Robert Emde argues that psychoanalysis is a developmental discipline that is well suited to add value to prevention science as, while it gives prominence to early experience it also assists parents and grandparents, in addition to children, in developmental adaptations. It promotes adaptive individual pathways in the midst of complexity.

Sigmund Freud’s developmental framework and the work of other early pioneers contributed to the development of preventative interventions. Anna Freud initiated interventions with war orphans. Erik Erikson made an important contribution around the importance of culture and the social world to health throughout the lifespan. Rene Spitz, Margaret Mahler, Donal Winnicott, Selma Fraiberg and John Bowlby all made significant contributions too. There are opportunities for psychoanalytic work in applying scientific knowledge to developing individuals, family relationships, parenting and intervention programmes.

Marianne Leuzinger-Bohler makes the point that psychoanalytic research has long been concerned with the search for the roots of psychopathology and disorders and understanding to what extent these disturbances can be avoided through adequate early parenting. A feature of early prevention projects has been ‘outreaching psychoanalysis’ in which therapists concerned with at risk children are working with parents and teachers in Kindergartens and educational settings.

Psychoanalysis has improved the lives of individuals for over one hundred years. However, the potential for psychoanalysis to enhance cultural evolution has not been realised. This goal could be achieved by employing psychoanalysis in the service of prevention if it can be made ‘exportable’, ‘user-friendly’, and accessible to large parts of the population. PATHS is one such application which is used as a developmentally-based curriculum for teachers to use in classrooms throughout the primary school years, that supports children’s social and emotional development.

The psychoanalyst Selma Fraiberg is the mother of the discipline of infant mental health, writes Claudia Gold. In a paper called ‘Ghosts in the Nursery’, Fraiberg and colleagues wrote about the first infant mental health programme in which a staff of social workers and psychologists visited the homes of mothers who had been abused. The staff formed close relationships with these mothers providing an environment of support and understanding while these mothers were interacting with their children. This led to an improvement of the parenting practices of these mothers. It was identified that the most important part of this intervention was the relationship between the person intervening and the mother. However, it was not designed to be therapy for the mother but rather the aim was to help the mother connect with her child. In infant mental health, the ‘patient’ is the relationship rather than the child or the mother. The problem is identified as being between the child and the caregiver. This results in the parent being an integral part of the treatment while the clinician is able to experience the relationship and note how the parent and child regulate and dysregulate each other.

Donald Winnicott argued that an infant does not exist in isolation but within the context of the child-caregiver relationship. Treating children is also about treating their environment, including parents, family and larger social networks. John Bowlby observed that in previous generations mothers were surrounded by their own mothers, sisters, cousins and other family members, all of whom were involved in raising the children. These helpers, writes Susan Hart, both allowed the mother to take breaks from her caregiving role but also provided support, advice and friendship. It also meant the child had access to alternative attachment figures which put the parent-child relationship under less pressure. In modern society, families are more vulnerable and parent’s inadequacies may lead to damage in the attachment relationship, as there is no one to step in when the parent is struggling to cope with the pressure of child-rearing.

According to the ‘transmission model’, a parent’s internal working models of attachment are behind parenting behaviours which then shape the quality of the child’s attachment to that parent. Internal working models guide the parent’s responsiveness to the child’s needs. Sensitive responsiveness promotes emotional security while less supportive parenting typically involves inconsistent responsiveness on the part of the parent. However, sensitive parenting behaviours was later found to account for a fairly small proportion of the association between parental internal working models and child attachment. This is called the ‘transmission gap’.

Belsky’s differential susceptibility framework has helped explain the transmission gap. This framework holds that individuals are differentially susceptible to the influences of rearing. This susceptibility is for better and for worse. Sensitive infants who are often more irritable suffer more in response to adversity but also benefit more from support. The transmission model, then, is more relevant to the more susceptible children than to others.

There is a growing recognition now, according to Sue Gerhardt, that improving the relationship between parents and babies is a much more cost-effective way of improving mental health than adult therapeutic interventions. Some government departments recognise that a range of social problems have their roots in early development but this has not been fully translated into practice. David Olds is a researcher behind the ‘family-nurse partnership programme’, a home visitation programme that begins during pregnancy and continues through the first two years of life. Olds has produced evidence of financial savings and prevention of social problems, lower rates of child maltreatment and improved child mental health, as a result of engagement with the programme. The key factor in any preventative programme, according to Gerhardt, is the intervener’s relationship with the family and success in creating a positive, supportive environment. One of the key tasks is helping the parent to reflect on what the baby is feeling and how to support their development. The magic ‘X’ factor in early intervention programmes consists in helping parents to develop ‘responsiveness’.