Holding the Future: Psychoanalytic Perinatal Work in Fragile Contexts

Reflections on Supporting Early Relationships in Challenging Environments

Introduction

In many low-resource and fragile contexts—characterized by poverty, displacement, conflict, or social upheaval—the perinatal period (pregnancy, birth, and early infancy) unfolds amid significant physical and psychological risks. These challenges affect not only maternal and infant health but also early bonding and identity formation.

Psychoanalytically informed perinatal interventions are increasingly recognized for their capacity to strengthen emotional resilience and relational attunement in such settings. Drawing on attachment theory, mentalization-based approaches, and trauma-informed care, these models seek to interrupt cycles of unprocessed trauma—often before words are available to describe them (Fonagy et al., 2002).

This reflection explores how psychoanalytic concepts can be adapted sensitively across cultures and social realities to support early caregiving relationships—helping caregivers hold their infants and, in doing so, hold the future.

The Psychic Significance of the Perinatal Period

The perinatal period represents a crucial developmental window for both the infant’s emerging sense of self and the caregiver’s evolving identity. Research on attachment (Bowlby, 1969) and infant observation emphasizes early attunement, mirroring, and containment as foundational for psychic development.

For caregivers, this time often awakens unconscious material—early losses, unmet dependency needs, or unresolved trauma. As Fraiberg, Adelson, and Shapiro (1975) highlighted in their seminal work Ghosts in the Nursery, caregivers’ unprocessed histories can silently intrude into present relationships, sometimes with adverse effects.

In fragile environments—marked by instability, intergenerational grief, or absent social supports—these “ghosts” may be amplified. Psychoanalytic work aims not only to support infants but to create symbolic and emotional space for caregivers to reconnect with their inner worlds.

Creating a Holding Environment Through Perinatal Intervention

Psychoanalytic perinatal work typically avoids directive approaches. Instead, it fosters a holding environment where thought, affect, and reflection can safely emerge (Winnicott, 1965). Common components include:

• Home visits or caregiver-infant groups led by trained community workers
• Support for reflective function—the ability to mentalize the infant’s inner states (Slade, 2005)
• Attention to the caregiver’s emotional history, including grief, trauma, or ambivalence
• Facilitation of symbolic thinking—helping connect bodily sensations, feelings, and behavior with meaning

While inspired by psychoanalytic pioneers like Bion (1962) and Winnicott, these approaches require adaptation to cultural and material realities. For example, mental health stigma or collective trauma may necessitate framing interventions in terms of physical health or caregiving support rather than explicit psychological language.

Interrupting the Transmission of Trauma

Intergenerational trauma often passes not through words but through affective and relational patterns—silence, dissociation, misattunement, or unconscious repetition (Kestenberg, 1992).

Caregivers overwhelmed by past violence or loss may struggle to interpret infant cues, resulting in chronic misattunement or emotional withdrawal. Psychoanalytic perinatal work creates space for these dynamics to emerge symbolically.

Simple reflective questions such as,
“What do you imagine your baby feels when he cries?”
can reveal unconscious beliefs or projections like,
“He’s punishing me,” or “She doesn’t like me.”

Through containment and differentiation, caregivers may begin to separate their own histories from their child’s, allowing new relational patterns to develop.

Cultural Adaptation: Embedding Psychoanalytic Work

Psychoanalytic approaches in low-resource or displaced contexts must be culturally sensitive. Western models cannot be transplanted without adaptation. Instead, interventions must engage with local concepts of motherhood, family, emotional life, and caregiving.

Extended family, religious figures, or traditional birth attendants may be central. Group work is often more culturally acceptable than individual therapy. Emotional suffering might be expressed somatically or spiritually rather than psychologically, requiring flexible and respectful responses.

As Kestenberg (1992) noted,
“The mother’s unconscious world is not Western or Eastern. It is human—but always shaped by history.” Psychoanalytic tools like holding, mirroring, and reflective function remain relevant but must be translated relationally and symbolically.

Fictionalized Illustration: A Mother in Displacement

In a displaced community, a young mother shares her fears with a community support worker. Her baby cries frequently, and she whispers,
“I think she blames me for not having a real home.”

Rather than dismissing this, the worker responds,
“It’s hard to feel blamed when you’re trying so hard.”

Gradually, the mother speaks of her losses—her partner, her home, her own mother’s silence during war. The baby, once fretful, begins to settle—not because circumstances changed, but because the emotional atmosphere around her shifted.

This subtle, symbolic shift illustrates a core psychoanalytic insight: when the caregiver is held, the infant can begin to feel held as well.

Building Local Capacity for Sustainable Practice

Successful perinatal programs in fragile settings do more than deliver care—they train local facilitators, promote reflective practice, and embed interventions within community structures.

Adapted psychoanalytic frameworks such as Mother-Infant Psychotherapy, Watch, Wait and Wonder, and Circle of Security have been implemented in Latin America, Sub-Saharan Africa, and refugee contexts in the Middle East.

The goal is not to replicate Western psychoanalysis but to nurture a culture of thinking about the baby—recognizing early relationships as emotionally vital and developmentally formative.

Conclusion: Symbolic Life in Dusty Soil

To practice psychoanalytically in perinatal settings marked by adversity is not to impose theory, but to create space for symbolic life to flourish, often against the odds.

The infant needs to be seen. The caregiver needs to be seen. This act of seeing—offered with cultural humility, emotional resonance, and sustained attention—can begin to break traumatic cycles.

It is not a solution, but a beginning.

References

Baradon, T., et al. (2005). Psychotherapy with Infants and Parents: Practice, Theory and Results.
Bion, W. R. (1962). Learning from Experience. Heinemann.
Bowlby, J. (1969). Attachment and Loss: Volume 1. Basic Books.
Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships. Journal of the American Academy of Child Psychiatry, 14(3), 387–421.
Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect Regulation, Mentalization, and the Development of the Self. Other Press.
Kestenberg, J. S. (1992). Infant Development and the Transmission of Trauma. International Journal of Psychoanalysis, 73(Pt 4), 485–495.
Slade, A. (2005). Parental Reflective Functioning: An Introduction. Attachment & Human Development, 7(3), 269–281.
Winnicott, D. W. (1965). The Maturational Processes and the Facilitating Environment. International Universities Press.