Atlas›Domain V · Systemic, relational, group & community›Guide 054
Guide V-054

Child-parent psychotherapy

Alicia Lieberman, Patricia Van Horn, Chandra Ghosh Ippen1998UCSF Child Trauma Research Program, USA
A 38 · L 42 · M 2020 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Child-Parent Psychotherapy (CPP) as set out in Lieberman, Ghosh Ippen & Van Horn (2015), Don't Hit My Mommy!, 2nd ed. (Zero to Three Press), the manual the developers require (the Wisconsin training agreement cites it as "2016"). Phase structure and phase session counts follow the NCTSN CPP fact sheet, which the UCSF Child Trauma Research Program reviewed for accuracy in October 2024. It is also the version reviewed by the US Title IV-E Prevention Services Clearinghouse. [source: NCTSN CPP fact sheet; ACF Clearinghouse; Wisconsin LC agreement]

Sources. Developer or developer-reviewed sources cover: the three-phase structure, the session counts for each phase, who attends, the dose and caseload, and the training and certification requirements. These come from the NCTSN fact sheet and the UCSF CTRP CPP page. The chapter structure of Lieberman & Van Horn (2008) and its four strategy families were verified on the Guilford book pages. Several in-session techniques, the handling of trauma avoidance and the adaptations for developmental disability were checked against a commentary by the developers (Ghosh Ippen, Noroña & Lieberman, 2014) and the case series it discusses (Harley et al., 2014). Not drawn on: the manual itself and the text of the 2008 book. Detailed procedures and fidelity strands therefore still come from implementation documents built on the manual: the New Mexico CYFD FY22 IMH CPP manual, a GV Health CPP overview that cites manual page numbers, the UW Barnard Center and Wisconsin learning-collaborative documents, the Napa County practice guidelines and Van Horn's 2012 slides. Most step-by-step instructions in Section 4 are still my operationalisation and are tagged [synthesis]. Where sources differ, the difference is noted.

What it is: a dyadic, relationship-based treatment for children aged 0–5 (the training documents say "under 6") who have experienced trauma (family violence, maltreatment, traumatic separation or loss, and similar) or who have mental-health, attachment or behaviour problems. The child and the primary caregiver are seen together, and other caregivers or siblings join when clinically indicated. It was developed by Alicia Lieberman and colleagues (Patricia Van Horn, Chandra Ghosh Ippen) at the UCSF Child Trauma Research Program. It grew out of Selma Fraiberg's 1970s infant-parent psychotherapy. Development was funded by NIMH from 1998, and the first RCT studied preschoolers whose mothers had experienced intimate partner violence. It integrates attachment, psychoanalytic, developmental, trauma, social-learning, cognitive-behavioural and cultural frameworks. The NCTSN fact sheet states three goals:

  • repair the effects of trauma on the child's social and emotional development;
  • build the caregiver's capacity to provide physical, relational and emotional safety;
  • restore trust and safety in the caregiver–child relationship.

[source: NCTSN CPP fact sheet; Van Horn 2012; Barnard LC overview; UCSF manuals page]

How change happens: in the first five years the attachment relationship is the main organiser of the child's responses to danger and safety. Trauma damages that relationship in several ways. The child may lose confidence in the parent as a protector. Each partner can become a trauma reminder for the other. Negative attributions build up, and co-regulation breaks down. CPP therefore treats the relationship itself. The therapist helps the caregiver and child put words to what happened, link it to current behaviour and feelings, and build a shared, coherent narrative. Alongside this the therapist restores safety, protective caregiving, reciprocity and affect regulation, so that the child returns to a normal developmental path. The developers describe this as "speaking the unspeakable" while promoting safety and hope. [source: NM CYFD manual, premises; Van Horn 2012]

Adaptations named by the developers (not covered here): Perinatal CPP (Lieberman, Diaz, Castro & Oliver Bucio, 2020, Make Room for Baby) and CPP for traumatic bereavement (Lieberman, Compton, Van Horn & Ghosh Ippen, 2003). [source: UCSF manuals page]

2. Framework

The developers' current version has three phases: the Foundational Phase (assessment and engagement), the Core Intervention Phase, and the Recapitulation and Termination Phase. The NCTSN fact sheet calls the last one the Closing Phase. The NCTSN fact sheet, reviewed by the developers, confirms the three-phase structure. The New Mexico manual splits feedback out as a separate phase. It is shown below as the last part of the Foundational Phase. [source: NCTSN CPP fact sheet; Napa guidelines; GV Health; NM CYFD manual]

Format and dose. Sessions are weekly. Published figures for length and number vary:

  • NCTSN fact sheet (developer-reviewed): sessions are weekly. Foundational Phase: 4–8 sessions. Core Phase: generally at least 20 sessions, then a review of whether more treatment would help. The Core Phase can be shorter for a single-incident trauma that has resolved, and longer with severity or developmental needs. Closing Phase: 4–8 sessions. Caregivers take part in all sessions; children attend most Core and Closing sessions. No single figure is given for session length or total count.
  • UCSF CTRP CPP page: weekly one-hour sessions, with length set by the complexity of the case. In the published RCTs treatment lasted about a year, with a mean of 32.82 sessions. Typical caseload: 10–12 families.
  • ACF Clearinghouse: typically 60–90 minutes, weekly, for 20–32 weeks, with duration set by clinical need.
  • NM manual: no more than 60 minutes recommended.
  • Napa guidelines: hour-long sessions; the RCTs lasted about one year, with a mean of about 33 sessions. This agrees with the UCSF figure.
  • Van Horn's 2012 slides: one toddler trial averaged 46 sessions over about 59 weeks.
  • Published community case series (Harley et al., 2014): two cases took 40 and 46 weekly sessions of about 60 minutes over 13–14 months. They had 6 and 11 Foundational sessions, 26 and 27 Core sessions, and 8 Closing sessions each.

How to reconcile these figures: plan by phase, as the NCTSN fact sheet does. That means 4–8 Foundational sessions, at least 20 Core sessions with a formal review at that point, and 4–8 Closing sessions. This gives a minimum course of roughly 28–36 weekly sessions. About a year is typical (the RCT mean was about 33 sessions), and complex cases run longer (46 sessions in one trial and one case). The ACF's 20–32 weeks is shorter than the phase-based plan; follow the developer-reviewed NCTSN figures. Default to one-hour sessions (UCSF CTRP; NM); the ACF's 60–90 minutes is the outer range. Sessions take place at home, in the clinic or wherever the family and provider agree, such as child care. The treatment unit is the child–caregiver relationship. [source: NCTSN CPP fact sheet; UCSF CTRP; ACF; NM CYFD; Napa; Van Horn 2012; Harley et al. 2014] [uncertain: only the ACF gives sessions up to 90 minutes, and the manual's own wording on session length is not given.]

Phase 1: Foundational Phase (assessment and engagement, including feedback)

  • Goals:
    • Build a collaborative partnership with the caregiver.
    • Learn each family member's history, trauma exposure, symptoms, strengths and context, including culture, socioeconomic and immigration stress.
    • Increase safety.
    • Address resistance, including in mandated referrals.
    • Explain how treatment may help.
    • Co-create the treatment plan and the CPP "Triangle".
    • Agree the session format.
  • Who attends: Mostly the caregiver and therapist alone; the child joins for one or two observation sessions. Intake is done without the child present. The NCTSN fact sheet gives this phase as 4–8 weekly sessions. [source: NCTSN CPP fact sheet; NM CYFD]
  • Typical sequence (GV Health, approximate):
    1. Session 1: intake and developmental history.
    2. Session 2: dyadic observation, plus the child's trauma history and symptoms.
    3. Session 3: the caregiver's own trauma history and symptoms, with the caregiver alone.
    4. Session 4: feedback and co-creating the Triangle, with the caregiver alone.
    5. Extra assessment sessions, collateral contacts and observation in other settings are added as indicated.
  • Measures: Measures named in the sources include the TESI or THS for the child's trauma history, the YCPC or CPSS for the child's symptoms, the LSC for the caregiver's trauma history, and the PCL-5, CESD-R and PSI for the caregiver's symptoms. The NM programme adds ACEs, DIAPER/DOVE, DC:0-5 Axis II caregiver dimensions and the CIAP, and requires these within four months. Instrument choice is set by the agency or programme. [source: GV Health; NM CYFD]
  • Feedback work: Review the results with the caregiver. Agree how the child will be told why they are coming to therapy. Prepare the caregiver for what the child may do in sessions, such as trauma play or dysregulation. Discuss the need for regulation breaks and regular weekly attendance. Explore cultural beliefs about talking to children about trauma. The NM manual warns that skipping or rushing this step "could be detrimental to treatment and outcomes". [source: NM CYFD]
  • Criteria for moving to Core:
    • A therapeutic partnership is established.
    • The caregiver can acknowledge and talk about the child's trauma history.
    • The caregiver can keep the child's needs in mind.
    • The Triangle has been agreed with the caregiver.
    • Safety is sufficient for dyadic work.
    The GV Health guidance states the stance as: do not target for change "that which we don't yet understand". [source: NM CYFD; GV Health]

Phase 2: Core Intervention Phase

  • Goals:
    • Strengthen the relationship.
    • Restore the child's sense of safety, attachment and appropriate affect.
    • Improve cognitive, behavioural and social functioning.
    • Co-construct a trauma narrative.
    • Identify and address trauma reminders.
  • Format [source: NCTSN CPP fact sheet; NM CYFD; GV Health]:
    • Collateral sessions with the caregiver alone may come first and continue as needed.
    • The first dyadic (or triadic) session introduces the child to CPP using the Triangle.
    • Weekly dyadic sessions follow. Within them the therapist chooses ports of entry and intervention modalities moment by moment (Section 4).
    • Dose: generally at least 20 sessions, followed by an assessment of whether more treatment would help (NCTSN).
  • Rostering benchmark: Training documents treat 16 or more Core sessions as a substantive case. This is a training criterion, not a clinical rule. [source: Wisconsin LC agreement]
  • Criteria for moving to Closing: The phase moves to closing when the caregiver and child have met the treatment-plan goals, a court permanency decision or other external event requires it, or there is a lack of progress (the triggers the NM manual names). [inferred] Clinical markers drawn from the stated goals are:
    • The child is back on a developmental track.
    • Arousal is regulated.
    • The caregiver responds protectively to reminders.
    • The dyad can tell the story and distinguish then from now.

Phase 3: Recapitulation and Termination (Closing) Phase

  • Goals and dose: Review treatment, consolidate gains and anticipate future challenges and trauma reminders. The NCTSN fact sheet gives 4–8 sessions for this phase, one or two of them with the caregiver and therapist alone. [source: GV Health; NCTSN CPP fact sheet]
  • Steps (NM manual):
    1. Reflect on and plan the ending with the caregiver.
    2. Complete the treatment evaluation, repeating the measures.
    3. Tell the child the ending is coming, then run "countdown" sessions.
    4. Review the family's story of treatment.
    5. Plan for future trauma reminders.
    6. Hold a final session.
    Reduce session frequency gradually where possible. [source: NM CYFD]

3. Guiding principles

Premises of the model [source: NM CYFD; Van Horn 2012]:

  • The attachment system organises responses to danger and safety. Read the child's symptoms as attachment-related fear and protest, not as isolated behaviours.
  • Early problems are best treated within primary attachment relationships. The caregiver is in the room and is the main agent of change, not an observer.
  • The family's ecology, including culture, poverty, immigration and community violence, belongs in the formulation. Ask about these and plan for them; concrete help is part of treatment.
  • Interpersonal violence is a traumatic stressor for the child, including violence the child witnessed. Name what the child saw and heard; do not assume they were "too young to notice".
  • The therapeutic relationship is a key change factor. How you treat the caregiver models how the caregiver can treat the child.
  • Treatment involves speaking the unspeakable while promoting safety and hope. Bring up the trauma deliberately, but only inside a frame of safety and a hopeful message.

Fidelity strands (the six named in the sources) [source: NM CYFD; GV Health; Napa]:

  • Reflective practice: How you are is as important as what you do; the strand cites Pawl & St. John, 1988. Use reflective supervision to track your own reactions, which are expected and informative.
  • Emotional process: Attend to what determines whether a parent's painful past is repeated with the child. Look for how the caregiver's history colours their perception of the child. The developers frame this as "ghosts and angels in the nursery", the title of Chapter 6 of Lieberman & Van Horn (2008). The NCTSN fact sheet traces the model to Fraiberg's Ghosts in the Nursery work. [source: NM CYFD; Guilford contents page; NCTSN CPP fact sheet] In practice, also ask about benevolent early care the caregiver can draw on, which is my reading of the "angels" half of the title [synthesis]. The chapter text and the Fraiberg and Lieberman papers are not drawn on [uncertain].
  • Dyadic-relational: Winnicott's "There is no such thing as a baby". Hold both partners' perspectives at once, and translate each to the other.
  • Trauma framework: Help the family know and feel what they were told not to know (Bowlby, 1988). Link current symptoms to the trauma in a way the caregiver agrees with.
  • Procedural: Follow the phases and steps, guided by reflection rather than rigid adherence (Ghosh Ippen et al., 2014). Do the Foundational Phase and feedback before dyadic trauma work, and use the fidelity forms.
  • Content: Cover the CPP content goals (see below), adapted to the family's needs as they change.

Therapeutic stance (as summarised by GV Health): notice feelings in the moment; find connections between experiences; translate meanings between parent and child; dare to bring up traumatic events; remember the suffering under the rage; look for the benevolence in the conflict; offer kindness, encourage hope and stay curious. [source: GV Health] Each translates directly into session behaviour:

  • Name affect as it happens.
  • Link past and present.
  • Speak for the child to the parent and for the parent to the child.
  • Do not collude with silence.
  • Respond to an angry parent's hurt.
  • Find the protective intent behind harsh behaviour.

Content goals. These give the therapist the targets for any session [source: NM CYFD; Van Horn 2012; Napa]:

  • Encourage normal development.
  • Keep affective arousal regulated.
  • Achieve reciprocity in close relationships.
  • Normalise the traumatic response.
  • Help the child and caregiver tell remembering from reliving, and then from now.
  • Put the trauma in perspective.
  • Help the child understand they are not to blame.
  • Restore trust in bodily sensations.
  • Support continuity of daily routines.
  • Co-construct a joint trauma narrative.

Ports of entry are chosen in the moment. Theory does not fix where to intervene. Choose the point most likely to advance the family's goals in that moment. [source: Van Horn 2012]

Collaboration and coordination are core. The competency wheel names coordinating care with other service systems as a central objective, along with acting as a conduit and integrating a sociocultural lens. [source: GV Health]

4. Intervention inventory

The inventory is grouped as follows:

  • (A) Foundational-phase procedures.
  • (B) The port-of-entry decision.
  • (C) The CPP intervention modalities as listed in the training-derived sources.
  • (D) Trauma-specific procedures.
  • (E) Closing procedures.

The names of procedures and modalities come from the sources cited. The Guilford description of Lieberman & Van Horn (2008) confirms four broad strategy families: play, developmental guidance, trauma-focused interventions, and concrete assistance with problems of living. A commentary by the developers and the case series it discusses (Ghosh Ippen, Noroña & Lieberman, 2014; Harley et al., 2014) confirm several in-session techniques; these are tagged where used. Otherwise the steps under each are my operationalisation of the sources' descriptions [synthesis]. All example language is illustrative. The manual's own case vignettes are not drawn on [uncertain].

Licensing and fidelity before delivering "CPP" under its name:

  • Training routes: Clinicians must complete one developer-recognised route:
    • the 18-month CPP Learning Collaborative, with a 3-day initial didactic and 2-day competency workshops at about 6 and 12 months. The NCTSN fact sheet counts 42 didactic hours over the 18 months and gives the cost as about US$2,500, plus agency costs such as supervision time;
    • training through an agency that is part of the CPP Agency Mentorship Program;
    • an endorsed 1–2-year CPP internship. [source: ACF; Barnard LC; NCTSN CPP fact sheet]
  • Eligibility: Clinicians must be master's- or doctoral-level psychotherapists with a mental-health degree. They must be licensed or supervised by a licensed, CPP-trained supervisor. The UCSF page also allows supervised trainees with at least two years of clinical experience. Supervisors must be licensed and have completed CPP training or be in it. Trainers need CPP certification and 10 or more cases, and must be nominated and complete a train-the-trainer process. Agencies should ideally keep three or more trained providers and at least one trained supervisor. [source: Barnard LC; Wisconsin LC; NCTSN CPP fact sheet; UCSF CTRP]
  • Requirements for the national roster (Wisconsin agreement, rev. 2023):
    • Attend 18 or more hours of Learning Session 1 and at least 12 hours each of Learning Sessions 2 and 3.
    • Read the whole 2nd-edition manual.
    • Treat at least 4 families with a child under 6 and at least one traumatic event. At least 2 of these must have 16 or more Core sessions, with dyadic work after the Triangle introduction, and at least one must include a full Foundational Phase. The other 2 need at least 4 sessions each.
    • Receive CPP reflective supervision at least twice a month.
    • Attend at least 23 consult calls.
    • Give two case presentations with clinical material.
    • Complete fidelity forms on at least 2 cases.
    Unaddressed "significant breaches in fidelity" prevent rostering. [source: Wisconsin LC agreement]
  • Time commitment (NCTSN summary): Read the manual. Complete 42 didactic hours over 18 months. Join one-hour consultation calls twice a month. Write up two cases (about 4 hours each). Receive reflective CPP supervision, ideally weekly and at least twice a month. This agrees with the Wisconsin requirements above. [source: NCTSN CPP fact sheet]
  • Fidelity instruments: Phase-specific therapist fidelity forms, plus supervisor and consultant instruments. Their items are not described here [uncertain]. The NCTSN fact sheet names no fidelity instrument. It points to the CPP Assessment Measures Guide on the developers' CPP website, which covers outcome and relationship measures rather than fidelity. A NREPP review noted that developer checklists are available. [source: NREPP; Wisconsin LC; NCTSN CPP fact sheet]

A1. Caregiver-only intake and engagement

  • Purpose: Build the partnership. Hear the caregiver's account of the referral and their feelings about treatment. Gather developmental history. Address mistrust or mandated-referral resistance before the child is involved. Use: first contact, always without the child. [source: NM CYFD; GV Health]
  • Steps:
    1. Meet the caregiver alone.
    2. Ask what brought them and what they hope will change.
    3. Ask how they feel about being referred, especially when the referral is mandated.
    4. Take a developmental history: pregnancy, birth, early care, separations, milestones, routines.
    5. Map current stressors: housing, money, immigration, legal or court involvement, other services.
    6. Ask what the caregiver already does that helps the child.
    7. Explain how CPP works: sessions together, play, and talking about hard things at the child's level.
    8. Agree on the next assessment sessions. [synthesis, built on the NM and GV Health sequence]
  • Example language (illustrative): "Before we meet together with your son, I'd like to understand what you've been through and what worries you most. You know him better than anyone, so I need your help to make sense of what he's doing."
  • Watch for: Whether the caregiver can name any concern of their own, rather than only the referrer's. Signs of shame or fear of child-protection consequences. The caregiver's style of describing the child: warm, hostile or flat. The first sign that it is working is that the caregiver returns and starts to bring their own agenda. [synthesis]

A2. Child and caregiver trauma-history and symptom assessment

  • Purpose: Document what the child has been exposed to, the child's current symptoms, and the caregiver's own trauma history and symptoms. These inform the formulation and the Triangle. The caregiver's own history is taken in a session without the child. [source: GV Health; NM CYFD]
  • Steps:
    1. Use the agency's chosen instruments (for example TESI or THS for the child's trauma history and YCPC for the child's symptoms; LSC, PCL-5, CESD-R and PSI for the caregiver).
    2. Ask about each event the caregiver endorses: what the child saw and heard, where the caregiver was, and what happened afterwards.
    3. Before asking about the caregiver's own trauma, explain why you ask. Pace it, and close the session with grounding.
    4. Note protective actions the caregiver took. [synthesis on steps 2–4; instruments as named in the sources. Do not reproduce items.]
  • Example language (illustrative): "Many parents tell me that what happened to them as children comes back when their own child is struggling. Would it be all right if I asked about some hard things in your own life? You can stop or skip anything."
  • Watch for:
    • The caregiver's dysregulation during their own history.
    • Denial that the child was present at events.
    • Current, unaddressed danger, which needs the safety response (A5).
    [synthesis]

A3. Dyadic observation and observation in other settings

  • Purpose: See how the dyad interacts. Look at regulation, reciprocity, how the child uses the parent for safety, and how the parent reads the child. The NM programme adds observation in child care and in foster placements. [source: GV Health; NM CYFD]
  • Steps:
    1. Offer the dyad age-appropriate toys and a semi-structured period of free play, including a separation or clean-up if this fits your service.
    2. Mostly observe. Note who leads, how distress is handled, physical closeness, and the parent's narration of the child.
    3. Afterwards, ask the caregiver whether this was typical. [synthesis]
  • Example language (illustrative): "I'm mostly going to watch today, to see how you two usually are together. Afterwards I'll ask you whether this was a typical day."
  • Watch for:
    • Trauma play appearing spontaneously.
    • Hypervigilance.
    • Role reversal.
    • The parent's negative attributions, for example "he does it to annoy me".
    [synthesis]

A4. Feedback session and co-creating the CPP Triangle

  • Purpose: Share what the assessment showed. Reach a shared understanding linking what happened to the child's current behaviour. Agree what and how the child will be told about why they are coming. Prepare the caregiver for dyadic work. This is done with the caregiver alone. [source: NM CYFD; GV Health]
  • Steps:
    1. Draft your own Triangle beforehand, ideally with your supervisor or team. [source: NM CYFD; GV Health]
    2. Review the measure results in plain language, starting with strengths.
    3. Build the Triangle with the caregiver. GV Health gives five elements:
      • Experience: what the child saw and heard, in prompts beginning "You saw..." and "You heard...".
      • Behaviour and feelings: the symptoms now, beginning "And now you...".
      • Protective steps: what the caregiver did to protect the child.
      • Hope: that things can get better.
      • Treatment: what CPP offers, beginning "This is a place where...".
      [source: GV Health, citing manual p. 78] The NM manual gives three elements: experience, behaviour/feelings and treatment. GV Health's "Triangle+" adds protective steps and hope [version note].
    4. Agree the exact words the caregiver is comfortable with.
    5. Discuss the following:
      • cultural beliefs about talking to children about trauma;
      • that the child may play out frightening events, and why that helps;
      • that the child will need regulation breaks;
      • why weekly attendance matters. [source: NM CYFD]
    6. Co-create the treatment plan. [source: NM CYFD]
  • Example language (illustrative): "When we meet with Maya, I'd like us to tell her something like this: she saw Daddy hurt Mommy and heard a lot of yelling; now she gets scared and hits when people shout; Mommy took her to Grandma's to keep her safe; and this is a place where we play and talk about scary things so they can feel less scary. How does that sound to you? What would you change?"
  • Watch for:
    • Caregiver agreement versus compliance.
    • Wanting to protect the child from the topic, for example "she doesn't remember". Explore this; do not override it.
    • The caregiver's own grief or guilt surfacing.
    It is working when the caregiver can say in their own words how the event and the behaviour connect. Do not start dyadic trauma work until then. [source: NM CYFD movement criterion; synthesis on wording]

A5. Increasing safety

  • Purpose: Safety comes before and during trauma processing. The Foundational Phase explicitly includes "increasing safety". [source: NM CYFD]
  • Steps [synthesis]:
    1. Assess current risk: ongoing IPV, contact arrangements with the person who caused harm, substance use, unsafe housing.
    2. Make a safety plan with the caregiver and connect them to IPV or legal advocates.
    3. Coordinate with child protection where involved.
    4. Judge whether dyadic trauma work is possible yet. If danger is ongoing, focus first on protection and concrete help (C7).
  • Example language (illustrative): "Before we talk about what happened, I want to make sure you and the children are as safe as possible now. Can we go through what you would do if he came to the house?"
  • Watch for: Minimising, and an unclear custody or visitation situation. Mandatory reporting obligations apply (Section 5). [synthesis]

A6. Introducing CPP to the child (first dyadic session)

  • Purpose: Tell the child, in words agreed with the caregiver, why they are coming. This signals that the trauma can be spoken about and that this is a safe place. [source: NM CYFD; GV Health; Wisconsin LC]
  • Steps:
    1. Set out the play materials, including some toys related to the trauma that the caregiver has agreed to.
    2. Welcome the child.
    3. The therapist and the caregiver (ideally the caregiver speaks part of it) deliver the agreed Triangle briefly and simply.
    4. Follow the child's response: play, turning away, or approaching the caregiver.
    5. Close by repeating that this is a place to play and talk about feelings. [synthesis on sequence; content from the sources]
  • Example language (illustrative): Mother: "You saw Daddy hit me and you heard me cry." Therapist: "And now sometimes you get really scared and angry. Mommy wanted to keep you safe. This is a place where we can play and talk about scary things and grown-ups help kids feel safe."
  • Watch for:
    • The child's immediate behaviour often shows what they know: for example, hiding, aggressive play or running to the parent.
    • The caregiver going back on the script.
    A child who engages in related play over the next sessions is a sign of progress. [synthesis]

B1. Choosing the port of entry

  • Purpose: In CPP the unit of intervention is the "port of entry": the clinical opportunity you choose in a given moment. The sources list six options:
    • the parent's or the child's individual behaviour;
    • the parent–child interaction;
    • attributions (each partner's representations of self and other);
    • representations of the absent parent;
    • the child's play;
    • either partner's perception of the therapeutic relationship.
    [source: Van Horn 2012; GV Health]
  • Steps:
    1. In each session, notice the moment carrying the most affect or the clearest link to the treatment goals.
    2. Ask which entry point is accessible now: behaviour, interaction, meaning, play, or the relationship with you.
    3. Choose a modality from Section C to work through that entry.
    4. If it does not take, move to another port. [synthesis on steps; the principle of in-the-moment choice is from Van Horn 2012]
  • Example language (illustrative): For representations of the absent father: "You've been looking at the door a lot. I wonder if you're thinking about Daddy." For attributions: "You said he hits you on purpose. I wonder if he hits when he's frightened, like he saw grown-ups do."
  • Watch for: Overusing one port, such as interpretation with a parent who cannot reflect yet. The best port is the one the dyad can use at that moment. [synthesis]

C1. Promoting developmental progress through play, physical contact and language

  • Purpose: Use the child's natural channels to support regulation, communication and developmental gains, and to give the dyad positive shared experiences. Use it in every session, and especially when the child is dysregulated or delayed, or when the dyad has few pleasurable moments. [source: GV Health; NM CYFD]
  • Steps [synthesis, except where tagged]:
    1. Offer developmentally matched toys.
    2. Position the dyad so they can see and reach each other. In one published case the therapist turned the child to face his mother and used bubbles and pinwheels to spark shared delight. [source: Harley et al. 2014]
    3. Invite the caregiver to join the child's play rather than direct it. Draw a withdrawn caregiver in by naming her as the child's safe base. [source: Harley et al. 2014]
    4. Encourage soothing touch or holding that the child accepts.
    5. Put words to the child's actions and feelings at their level: "you're building it high", "you're mad it fell". Narrate both partners' feelings, and ask reflective questions such as "I wonder what he is trying to tell you?" [source: Harley et al. 2014, for the narration and the question]
    6. Highlight moments of mutual enjoyment. The developers' commentary names highlighting moments of connection as a key move. [source: Ghosh Ippen, Noroña & Lieberman 2014]
  • Example language (illustrative): "Look how he checks your face after he jumps. He wants to know you saw him."
  • Watch for:
    • The caregiver taking over or withdrawing.
    • Touch the child resists, which should not be forced.
    It is working when the length of reciprocal play increases and the child uses the caregiver for comfort. [synthesis]

C2. Unstructured reflective developmental guidance

  • Purpose: Give developmental information embedded in the moment, not as a lecture. It helps the caregiver understand age-expected behaviour, trauma responses and the child's perspective, and so revise negative attributions. Use it when the caregiver misreads normal or trauma-driven behaviour. [source: GV Health; NM CYFD]
  • Steps [synthesis]:
    1. Wait for a concrete behaviour in the session.
    2. Ask the caregiver what they think it means.
    3. Offer developmental or trauma information as one possibility.
    4. Invite the caregiver to test it against their knowledge of the child.
    5. Reflect together on what the child might need.
  • Example language (illustrative): "Lots of three-year-olds say 'no' to everything. It's how they practise being their own person. And kids who've been through scary things often need to feel in charge even more. What do you think is going on for her?"
  • Watch for: Didactic overload. Keep it to one idea, tied to what just happened. It is working when the caregiver starts generating these explanations themselves. [synthesis]

C3. Participatory developmental guidance

  • Purpose: The NM manual lists this alongside unstructured guidance. Here the caregiver tries a new way of responding in the session with the therapist's support. [source: NM CYFD; the procedure is not described, so it is uncertain]
  • Steps [synthesis]:
    1. Suggest a specific alternative response, such as getting down to the child's level or naming the feeling before setting a limit.
    2. The caregiver tries it.
    3. Debrief what happened and how the child responded.
  • Example language (illustrative): "Would you like to try kneeling down next to him and telling him you can see he's scared? Let's see what he does."
  • Watch for: The caregiver feeling coached or judged. Frame it as an experiment. [synthesis]

C4. Modelling protective behaviour

  • Purpose: Show, and help the caregiver take on, protective responses when the child is in danger or acts dangerously: aggression, running off, self-endangering play. This restores the caregiver as the protector. [source: GV Health]
  • Steps [synthesis]:
    1. When danger arises, intervene calmly and physically if needed, for example by stopping a child who is about to hit or climb.
    2. Say aloud that grown-ups keep kids safe.
    3. Hand the protective role to the caregiver as soon as possible.
    4. Afterwards, reflect with the caregiver on what happened and how it felt.
  • Example language (illustrative): "I won't let you hit Mommy. It's my job and Mommy's job to keep everybody safe here." To the caregiver: "Can you hold his hands gently and tell him you'll keep him safe?"
  • Watch for: The caregiver freezing or responding punitively, both possibly trauma reactions. It is working when the caregiver steps in protectively and unprompted. [synthesis]

C5. Interpretation linking past and present (insight-oriented)

  • Purpose: Help the caregiver, and at a suitable level the child, see how past experiences shape current perceptions and reactions. This includes how the caregiver's own history (the emotional-process strand) colours their view of the child. Use it when there is enough alliance and caregiver reflective capacity. [source: GV Health; NM CYFD]
  • Steps [synthesis]:
    1. Notice a repeated, affect-laden pattern, such as the caregiver freezing when the child shouts.
    2. Wait for a moment when the caregiver is regulated.
    3. Offer a tentative link: "I wonder if...".
    4. Let the caregiver accept, modify or reject it.
    5. Return to the child's experience.
  • Example language (illustrative): "When he yells, you go very still. I wonder whether it takes you back to when your father yelled, and you had to freeze to stay safe."
  • Watch for:
    • Premature interpretation, which feels like blame.
    • The caregiver becoming dysregulated.
    It is working when the caregiver brings their own links and responds differently in the moment. [synthesis]

C6. Emotional support and empathic communication

  • Purpose: Hold the caregiver's distress, validate their experience and model attuned responsiveness. The stance of "remember the suffering under the rage" applies here. Use it throughout, especially when the caregiver is overwhelmed, grieving or ashamed. [source: GV Health]
  • Steps [synthesis]:
    1. Name the caregiver's feeling.
    2. Acknowledge what they have been through.
    3. Point out their efforts and their protective intent.
    4. Bring the attention back to the child once the caregiver is calmer.
  • Example language (illustrative): "You've been carrying all of this on your own. It makes sense you're exhausted. And you still got her here today."
  • Watch for: The session turning into individual therapy for the caregiver at the child's expense. If so, schedule collateral sessions (D5). [synthesis]

C7. Concrete assistance, case management and crisis intervention

  • Purpose: Address practical threats to safety and stability, such as housing, food, legal or immigration issues and benefits, because family ecology is part of the model. Respond to acute crises. [source: GV Health; NM CYFD premise 3]
  • Steps [synthesis]:
    1. Ask about practical needs at every phase.
    2. Help the family directly with calls, letters, referrals and court reports.
    3. In a crisis, put safety and stabilisation first and set dyadic work aside.
    4. Coordinate with other systems, which is the central objective on the competency wheel. [source: GV Health]
  • Example language (illustrative): "It's hard to think about anything else while the eviction is hanging over you. Let's spend part of today working out who to call."
  • Watch for: Crisis work crowding out treatment week after week. Agree a balance with the caregiver and your supervisor. [synthesis]

D1. Trauma play with trauma-related toys

  • Purpose: For children old enough to use play to process experience, let them play out the trauma with the caregiver present. The play is then witnessed, regulated and given meaning. [source: NM CYFD]
  • Steps:
    1. With the caregiver's permission given in the Foundational Phase, include toys relevant to the trauma, such as ambulance, police, figures for family members, or a bed. [source: NM CYFD]
    2. Follow the child's lead.
    3. Narrate the play.
    4. Link it to what happened when the child is regulated.
    5. Help the caregiver respond protectively within the play, for example the parent figure stopping the hitting.
    6. Steer stuck, repetitive play towards safety or rescue endings. [synthesis on steps 2–6]
  • Example language (illustrative): "The daddy doll is hitting. The little girl is hiding. I wonder if that's like when you saw Daddy hit Mommy. Mommy, what could the mommy doll do now?"
  • Watch for:
    • Escalating arousal, which calls for a regulation break (D2).
    • Caregiver distress at watching the play.
    • Rigid repetitive play with no change, which suggests the child is reliving rather than processing.
    Progress shows when the play varies, includes protection and resolution, and the child can then calm. [synthesis]

D2. Emotion-regulation breaks

  • Purpose: Prevent overwhelm during trauma processing. The NM manual says the infant needs breaks for emotion regulation, and this is discussed in the feedback session. [source: NM CYFD]
  • Steps [synthesis]:
    1. Watch for arousal cues such as frantic play, glazed look, aggression or clinging.
    2. Pause the trauma content.
    3. Help the caregiver soothe the child through holding, rocking, a snack or a calming game.
    4. Name what happened: "that got too scary; we stopped and you're safe now".
    5. Return to the content later, or in another session, if appropriate.
  • Example language (illustrative): "That was a lot. Let's take a break and get cosy with Mommy. We can come back to the story another time."
  • Watch for: Breaks used to avoid all trauma content, by the caregiver or the therapist. Track whether returning to the content becomes possible. [synthesis]

D3. Co-constructing the joint trauma narrative

  • Purpose: This is the central trauma goal: caregiver and child co-create a shared, mutually meaningful story of what happened. The story includes that the child is not to blame, what was done to protect, and that then is different from now. [source: NM CYFD; Van Horn 2012; NCTSN CPP fact sheet] None of the sources gives a formal step-by-step narrative procedure, and the manual is not drawn on [uncertain]. The steps below combine published case material with synthesis.
  • Steps [synthesis, except where tagged]:
    1. Start from the introductory (Triangle) session. It acknowledges the child's trauma history and links it to the child's current feelings and behaviour. [source: Ghosh Ippen, Noroña & Lieberman 2014]
    2. Build the narrative gradually from the Triangle, from play and from the child's spontaneous comments. Family dolls and a playhouse were used in a published case. [source: Harley et al. 2014, for the dolls]
    3. Help the caregiver tell the story in simple, age-appropriate words, often in short segments. The therapist can also speak for the child to the caregiver, voicing the child's fear then and safety now. [source: Harley et al. 2014, for speaking for the child]
    4. Include what happened, what the child felt and did, what grown-ups did to protect, that it is over or what is different now, and that it was not the child's fault. Where it fits, help the caregiver tell the child they are sorry about what the child went through. [source: Ghosh Ippen, Noroña & Lieberman 2014, for the apology]
    5. If the child avoids the story, follow the child's cues. Rebuild safety through play, and allow brief returns to the history before the child pulls away. [source: Ghosh Ippen, Noroña & Lieberman 2014]
    6. Where useful, use drawings or storybooks. For example, the UCSF manuals page points to Piplo Productions therapeutic stories.
    7. Revisit and expand the story across sessions.
  • Example language (illustrative): "So the story is: there was a big fight, Daddy hurt Mommy, you were scared and hid under the table. Mommy called for help and the police came. Now you and Mommy live at Grandma's and Daddy doesn't come there. It wasn't your fault."
  • Watch for:
    • A caregiver version that excludes or distorts the child's experience.
    • Retraumatising pace.
    • Pressure on the child to "tell".
    It is working when the child adds to the story, when trauma play diminishes and when symptoms ease. [synthesis]

D4. Identifying and addressing trauma reminders

  • Purpose: Help the dyad recognise the reminders (sounds, people, places, smells, the other's behaviour) that trigger dysregulated affect and behaviour. Respond to them by distinguishing remembering from reliving and then from now. [source: NCTSN; Barnard LC; Van Horn 2012]
  • Steps [synthesis]:
    1. With the caregiver, list the child's known reminders, including the caregiver's own: for example, the child's anger reminds the caregiver of the partner.
    2. When a reaction occurs in a session, name it as a reminder.
    3. Help the caregiver soothe the child and say that it is now, not then.
    4. Plan responses for home.
  • Example language (illustrative): "When the door banged, you jumped. That sound reminded your body of the scary time. You're here with Mommy and you're safe now."
  • Watch for:
    • The caregiver taking the child's reminder reactions personally.
    • Unrecognised mutual triggering.
    The sign it is working is shorter, less intense reactions and faster repair. [synthesis]

D5. Collateral sessions with the caregiver alone

  • Purpose: Strengthen the caregiver's capacity to acknowledge the child's trauma and hold the child's needs in mind. Process material too adult or too distressing for the child, and prepare for dyadic sessions. Use them before Core dyadic work and as needed throughout. [source: NM CYFD; GV Health]
  • Steps [synthesis]:
    1. Schedule these as needed, for example monthly or when a session raised strong caregiver affect.
    2. Review recent dyadic sessions.
    3. Explore the caregiver's reactions and history.
    4. Plan how to bring insights back into dyadic work.
  • Example language (illustrative): "Last week when she played the hospital game, you looked shaken. Can we talk about what that was like for you, just the two of us?"
  • Watch for: Collateral sessions replacing the dyadic work. [synthesis]

E1. Recapitulation and termination

  • Purpose: Consolidate gains, retell the family story of treatment and plan for future reminders. End in a way that does not repeat traumatic loss. [source: NM CYFD; GV Health]
  • Steps:
    1. Discuss and plan the ending with the caregiver.
    2. Repeat the measures and review them together.
    3. Tell the child, using an agreed explanation.
    4. Run countdown sessions.
    5. Review the family's story: what happened, what changed, what they did.
    6. Make a plan for future trauma reminders and developmental challenges.
    7. Hold a final session.
    8. Taper the frequency where possible.
    [source: NM CYFD; the ordering and details of the countdown are synthesis]
  • Example language (illustrative): "We have four more times together. Let's make a calendar so you can see. Each time, we'll remember some of the things you and Mommy learned here."
  • Watch for [synthesis, except where tagged]:
    • A regression near the end. This is often expected and should be named as a reaction to the goodbye. In one published case a parent–child dysfunctional-interaction score rose into the clinical range at the end. The authors linked this partly to the parent's anxiety about losing the therapist's support. [source: Harley et al. 2014]
    • The caregiver ending abruptly to avoid the goodbye.
    • A forced ending, such as a court decision or placement move. Plan for this explicitly with the child.
    • Aim for a corrective goodbye. In a published case the therapist acknowledged her own sadness at ending and helped the child put his feelings into words. She also made sure school services were in place before the last session. [source: Harley et al. 2014]

5. Handling problems

The sources give few procedures for specific problems. The NM manual names four: addressing resistance (including in mandated treatment), increasing safety, lack of progress as a trigger for termination, and reflective supervision as the main support. The developers' 2014 commentary and the case series it discusses add guidance on trauma avoidance and developmental disability. Everything else in this section is my own synthesis built on CPP's stated principles. Each item is tagged accordingly.

  • Mandated or reluctant caregiver. Addressing resistance is a named Foundational task [source: NM CYFD]. Response [synthesis]:
    • Name the mandate openly.
    • Separate your role from the referrer's: say what you will and won't report.
    • Find a goal the caregiver owns, such as "less tantrums" or "getting CPS out of my life".
    • Extend the Foundational Phase rather than starting dyadic work on compliance alone.
  • Caregiver denies or minimises the child's exposure ("she was asleep", "she doesn't remember"). The criterion for moving to Core is that the caregiver can acknowledge and talk about the child's trauma [source: NM CYFD]. Response [synthesis]:
    • Give developmental guidance on what young children perceive and remember in the body.
    • Explore the caregiver's own reasons for protective silence: shame, fear, cultural norms.
    • Point to the child's behaviour as the child's way of telling.
    • Do not move to the Triangle introduction until there is some agreement.
  • Ongoing danger (current IPV, unsafe contact with the person who caused harm) [synthesis]:
    • Put safety planning, advocacy and coordination with child protection and courts first (A5, C7).
    • Postpone narrative work, since you cannot tell a child "it's over" when it is not.
    • Report child-protection concerns as your jurisdiction requires, and where possible tell the caregiver in advance how reporting works.
  • Child overwhelmed in session (escalating aggression, dissociation, inconsolable distress) [synthesis built on NM's regulation breaks]:
    • Stop the trauma content and help the caregiver soothe the child (D2).
    • Reduce the intensity of materials.
    • Shorten trauma segments and end every session regulated.
    • Review the pace with the caregiver in a collateral session.
  • Caregiver overwhelmed or triggered by the child's play or behaviour [synthesis]:
    • Pause and ground the caregiver.
    • Name the reminder (D4), and use emotional support (C6).
    • Move the processing of the caregiver's own trauma to collateral sessions (D5).
    • Consider referral for the caregiver's own individual treatment, for example of PTSD or depression found at assessment, alongside CPP.
  • Negative attributions ("he's evil like his father") [synthesis]:
    • Treat the attribution as a port of entry (B1).
    • Explore where the view comes from.
    • Offer an alternative reading of the behaviour (C2).
    • Highlight moments that contradict it.
    • Interpret links to the absent parent only when the alliance allows (C5).
  • Stuck trauma play (rigid repetition without relief) [synthesis]:
    • Introduce protective or rescuing elements through the caregiver's figure.
    • Name feelings and link the play to the real event when the child is calm.
    • If there is no change after several sessions, review the formulation in supervision.
  • Stalled progress [synthesis, except where noted]:
    • Repeat the assessment measures.
    • Revisit the Triangle and the treatment plan.
    • Check whether the Foundational Phase was rushed: the NM manual warns this is "detrimental".
    • Check for unaddressed ecological stressors.
    • Bring the case to reflective supervision and consult calls.
    • Lack of progress is a recognised trigger for planned termination [source: NM CYFD]. Agree it openly and refer on rather than letting the case drift.
  • Missed sessions and irregular attendance [synthesis]:
    • The NM programme raises the need for regular weekly sessions at feedback [source: NM CYFD].
    • Problem-solve the barriers: transport, timing, home visits.
    • Use concrete assistance (C7).
    • Contact the family after missed sessions and frame it as caring, not monitoring.
    • Tell the child next time why the gap happened.
  • Rupture with the caregiver (feeling judged, siding with the child, cultural misunderstanding). The caregiver's perception of the therapeutic relationship is itself a port of entry [source: Van Horn 2012]. Response [synthesis]:
    • Name the rupture.
    • Take responsibility for your part.
    • Ask what they felt.
    • Re-establish the partnership, looking for "the benevolence in the conflict" [source: GV Health].
  • Therapist reactions (anger at the caregiver, rescue fantasies, secondary traumatic stress). Reflective practice is a fidelity strand, and the rostering requirements include twice-monthly reflective supervision [source: NM CYFD; Wisconsin LC]. Use supervision specifically for your own reactions. [synthesis]
  • Multiple caregivers, foster care and contested custody. The format can include several caregivers or siblings when clinically indicated [source: Barnard LC]. The NM programme also observes foster placements [source: NM CYFD]. Response [synthesis]:
    • Decide with the team which caregiver relationship is the treatment focus.
    • Hold separate collateral sessions where caregivers conflict.
    • Be explicit about what information goes to the court.
    • Plan an ending if permanency decisions change placement.
  • Cultural beliefs against discussing trauma with young children. This is discussed at feedback [source: NM CYFD]. Response [synthesis]:
    • Explore the belief respectfully.
    • Find culturally congruent ways and words to acknowledge the event, for example through stories or through family or faith practices.
    • Do not override the caregiver's position; negotiate the Triangle wording with them.
  • Caregiver mental illness or substance use limiting participation [synthesis]:
    • Coordinate concurrent treatment.
    • Adjust session length.
    • Assess whether the child is safe in that care.
    • Consider involving another stable caregiver.
  • Child avoids the trauma story (turns away, changes the game, escapes into rough-and-tumble play) [source: Ghosh Ippen, Noroña & Lieberman 2014; Harley et al. 2014]:
    • Follow the child's rhythm; do not push the narrative.
    • Rebuild relational safety through play and daily interactions.
    • Allow brief returns to the history, then let the child retreat.
    • In collateral sessions, track whether the avoidance is easing and whether the caregiver is reinforcing it. [synthesis]
  • Child with a developmental disability or limited symbolic play [source: Ghosh Ippen, Noroña & Lieberman 2014; Harley et al. 2014]:
    • Assess the caregiver's beliefs about the cause of the delay, their view of the child and of themselves, and how they are coping.
    • Expect parental grief, and work with it. It can return at each missed milestone.
    • When play cannot carry the story, use body-based regulation: deep-pressure hugs, movement, breathing and rhythm. One published case added a co-treating occupational therapist halfway through treatment.
    • Coach the caregiver to read the child's cues, rather than doing activities one-to-one with the child yourself.
    • Coordinate with early intervention, the school (IEP) and medical teams, and help the family access entitlements. In one case, linking the family to benefits and services came first.
  • Fidelity drift (becoming individual parent therapy or unfocused play) [synthesis]:
    • Use the phase fidelity forms.
    • Check each session for the content goals.
    • Ask in supervision: what is the port of entry, and what is the link to the trauma framework?

Sources

Sources:

Further reading (not drawn on):

  • Lieberman, A. F., Ghosh Ippen, C., & Van Horn, P. (2015). Don't Hit My Mommy! A Manual for Child-Parent Psychotherapy with Young Children Exposed to Violence and Other Trauma (2nd ed.). Zero to Three Press.
  • Lieberman, A. F., & Van Horn, P. (2005). Don't Hit My Mommy! A Manual for Child-Parent Psychotherapy with Young Witnesses of Family Violence (1st ed.). Zero to Three Press. This edition is cited by the developers' 2014 commentary.
  • Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with Infants and Young Children: Repairing the Effects of Stress and Trauma on Early Attachment. Guilford Press.
  • Lieberman, A. F., Diaz, M. A., Castro, G., & Oliver Bucio, G. (2020). Make Room for Baby: Perinatal Child-Parent Psychotherapy to Repair Trauma and Promote Attachment. Guilford Press.
  • Lieberman, A. F., Compton, N. C., Van Horn, P., & Ghosh Ippen, C. (2003). Losing a Parent to Death in the Early Years. Zero to Three Press.
  • Works quoted in the NM manual's fidelity strands: Pawl & St. John (1988); Winnicott (1965); Bowlby (1988); Ghosh Ippen et al. (2014).
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