Thinking Three, Revisited Infants, Coparents, Gender Roles, and Cultural Contexts

Abstract

Tracing its beginnings to the mid-1990s, coparenting theory and research, guided greatly by Minuchin’s structural family theory, have deepened socialization perspectives in the field of developmental psychology. Coparenting theory has perhaps had its largest impact in the field of infant-family mental health, where empirical investigations of coparenting and family level dynamics have dovetailed with studies of family alliances and triangles and inspired creative interventions to support families of infants and toddlers. In this article, the authors retrace some of the early accounts of coparenting and triangular interactions during infancy, highlighting symmetries with analogue conceptualizations discovered in the field of family therapy. Emphasizing key concepts and lessons divined from the infant-family mental health literature holding value for the practice of family therapy, the article also recognizes the dominant Euro-Western bias that has shaped much of the extant literature to date. A closing section addresses two important areas calling for more concerted attention by infant-family mental health experts and family therapists alike – under-appreciated and misunderstood elements of men’s psychology connected to their core self-definition, and cultural distinctions in normal family processes. In both cases, if misread or misunderstood by the helping professional, the recipients of therapeutic services may experience failures of empathy.

The late 1990s and early 2000s were germinative times for the fields of coparenting and infant-family mental health. In 1985, Patricia Minuchin had penned a seismically instrumental critique calling out a negligence in the annals of developmental psychology, which had unnecessarily restricted its theories of children’s social and emotional change and growth to focus on forces within child-parent (dyadic) relations. Minuchin (1985) remarked that limiting the focus to children and dyads trivialized the fact that a dyadic phenomenology did not reflect children’s significant reality, especially after the earliest weeks and months of infancy. By isolating child development as being principally guided by the dynamics of twosomes while overlooking broader family systems and family-level dynamics, she maintained, developmentalists had all but ignored a key family systems principle - that no individual can be fully understood outside of the family contexts in which they function. In the decade that followed, a small number of developmentally oriented clinical scientists responded to Minuchin’s provocation and undertook new, detailed, and systematic observations of families – with explicit focus on child-family triangles. Perhaps fittingly, much of this seminal work began with families of infants (McHale & Fivaz-Depeursinge, 1999), though several scholars made expeditions into studying family systems with older children (McHale & Cowan, 1996). This article reflects on this seminal work and some of its relevant aftereffects, focusing on the concept of coparenting.

In these germinative years of the 1990s and early 2000s, the term “coparenting” was not commonplace – indeed, the only references to the term “coparenting” that could be found in the field’s major child development journals prior to 1995 used the term in limited application to post-divorce families. Empirical research and high visibility publications exploring coparenting and family systems in families that had not divorced remained few and far between. Moreover, there existed temptations - many that still endure, to relegate coparenting to a mere “function” of the “marital couple” (Weissman & Cohen, 1985). There was an insidious, heteronormative view of the two-parent nuclear family as the ideal for the healthy development of offspring (Talcott & Parsons, 1955), and a major, influential research stream focused on the growth-stultifying effects of child-related marital conflict (Grych & Fincham, 1990) that reinforced this view of family as comprised of biological mother, father, and child or children.

Echoing the concerns of marital health and marital conflict were influential articles arguing that children’s emotional security was a product of their past experiences with marital conflict (Davies & Cummings, 1994). Developing alongside these treatises focused on marriages and children were creative expansions of attachment theory ranging from children’s bonds with individual caregivers to their connections with the family group (Marvin & Stewart, 1990). With this zeitgeist and converging lines of thinking, it was just a matter of time before the growing interest in how conflict expressed by the “marital couple” affected children and edged developmental psychologists ever closer to conceptualizations of mother-father-child triads as a single unit. In some articles of the time, researchers even began appropriating metaphors core to the field of family therapy, among them “enmeshment” and “triangulation” (Bowen, 1972; Minuchin, 1974; see for e.g., Byng-Hall, 1999; Fivaz-Depeursinge & Favez, 2006; Kahen Johnson, 2003; Stevenson-Hinde, 1990) to describe the dynamics of non-clinical families.

With this gradual progression, there remained a decidedly Euro-Western flavor to literature written about families - a bias since identified in most major subfields of developmental psychology and family therapy. Family studies of the 1990s were mired in what was initially labeled “white middle class bias” (Marks, 2000) – now widely recognized as a dominant bias in most social science research enrolling participants who hail from “Western, educated, industrialized, rich and democratic (WEIRD) societies (Henrich et al., 2010). The absence of diversity in family systems studies unwittingly reinforced an endemic, implied bias that variation from the mythological Talcott and Parsons “ideal” family bred pathology and problematic child development. Walsh (1982) had advocated pursuit of more fully inclusive views of functional family systems and “normal family processes” – a stance that was wholly consistent with S. Minuchin’s (1974) recognition that in any family, children’s coparents were the two (or more) adults comprising that family’s executive subsystem and guiding the child’s socialization and development. Yet, it was not until the early 2000s that initial advocacy to use the term coparenting to illustrate the structural relationship and dynamics of caregiving adults in a fuller range of family constellations (McHale et al., 2002) first made their appearance in the parenting literature.

While there has since been significant movement from these early solecisms, there is wisdom in re-tracing the decades-long advance toward more inclusive and universal perspectives on coparenting, triangles, and child development, especially as they relate to case conceptualization and intervention. In this article, we do so by revisiting the early days of coparenting theory and research in the late 1990s and early 2000s. We highlight several lessons sometimes now forgotten in an era when scores of new manuscripts bearing the moniker “coparenting” find their way to publication annually. We harken back to a 2003 article by McHale and Alberts, “Thinking Three: Coparenting and family-level considerations for infant mental health professionals”, and underscore some of its foundational points that have proved enduring. We then comment on newer ideas that likewise have relevance to this special issue on the infant in family therapy. We conclude with observations about two issues that, at least within the field of infant mental health itself, have been relatively slower to evolve - but that have the potential, if more evocatively examined, to meaningfully influence both the theory and practice of infant-family mental health and the field of family therapy.

Thinking Three: Some Basics

Reflecting back on the state of developmental psychology theory and research in the 1908s, P. Minuchin’s 1985 article appeared at around the same time as a new wave of research examining the transition to parenthood in married, two-parent families (e.g. Belsky, Lang & Rovine, 1985; Cowan & Cowan, 1992; Feldman, Nash & Aschenbrenner, 1985; Grossman, Pollack, Golding & Fedele, 1987). Though ostensibly this body of work suggested a triadic focus and elevated the allegory “making room for the baby”, the principal foci of the transition to parenthood research stream were not triangles but rather couple relationships and child-parent dyads. Lewis (1989) did, however, provide useful leads in identifying individual markers of and differences in early triadic (father-mother-child) family process. To be fair, in the 1980s and early 1990s, the now clear distinction between marital and coparenting relationships had not yet been drawn, and as a result the two concepts (the first of which is dyadic, the second of which is, at minimum triadic) were sometimes treated interchangeably. In ensuing years, conceptual and empirical efforts would begin to clarify that while inter-related, dyadic and triangular relationship processes were decidedly not the same.

McHale and Alberts (2003) recognized that the burgeoning field of infant mental health had itself also been predominantly focused on dyadic relationships – in particular, on the dyadic relationship between infant and mother. Their article hence advocated that infant mental health professionals take time to familiarize themselves with family systems approaches and more specifically, the value added by contemplating infants’ development within family triangles (Bowen, 1961, 1972; Bell & Bell, 1979; Donley, 1993; Kerr & Bowen, 1988). In many respects, their report was a harbinger for a 2004 keynote at the World Association for Infant Mental Health Congress – “When Infants Grow Up in Multi-Person Relational Systems”. Though relevant scholarship reviews had been accessible previously (e.g., McHale & Fivaz-Depeursinge, 1999), the McHale and Alberts (2003) article – successfully translated the recommendations to the infant mental health guild through their professional bulletin and newsletter “The Signal”.

McHale and Alberts (2003) acknowledged that mother-father-child triads had in fact been attended to in certain psychoanalytic writings for some time (providing several examples involving separation-individuation, splitting in the service of ambivalence, and most notably navigation of the oedipal crisis (Brickman, 1993; Ermann, 1989; Frank, 1988, Henderson, 1982, Juni, 1995). They also pointed out, however, that neither triangles nor the intrapsychic process of experiencing a triad during the baby’s first year of life had been taken up by psychodynamic theory (Abelin, 1975; Lemche & Stoeckler, 2002). It was with respect to the latter that McHale and Alberts (2003) called attention to what was at that time newly emerging scholarship demonstrating the competent infant’s triangular capacities - observable during even very early infancy - a topic to which we will return later in this article.

Studying Coparenting and Triangular Interactions.

The crux of McHale and Alberts’ (2003) article was on observations of coparenting and triangles, including both macro- and micro-analyses of family-level interactions involving mothers, fathers, and babies. Observational forays into studying coparenting and family-level dynamics (see McHale & Cowan, 1996; McHale & Fivaz-Depeursinge, 1999 for early summaries) had been particularly timely, as family scholars of that time had begun to talk about the unique challenges of studying and building consensus on the dynamics of multi-person family units. Nelson and Utesch (1990) pointed out that the more abstract the concept, the greater the inference required to interpret it with their commentary on structural family therapy’s duty in accurately identifying influential family processes and dynamics such as cohesion, collusion, triangulation, and detouring. The more concrete the concept, the more easily it lent itself to direct observation. In a similar vein, Green and colleagues (1985; 1988) had cited limits of concordance when researchers compared inter-rater reliability in their assessments of families. Though family therapists themselves seldom operated from research-driven guidelines or protocols, their inferences about family processes were typically grounded in observable behavioral referents. McHale and Alberts (2003) made a case that accurate inferences about important coparenting and triangular processes and dynamics during early infancy, though less familiar or well-understood than family processes with older children, were altogether possible -- and that such inferences could be anchored in observable behavioral referents detectable during routine family interactions, without sacrificing conceptual meaningfulness.

To make this case, they presented new analyses from their own major study of transitions to coparenthood among families in a non-clinical, working-class sample of families in central Massachusetts, and tied their study of coparenting in community families to investigations of triangular relationships in clinical populations emanating from the Centre d’Etude de la Famille (CEF) in Lausanne, Switzerland. In the years just prior, the CEF had introduced innovative studies of early family alliances among mothers, fathers and babies negotiating an assessment they named the Lausanne Trialogue Play (LTP)¹. Now a well-known anchor assessment in the field of infant-family mental health, the LTP is comprised of four “parts”, or segments. In Part 1, one parent plays with the baby while the other is simply present; Part 2 is a second “2+1” in which the coparents switch roles; Part 3 has the family engage as a “three-together” with all family members asked to play with one another; and in Part 4, there is a final 2+1 with the coparents actively engaging as the child is placed in the third-party position. The individual, dyadic and triadic behavioral sequences enacted during the LTP provide a visible, easily observable glimpse into the family’s structure and process.

Though the LTP was not yet widely known or used in the late 1990s and early 2000s, McHale, Alberts and their colleagues had adopted the procedure as one of the core assessments completed during 3-month postpartum home visits in their longitudinal study of community families. Though they were constrained by the newly evolving and cumbersome video technology of the day, they were able to approximate the sophisticated, multi-camera edited recordings of families that had served as the basis for investigations in the Lausanne studio studies on their 3-month home visits. They accomplished this feat by bringing and situating a large mirror behind infants as the babies played with their parents, positioned in a triangular configuration, and seated in a specially constructed infant chair built by the same firm that had constructed the device used in the Lausanne clinical lab.

Capturing the triangular images and interactions on video-recordings thanks to a strategically situated camera and tripod placed in the room where the play interactions took place, the team obtained the triangular images and interactions needed for trained coders to later review the recordings and in careful microanalytic work, document sequential patterns. Alberts herself oversaw this micro-analytic coding work; meanwhile, a separate team of doctoral students training in child and family therapy simultaneously and blindly rendered higher order judgments describing coparenting cohesion (the extent to which the coparents engaged warmly and cooperatively), coparenting conflict (spoke or acted contentiously), or discrepancies in engagement (withdrew or disengaged from the three-person play) - using McHale, Kuersten and Lauretti’s (2000) Coparenting and Family Rating System (CFRS).

Theirs was a pioneering enterprise; although the CFRS had previously been used in research in which families engaged in structured and unstructured play with their infant and toddler aged children, it had never previously been applied to evaluations of the LTP. In the initial study documenting coparenting and triangular interactions during infancy (McHale, 1995), the CFRS global ratings had factored into three conceptually meaningful scales – hostility-competitiveness, family harmony, and discrepancies in parental engagement, factors that replicated exactly in an independent study of older children by McConnell & Kerig (1999). More significantly, the early evolving coparenting and triangular patterns of hostility-competitiveness, family harmony, and parenting discrepancies detected during infancy prospectively predicted children’s socioemotional adjustment during the preschool years (McHale & Rasmussen, 1998) as evaluated by both parents and teachers - a seminal finding that triggered a groundswell of new studies tying coparenting during infancy to children’s socioemotional adjustment.

McHale and Alberts’ (2003) report provided evidence that key sequences of interaction observed by the micro-raters appeared influential in underpinning the clinical raters’ higher-order determinations about core family dynamics and processes. This finding of relationships between micro-sequences and global evaluations was perhaps not particularly surprising to experienced family therapists, who actively seek out cyclical patterns of interactions that sustain relational problems within families. However, taken together with the ancillary findings that global evaluations of coparenting from coparent-infant play were prognostic of later child adjustment outside the family, the data provided rare empirical corroboration of family therapy practices. The decades-old practice of ferreting out and punctuating interaction sequences exhibited in the ebb-and-flow of family therapy sessions - as a pre-requisite for engaging collaboratively with family members to develop alternate, growth-promoting relational patterns - stood on firm ground. But more to the point, the study highlighted the salience of triangular interactions during infancy as meaningful, observable, and of potential significance to the practice of family therapy with families of infants.

One of McHale and Alberts’ (2003) conclusions - that the state of the emerging scholarly knowledge base was not yet to a point where diagnostic guidance could be offered, is still largely true today, although this circumstance is also changing. We will address more recent work from an International Coparenting Collaborative in the next section. We wish to close this section, however, by taking note of one other set of discoveries concurrently making the infant mental health rounds in the 1990s that gave deeper meaning to the relevance of coparenting of infants.

Daniel Stern (1985) had drawn together emerging scholarship on the incredible interpersonal competencies of even weeks-old infants, and his exposition of intersubjectivity during infancy had profound and enduring influence within the infant mental health field. Far from being passive and dependent absorbers of the relational surround, as portrayed in much psychoanalytic thought, babies actively sought out and co-constructed meaning in relationships. Although Stern’s focus was on their doing so in their dyadic relationships with mothers, the competencies babies universally possess and their potential impact are likewise positioned in triangular and other social contexts. Although McHale and Alberts (2003) alluded to the importance of this new appreciation of babies as active partners, their analyses did not do justice or give adequate voice to the baby’s role in influencing triangular interactions in their study of coparenting. Such analyses were, however, completed by Fivaz-Depeursinge and the Lausanne group, and highlights of these investigations will be featured in the next section.

Thinking Three: Newer Insights

Studies of Triangles: Advanced Scholarship from the CEF.

Throughout the first two decades of the 2000s, the CEF in Switzerland, led by clinical scientist Elisabeth Fivaz-Depeursinge, was a hotbed of new scholarship central to the study and understanding of family triangles. The CEF published article after article detailing small N discoveries from LTP studies that in many cases echoed, and in many extended, wisdom that had emanated from the field of family therapy itself. For example, Fivaz-Depeursinge (2008; Fivaz-Depeursinge & Favez, 2007) identified infant behaviors during the LTP that occurred in the context of two-for-one alliances and two-against-one coalitions, echoing detouring, scapegoat, and go-between patterns previously detailed by structural family therapists.

With respect to studies of the LTP itself, Frascarolo and colleagues (2004) presented a case that those working with families could scrutinize LTP interactions with a functional hierarchy in mind. First and foremost was the question of whether all family members were engaged – without participation and engagement by all, coordinated family patterns could not be achieved. Engagement itself wasn’t enough – involvement by all created the possibility that disorganization and even collusive dynamics, pitting the preferences of one family member or dyad against the strivings of another, could transpire. But if all family members engaged and managed to stay organized without behaving in a conflicted or enmeshed manner, there came a possibility of attaining a joint focus, all as one engaging in common conduct as a triad. Such joint attention sharing or focalization – unquestionably a significant indicator of family coordination with infants and toddlers, then paved a way for positive, generative affect sharing and attunement – not guaranteed, but more attainable without disconnected or negative affect when family members were sharing a joint focus. This conceptual model was based on multiple studies of families navigating the LTP at the CEF, and also gave rise to research-related coding systems less portable or directly usable by practicing therapists but denoting clear markers of meaningful interaction patterns that were seeable and quantifiable during infant-family interactions (e.g., FAAS - Favez et al., 2011; GETCEF - Fivaz-Depeursinge et al., 2009).

Infants’ Visibility in Family Therapies.

Despite the bustle of activity at the CEF and in the small number of hospitals, clinics, and labs exploring triangular dynamics during infancy in the years following “Thinking Three” (and increasingly, articles in developmentally oriented journal outlets incorporating tenets from family systems theory and therapy literatures), there was little parallel influence of infancy research on the practice of family therapy itself. A case had been made for the relevance of attachment theory for family therapists by John Byng-Hall (1995), who had introduced the concept of a secure family base and outlined how, for infants, such a secure base demanded:

“an expectation of reliable handover and hand-back within the family network, or with appropriate outside carers. Children need a sense that relationships between adults are sufficiently collaborative to ensure that care is always available. A secure family base involves a shared awareness that attachment relationships need to be protected and not undermined (p. 46)”.

Byng-Hall (1995) argued that attachment theory had something to offer all family therapists. It did not call for a new school of family therapy with set premises and specific techniques. In other work, however, there were guidelines provided for key accomplishments in work with families of young children. Ecosystemic Structural Family Therapy (ESFT) was one such model. ESFT is a treatment, supervision and training model developed by Marion Lindblad-Goldberg and elaborated at the Philadelphia Child and Family Therapy Training Center (Jones & Lindblad-Goldberg, 2002). Lindblad-Goldberg and her colleagues centered the family’s executive coparenting subsystem and emphasized the pivotal importance of a healthy coparental alliance, as had S. Minuchin (1974) and structural family therapy before her. ESFT, however, also acknowledged individual and dyadic functioning, including secure child-caregiver attachments, and each family member’s distress tolerance and capacity for emotion regulation. These four elements, ESFT held, are equal pillars in the strong house needed to safeguard children’s emotional health.

ESFT acknowledged that many of the tenets concerning children’s attachments and other elements of the expanded ecosystemic model had not been adequately studied or accessible to Minuchin when structural family therapy was first developed. Her updating of the structural model to integrate advances in developmental psychology hence opened a door for better understanding and integrating infancy research. That door did not fully open, as most ESFT clinical research focused on families with older children. Still, the beginnings of a future reconciliation were meaningfully drawn.

ESFT also seeded what in more recent years has become a long-overdue reckoning with the social determinants of individual and collective family health - factors from outside the family impinging on adaptation and adjustment - and targeting extrafamilial factors as reasonable marks for therapists to understand and address to enhance family functioning. More broadly, it invites family therapists to understand meaning by attending to the connections between the dynamics of family interiors and the family’s historical and concurrent embeddedness in its environmental context. In this regard it is consistent with multi-systemic family therapy, which though typically focused on much older children and severe behavioral challenges, explicitly takes into consideration other systems in which children and families are embedded (Henggler et al., 2009). In the case of families with infants and toddlers, acknowledging and understanding the embeddedness of individual coparents and the family triangle or system in ecological context, systems within systems, can better guide the therapist’s efforts within the family interior.

In other efforts to bridge systemic thinking and practice with attachment theory, Rudi Dallos and Arlene Vetere drew attention to the systemic concept of triangulation. As Dallos and Vetere (2012) outlined, the attachment tradition had focused almost exclusively on dyads in both theory and research, beginning with parent-child attachments and moving to the study of adult romantic partners. This was in contrast with systemic theory, in which the triangle is understood as the basic human relationship, such that whenever two people interact, their interactions are affected by their shared relationships with the same third person. There are many ways in which the triangle is important during infancy; as Byng-Hall (1995) had suggested, each caregiver can materially influence the child’s attachment relationship with the other, and children’s sense of family-level security is affected not just by their relationship with each coparent individually but with the relationships among them.

Dallos and Vetere maintained that the process of triangulation in intimate relationships was the link between attachment theory and systemic thinking, noting that “systemic theory has lacked both a coherent theory of love and a theory of trauma responding to underpin the exploration of meaning, narrative development, pattern and process (p. 118)”. Despite their emphasis on attachment, Dallos and Vetere’s clinical and conceptual efforts did not extend to families with infants. Their therapeutic approach also relied on a distinctly narrative application. However, their casting of pattern and process as attempted solutions, guided by embodied fears developed over time, is highly relevant. It is possible to understand triangular patterns, at the level of behavioral exchange and affective communication among partners, as coparents’ efforts to resolve issues of longstanding – including concerns about family security carried forward from origin families (McHale et al., 1996). As child-parent psychotherapy has made abundantly clear, making sense of the past creates space for babies (Narayan et al., 2016), and this is every bit as true in triangular spaces as it is in relationship dyads.

Recognizing the Baby’s Contributions to the Family Group Dynamic.

There is unquestionably a draw when approaching therapeutic work with families of infants and toddlers to focus primarily or exclusively on the coparenting adults and to undervalue the child’s contributions. This is perhaps especially so when a predominantly or exclusively narrative approach is relied upon (Opie et al., this volume), for preverbal infants have no stories to convey through the spoken word. However, infants contribute and communicate through other, non-verbal channels, and their contributions (and potential contributions) can be integrated into therapy in creative and meaningful ways. Earlier, we referred to research documenting infants’ early emerging triangular capacities – the competency for sharing interest and affect with multiple partners during a social exchange. These capacities are well-established by 6–9 months but can be systematically observed in babies as young as three months old (Nadel & Tremblay-Leveau, 1999).

Triangular bids function to share affect to influence the flow of interaction; for example, protest changes a situation, interest or pleasure signals a wish to continue. The four parts of the LTP enable clear visualization of these infant capacities; for example, when playing with one of their parents in Parts 1 and 2 (the 2+1 segments), even very young babies at high points of pleasure or distress turn from the active to the third-party parent, to share their joy with that parent too, or to call for his or her help. McHale and colleagues (2008) established that even in non-clinical families, infants’ triangular capacities are systematically related to the quality of coparenting in families; Fivaz and her colleagues provided vivid examples of how infants’ triangular behavior can be interpreted as reinforcing or sustaining problematic family patterns in clinical families.

Infant behavior during triangular interactions can be a point of entry, but can also be used to query parental motivations, reframe behavior, or raise mindfulness. For example, in some families, coparents display substantially different engagement styles when engaging with their child in the LTP, one highly stimulating, another temperate and serene. Moments can sometimes be identified in the flow of interaction when the baby responds positively to each – and conversely, turns away from or protests over- or under-stimulation. Parents can be helped to recognize how their infant seems to enjoy both, at times, and asked how they know when the baby prefers which. Parents are often bewildered to see the baby’s clear communicative messages during video feedback following triangular interactions (such feedback as is often provided in LTP debriefings, discussed below), and infant signals offer therapists regular opportunities to speak for the baby.

Interventions designed to promote infant-family mental health.

Though in practice most family therapies have not integrated infants and infant voice in these ways, there have been coparenting-focused, as well as family group interventions introduced by several active clinicians and family scholars over the past decade. Focused Coparenting Consultation (FCC; McHale & Irace, 2011) is one of these interventions that has received empirical support. FCC is a brief, flexible intervention that follows a three-stage model. It begins by raising parents’ mindfulness about the impact of coparenting for infants or children and their resolve to strengthen their own coparenting. Next, it teaches parents new communication tools to better contain conflict and to problem-solve differences. Finally, with consciousness raised and new skills learned, guided enactments about current, child-related concerns are completed under the watchful eye of the interventionist.

Variants of FCC exist for diverse family constellations, including unmarried and divorced coparents, and FCC shows material impact not only on coparenting but on other important markers of individual and dyadic functioning (McHale et al., 2022a; 2022b). A limitation of FCC, however, has been its focus on adults without actively including the child. Although photographs of children are on display in the variant designed for post-divorce families (Through the Eyes of the Child; McHale & Carter, 2019), and the child is the center of all sessions and conversations (FCC closes all off-track conversations about non-child related family problems), the promise of including the infant in sessions themselves has not been capitalized upon. The concept of “holding the child in mind” (like the concept of holding the triad in mind during dyadic child-parent psychotherapy (Iwaoka-Scott & Lieberman, 2015), however, remains at the core of all successful FCC interventions.

Regarding therapies with the triad or the whole family group, there have been numerous successful studies of LTPs with video feedback (see Philipp, this volume, for a more detailed review). The idea of using feedback to families as a therapeutic tool following completion of LTP assessments began with a few spontaneous “trial interventions” in Lausanne revealing that certain parents, if accompanied, were able to adjust their framing interactions. When they made such adjustments, infants usually responded in kind by engaging. Trial interventions then became deliberate strategies in systems consultations, showing effectiveness when used by experienced LTP consultants (Favez, Frascarolo, Keren, & Fivaz-Depeursinge, 2009; Fivaz-Depeursinge & Philipp, 2014). Subsequently, Philipp’s (2012) Reflective Family Play (RFP) developed with families playing together and adults reflecting on their play. RFP blends the LTP consultation model with tenets from the intervention Watch, Wait and Wonder. The LTP offers the structure in which to play, challenging the coparents to coordinate. RFP instructions, which ask coparents to reflect and follow the child’s lead as per WWW, target reflective capacity. Though evidence is limited, there are data to indicate that RFP influences both child and family functioning (Philipp et al. 2018). Reports of effectiveness of other brief interventions that have included video feedback following an LTP administration have also appeared (e.g., Olhaberry et al., 2017). Though such interventions differ from most family therapies that engage with couples and or older children, they succeed in creating a reflective space in which coparents can see and understand their infant as a distinctive individual possessing distinct mental states. Of note, in these interventions infants need not be present throughout the therapy. However, when the baby is seen (on video), holding the actual (observed) infant in mind - even in sessions when the child is not physically present – becomes more possible. This, advantage, also documented in the dyadic Circle of Security intervention (Cassidy et al., 2011), is one that most versions of FCC to-date, along with most conventional family therapies, have not yet capitalized upon.

Coparenting in case conceptualization.

A final advance especially worthy of note is a more recent one, that holds significant promise for case conceptualization and treatment planning in family therapy. Since March 2022, an International Coparenting Collaborative (ICC) has been working to divine insights and advances from a quarter century of coparenting research involving families of infants. Their objectives are to offer guidelines to practitioners for infant-family intake assessments that can reliably and validly capture core coparenting features of engagement, teamwork, conflict, and child focus. Central to this work is guidance for use of ecomaps to chart the functional members of the infant or toddler’s coparenting system, observational assessments centered by the LTP, self-reflections of coparenting using a Coparenting Scale, and separate evaluations of the child and their symptomatology provided by each coparent (McHale et al., 2023).

The initiative will offer guidance on specific behavioral referents from LTP observations signifying engagement, teamwork, conflict, and child focus. It will also provide strategies for engaging coparents in feedback sessions to review both observational and self-report data -- with the aim of elevating coparental mindfulness and building teamwork for undertaking the work of addressing the child’s behavioral and emotional challenges. Data are being gathered at diverse practice sites in six different nations (Switzerland, Italy, Sweden, Israel, Canada, and the United States), in hospitals, clinics, and forensic settings. Though the ICC has deliberately chosen not to recommend or endorse specific forms of therapeutic intervention for addressing child and family issues and concerns, they do intend to gather and present data concerning the frequency of therapeutic focus on coparenting issues. They will also revisit the question of coparental mindfulness and perceived behavioral change at the point of discharge. The ICC efforts promise to provide a set of concrete guidelines and recommendations that may prove to be of significant value in advancing greater inclusion of infants and infant-mental health principles in family therapy.

Thinking Three: Growing Points

There are a great many growing points potentially worthy of note, but given space limitations, we have chosen to focus on just two that – if taken to heart – would materially transform the theory and practice of infant-family mental health and, by extension, family therapy involving the infant. The first concerns a seldom broached topic - the regard with which men and fathers are held within the field of infant-family mental health. The second concerns the ongoing, though largely silent, Euro-Western perspective on “normal family processes” that continues to percolate in research, theory, and practice.

Attending to the Psychology of Men and Fathers.

It may seem odd to bring up the regard with which men and fathers are held by practitioners (although see Lim, McMillan, Robertson & Fletcher, this edition). After all, the history of the field of psychology is one that was dominated, throughout its formative stages by men, and there have been numerous scholarly critiques that so many of the concepts and theories that serve as the field’s foundations did not adequately take into consideration the sensibilities of women (Gilligan, 1993). In critiquing schools of family therapy, Hare-Mustin (1978) and Leupnitz (1988) contended that while family therapy had ostensibly corrected a gender bias endemic in psychodynamic theory - the ascription of primary blame to mothers for children’s emotional disturbances - gendered biases remained. Case conceptualizations casting mothers as over-involved and ineffectual, and fathers as absent and under-involved still viewed mothers negatively and pathologically, they contended. Mothers, they stressed, were locked into economically dependent, emotionally isolated, hyper-responsible positions. Were fathers in families to assume greater responsibilities to their children, mothers could move out of the crazy-making circumstances society had foisted upon them. More recent intersectional feminist theories hold that gendered power dynamics engender inequality and dominance by men both in immediate and extended families, mirroring gender inequalities in wider social systems like education and healthcare, workforce, legal and political systems (Collins and Bilge, 2016).

Why is it then that men and fathers might be deserving of greater understanding, support, and regard in infant-family mental health interventions? There are several answers to this question. The first concerns the effects of role conflict. When men first discover they are going to become fathers, they almost universally experience pride, joy and hope, regardless of their family circumstances. They soon come to discover that systems of care are not set up for fathers and that they rather prioritize and promote maternal and child health, to maximize a “healthy start” toward development of a strong mother-child bond (Lu et al., 2010). Men’s roles as a support to mothers during and after the pregnancy are emphasized, as are their roles as financial providers. Western fathers now also receive societal messages that they should step up to be meaningfully involved in their children’s emotional lives. In response, men’s “can-do” attitude and perseverance in the face of challenge (Levant, 2008) are activated. Unfortunately, though, so too is another less desirable attribute - men’s denial of emotion, which is frequently perceived by men as necessary if they are to meet the multiple demands of new fatherhood. Such denial is accepted as proper and normative, is rarely questioned, or even noted by others, reinforces formulaic expectations of men and masculinity, and closes off men’s help-seeking.

Perhaps not surprisingly, multiple analyses indicate that traditional masculinity is associated with stress and conflict, poor health, poor coping, and poor relationship quality (Courtenay, 2000). It is also not uncommon for there to be challenges in involving fathers, especially marginalized fathers but other men too, in therapeutic encounters. Among public health agency providers, men’s resistance is frequently framed as signifying lack of serious commitment to fatherhood, family, and relationships. The phenomenology of disconnected fathers, however, is that of not feeling welcomed. Fathers perceive, often rightfully, that services set up to be delivered by women and to support mothers are off-limits - or at least that their presence creates an inconvenience. Providers themselves sometimes report greater comfort working with mothers alone than with mothers and fathers together. Men’s reluctance to invade the space of women supporting women can therefore be viewed as taking flight from a situation where they are not truly needed or welcome – though alternatively their gesture to step aside so their children’s mothers can garner needed support can also be seen as respectful and caring.

There is also the greater issue of what happens when men do enter a therapeutic space, whether one navigated by female health care providers and home visitors, one provided by (largely female) credentialed infant-family mental health professionals, or one led by family therapists. At least in the latter case, men may have an expectation of being seen and heard, to the extent that accrediting bodies (such as the North American Commission on Accreditation for Marriage and Family Therapy Education) include gender and diversity as core competencies when assessing clinical practice (American Association for Marriage and Family Therapy, 2015). Equally, however, many men hold a view that therapy is a province of women, one that involves talk and emotion sharing - competencies men perceive women to possess in greater quantities than they do. Perhaps as a result, men also frequently frame therapies as win-lose scenarios, where one party surrenders all autonomy, while the other has their preferred solutions rubber-stamped by the therapist. Because the medium of therapies is emotion talk, men enter in one-down positions and hence fear not only not being heard, but losing what small amount of autonomy and voice they feel they have retained.

Much has been written about the paradox of men feeling powerless in a society where there is male dominance and gender inequality (Mankowski & Maton, 2010). But in the case of individual fathers of infants, an especially significant form of powerlessness relates to an unseen, unspoken loss of one key component of the male self. It is a component countless men silently experience upon entry into relationships and parenthood – the dissipation of an autonomous, independent self. That is, among new fathers who may be potential clients of mental health providers, the hesitancy to engage is not just a function of emotion suppression in response to the multiple role strains they experience but is attributable to containing any further loss of freedom and autonomy. This issue of losing independence and autonomy is unlikely to ever be raised spontaneously by men, even when therapists maintain a curious stance about client experience and honor the client as the expert in their life. Why might this be?

According to Chodorow (2018), autonomy as a core element of men’s personality (in contrast with connectedness, a core element of women’s personality) can be traced to boy’s and girl’s social-emotional experiences from infancy forward. Girls’ and women’s sense of connectedness as an element of their core selves results not just from societal expectations, but from their own lived experience as daughters and a birthright bond with their mothers. By contrast, Chodorow argues, boys’ and men’s separateness as an element of their core self is embodied through establishment of an identity separate and apart from the mother. While men obviously experience and crave connectedness and women experience and crave autonomy, the core and embodied sense of separateness that defines men’s self-identity is at issue – and it is frequently, perhaps nearly always, overlooked by helping professionals. Separateness can contribute to a sense of isolation, but it is also a celebrated and core feature of men’s lives, one that men believe they must set aside or at least kept in check for effective intimate relationships and investment in fatherhood.

Recall our earlier discussion of ESFT, in which we pointed out that appreciating the embeddedness of each individual coparent and of the family triangle in their ecological context can guide better therapeutic understanding of the family interior. Unfortunately, comparatively speaking, most infant-family mental health therapists have incomplete understanding of the lived experience and life circumstances of unmarried, marginalized fathers as coparents. To the extent that fathers show reluctance to engage in therapeutic work, implicitly pathologizing them makes matters worse. Bringing to bear (in outreach, engagement, and therapeutic work) poorly-fitting concepts and constructs that do not map onto men’s own realities (e.g., that fathers need to be educated about the importance of fatherhood, that fathers need to contain their frustration and anger so they do not behave abusively toward mothers and infants, that fathers must find substantive work to financially support their children as the prime show of their worth) does not help (Roy & Dyson, 2010). Viewing men and fathers from a deficit- rather than a strengths-based perspective devalues and disorients them, and ironically, quite commonly drives them away from the therapeutic enterprise – reinforcing the false stereotype of fathers as uncaring and distant.

Though this critique of how fathers are viewed is indisputably most common in work with fathers from marginalized populations with limited power in society—groups who experience lack of privilege in many of their daily life contexts - the case being made here is equally true of many to most men and fathers, at least those in Euro-Western family systems. Men’s self-definition as autonomous individuals is important to them, but it often gets obscured by renderings that either focus on men’s power, authority, and privilege, or on men’s faults – such as their dormant violence potential or their incapacity to commit, love, and devote. Being seen and approached as generic rather than gendered beings creates a context for men to experience failures of empathy. Conversely, a mental health provider’s recognizing and honoring that an essential core of men’s self-definition is their separateness, autonomy, independence, and individuality goes a long way. Communicating the understanding that these are core elements of the male self that men selflessly curtail and even jettison altogether upon commitment to child and family - allows men to believe that interventionists see and value them and their devotion.

We believe the therapeutic stance of helping professionals is crucial. Recognizing and honoring men’s perceived self-sacrifice in retiring their male-connected independent individual identity to dedicate themselves to the wellbeing of their child and family would resonate with many fathers. Expressing this admiration sincerely, in ways that feel authentic - and perhaps even creating space to consider occasional recovery of minimalized elements of the lost and once-celebrated self – would inject a needed, missing element into many infant-family therapies. For paradoxically, recognizing men’s justified sense of loss may spark the very commitment, investment and connection that is much harder won when attempting to impose solutions that knowingly or unknowingly trivialize or denigrate men’s autonomous self.

These suggestions are intended to augment existing best practices by pulling back a curtain on the psychology of men and fathers - not to suggest changes in the significant gains made in supporting family relationships. One core tenet of coparenting theory is that coparenting can be approached and strengthened without attempting forays into men’s and women’s intimate, romantic lives. The successful Focused Coparenting Consultation (FCC) described earlier was named “Figuring It Out for the Child” for good reason – it placed the child at the center and attended to the child’s needs. This child-first metaphor was appealing to both men and women and allowed many uncoupled coparents to work effectively together to articulate common goals for their shared child. A similar tack has been taken in FCC work with high conflict post-divorce couples – child at center, common aims to work collaboratively. This frame appeals to teamwork and downplays “power”. Numerous commentators have observed how men often tend to define power more in comparison to others than as shared with others (i.e., ‘power over’ instead of ‘power with’; Mankowski & Maton, 2010). Rather than feeling powerless in association with a second parent with whom they do not “match up”, cultivating a spirit of “all for one” appeals to men’s base sensibilities of fairness and selflessness to put the baby first.

In summary, we believe that the inclusion of a perspective on men’s separateness, autonomy and independence when reaching out to and building rapport with fathers will help solidify men’s openness to being part of family interventions. Finding ways for both fathers and mothers to secure not just time with one another away from the baby, but time alone reinforces the human need for both separateness and connectedness. Recognizing and honoring this desire for time for the self may also help fathers feel less guilt about desiring time in their lives to stay connected to male friendships, particularly important to young men in many cultural groups.

Cultural Relativity.

Our final point is a related one, that harkens back to several points and presumptions from earlier in this article. As we noted, numerous scholars have drawn connections between the similarities between family systems theories and attachment theories. They have highlighted the relevance of the family group as a secure base for the infant and young child’s strivings. They have also expounded on how individual actors within a family system can support or undermine infants’ developing attachments with other coparents. In healthy family systems, infants are free to bond with and love all their important attachment figures. Supportive, coparenting adults recognize this fundamental human need in their children and strive to ensure it can be so. But there are other convergences between attachment and family systems, as well. For example, Rothbaum and colleagues (2012) outline how family system theorists’ portrayal of enmeshment as involving an overly close parent-child dyadic subsystem shares commonalities with attachment theory’s linkage of infants’ ambivalent attachments to their mothers’ preoccupied states of mind with respect to attachment. Similarly, they single out family system theorists’ identification of pursuer-distance cycles in couple relationships as consonant with a mismatch between intimate partners with preoccupied and dismissive states of mind with respect to attachment. However, these conceptualizations may very well be culture-bound.

Rothbaum and colleagues draw attention to cross-cultural family studies suggesting that the dynamics of these systems theories reflect, in part, Euro-Western ways of thinking and Euro-Western patterns of relatedness. For example, Pachter and Harwood (1996) called out the McMaster Family Assessment Device, commonly used in the kinds of family research detailed in this article and an influence on the revision of the DC 0–5 Axis II, as failing to differentiate normal enmeshment among many Puerto Rican families (i.e., strong emotional attachments combined with clear generational boundaries) from clinical enmeshment, which involves a breakdown of generational boundaries. This is an issue of measurement and inference; perhaps even more significant are data indicating that extremely close ties between Japanese mothers and children, common and perceived as adaptive, are not linked to adverse effects in Japanese children the same ways as they are among children in the West.

Regarding couple dynamics, in Japan there is less emphasis on the importance of the exclusive spousal relationship, so central in family scholars thinking during the transition to parenthood era of family research in the late 1980s and early 1990s. There is hence also less call for Japanese mothers and fathers to reserve alone time to nurture their romantic relationship or to air and resolve family conflicts by explicitly communicating about their differences (Durrett et al., 1986). As Rothbaum et al. (2012) recognized, the Euro-Western concerns with too-close mother-child relationships, emotionally distant marriages with scant verbal communication, and marginally involved fathers may not signal pathology and dysfunction in quite the same ways in non-WEIRD cultures. The infant-family mental health field has itself been dominated by WEIRD infant-family experts and researchers and the intrinsic implicit biases about children and families they bring, though efforts are being made to correct this situation (Iruka et al., 2021). As parallel efforts increase to include the infant in family therapy, due diligence must be given to the cultural contexts in which coparenting is taking root.

Conclusions

We have attempted to trace the lineage of thinking within the infant-family mental health field and its relevance to aspirational efforts to involve the infant more inclusively in family therapy. Observations of family triangles and family groups promise to accelerate this aspirational goal, for it is only after assessing the interactions of the family unit that therapists can know the best system level to target. While our focus has been on coparenting, equally effective for certain families may be interventions that address marital, parent-infant, or individual subsystems. This is a dawning and exciting new area for theory, research, and clinical practice, and one that promises to deliver benefits to more of the world’s children if embraced fully. We enthusiastically await coming initiatives.