a phenomenon researchers have termed the “sleeper effect.”

Mentalization-Bevorderende Kinder Therapie (MBKT): building the capacity to understand minds

Where PIP focuses on the dyadic relationship in infancy, MBKT – the Dutch term for Mentalization-Based Treatment for Children, or MBT-C – targets a somewhat older age group and a specific developmental capacity: the ability to mentalize. Mentalization refers to the capacity to understand behavior in terms of underlying mental states – thoughts, feelings, desires, and intentions – both in oneself and in others.

MBT-C is a transdiagnostic, time-limited individual child psychotherapy with parallel parent sessions that aims to promote mentalization and emotion regulation. It is primarily used with children in middle childhood (ages 5-12) and draws on psychoanalytic principles while integrating findings from attachment theory and developmental research.

What does mentalizing look like – and when does it break down?

When parents mentalize about their children, they engage in imaginative mental activity – essentially asking, “What is making my child behave this way right now?” and genuinely trying to understand the feelings, thoughts, and goals behind the behavior. Children develop this same capacity over time, and when it is underdeveloped or disrupted – by trauma, anxiety, relational difficulties, or other stressors – it can manifest in a wide range of emotional and behavioral problems.

Mentalization-based approaches have been shown to increase reflective functioning in children, adolescents, and families across a growing body of research, with promising findings for both internalizing problems (like depression and anxiety) and externalizing ones (like aggression and conduct difficulties).

The structure of MBKT/MBT-C

A distinctive feature of MBKT is its integration of reality and fantasy through the dual use of talk and play within sessions. MBT-C promotes the child’s ability to interpret the meaning of others’ behavior by considering their underlying mental states and intentions, as well as to understand the impact of their own behaviors on others.

Treatment is typically short-term, running 9-12 sessions for the time-limited model, though the approach developed by Verheugt-Pleiter and colleagues – the first systematic account of MBT with children – describes an open-ended, long-term psychotherapy that integrates mentalization-based principles with classical psychoanalytic ideas, especially from the Anna Freudian tradition of developmental therapy. Sessions involve intensive engagement combining verbal reflection with play-based work, allowing the child to move fluidly between symbolic and concrete modes of communication.

Parents are not peripheral to MBKT – they are an integral part of the treatment. Parallel sessions work to enhance parental reflective functioning, helping caregivers develop their own capacity to hold the child’s mental states in mind. Assessment in MBT-C examines mentalizing strengths and difficulties in both the child and parents, including building blocks such as attention regulation, emotion regulation, and explicit mentalization – providing a nuanced formulation rather than a global diagnostic label.

Evidence for MBKT

The evidence base for MBKT/MBT-C has been growing steadily. A 2024 randomized controlled trial involving 222 school-age children found that those who received MBT-C showed significantly greater reductions in emotional and behavioral problems compared to a group-based parenting and social skills intervention, particularly at six-month follow-up. Crucially, both children and parents in the MBT-C group showed greater improvements in emotion regulation – gains that were sustained over time.

How these two approaches complement each other

Despite targeting different developmental stages, PIP and MBKT share a common psychoanalytic lineage and a relational focus. Both recognize that the child cannot be treated in isolation from their relational world. Both work with the parent as a key agent of change. And both take seriously the inner life – conscious and unconscious – as the site where therapeutic transformation occurs.

PIP intervenes at the earliest stage, when the infant’s brain and attachment system are most malleable, working through the parent to reshape the relational environment the baby inhabits. MBKT picks up in middle childhood, building the child’s own capacity to navigate their inner world and relationships with growing sophistication. Together, they represent a coherent psychoanalytic vision of child mental health – one that spans from the cradle through early school years and recognizes that healing relationships is, at its core, what child therapy is about.

What do you think? If a parent’s unresolved past can quietly shape their infant’s attachment – even without any conscious intention – how much does awareness of one’s own emotional history matter in caregiving? And given that mentalization develops gradually through relationships, what might it mean for a child’s long-term wellbeing if that capacity is supported early through therapy?

References

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Table of Contents

The psychoanalytic foundation of child psychotherapy 🔗

Parent-Infant Psychotherapy: healing the earliest bond 🔗

Origins: Fraiberg and the “ghosts in the nursery” 🔗

What happens in a session 🔗

Why early intervention matters 🔗

Mentalization-Bevorderende Kinder Therapie (MBKT): building the capacity to understand minds 🔗

What does mentalizing look like – and when does it break down? 🔗

The structure of MBKT/MBT-C 🔗

Evidence for MBKT 🔗

How these two approaches complement each other 🔗