key: cord-0065097-q5q2dvrv authors: Schestag, Lena; Mehner‐Gentner, Janina; Stein, Lea; Rossi, Hildegard; Fischmann, Tamara; Leuzinger‐Bohleber, Marianne; Fritzemeyer, Korinna title: Ghosts in the nursery in exile—Supporting parenting in exile during the COVID‐19 pandemic date: 2021-05-27 journal: nan DOI: 10.1002/aps.1702 sha: 98843d03f62315aad04c393386d41db66454e94a doc_id: 65097 cord_uid: q5q2dvrv The early prevention project “Strong together!” supports refugee parents and their young children (0–4 years) in Berlin, Germany. It aims to mitigate the transmission of trauma to the generation born in exile. For refugee families who have only recently arrived in Germany, the COVID‐19 pandemic poses a particularly great challenge. Not only are they confronted with numerous challenges in respect to re‐building their lives in Germany after fleeing war and persecution, but are also vulnerable to conscious and unconscious anxieties, fantasies, and conflicts evoked by the pandemic and the threat it poses to their lives. This was observed in the context of the mother–child groups of “Strong together!”. Many expressed great insecurity, heightened levels of anxiety, re‐experiencing of traumatic scenes, and over‐strictly self‐isolating themselves and their children, even attraction to fundamentalist ideologies. In this paper, some of the empirical and clinical findings of “Strong together!” are summarized and reflected on within a framework of psychoanalytic trauma theory. Based on decades of clinical and interdisciplinary research it can now be considered a consensus in both research and practice that traumas experienced by the parental generation, if left unprocessed, can cause multiple, longterm burdens on subsequent generations (Danieli, 1998; Grubrich-Simitis, 1979; Leuzinger-Bohleber, 2015; Moré, 2013 ; see also Fritzemeyer, 2019; Leuzinger-Bohleber & Hettich, 2018a) . However, transgenerational transmission of trauma remains the subject of a wide range of research to date. To better understand its effects, we approach trauma from a sequential understanding (cf. Keilson, 1979 ; see also Becker, 2006; Zimmermann, 2012) . This aspect of trauma seems to be especially apparent in the context of persecution, flight, and migration, as these cannot be considered independently of current political and social conditions. Furthermore, specific phases of flight must be acknowledged. Each phase, as well as in interaction with other phases, can have a severe impact on the affected person. The external safety of the refugees also cannot be considered restored by arriving in Germany, as this goes hand in hand with various other stressors (cf. Schouler-Ocak & Kurmeyer, 2017) . For a child born in times of war, the cumulative impact of the persecution and flight phases, each challenging and sensitive in their own right, can potentially cause an extraordinary burden. They might be seen as great risks to the mother and the development of her child (Burkhardt-Mußmann, 2016; Leuzinger-Bohleber & Lebiger-Vogel, 2016; Moro, 2014) . If the parents' unprocessed traumatic experiences become "ghosts in the nursery" (Fraiberg, 1980) , they can severely burden the mother-child interaction and the subsequent psychological development of the child Leuzinger-Bohleber & Lebiger-Vogel, 2016; Moré, 2013) . The COVID-19 pandemic and all the uncertainties and fears which accompany it can exacerbate existing obstacles to re-building one's life in exile. We will describe these obstacles based on our experience with refugee mothers and their babies in the project "Strong together!". After giving an overview of the project "Strong together!", we will briefly discuss the multifaceted traumatic experiences of the participating mothers. Case descriptions shall then illustrate the effects of the outbreak of the COVID-19 pandemic on this particularly vulnerable group. We will discuss how the pandemic and the threat to life that it imposes rupture the refugee mothers' tentative attempts to rebuild a sense of safety in exile after having experienced multiple threats to their lives in their mother countries; and how mother-child groups have the potential to mitigate some of the pandemic's detrimental effects. "Strong together!" is an early prevention project for refugee families with young children (0-4 years) implemented at the Kindergesundheitshaus e.V. (children's house of health) located on the grounds of a large hospital in Berlin-Neukölln, an area known for a great number of migrants and the risk of the development of parallel societies. The project stands in the long tradition of psychoanalytical understanding of the long shadows of war, persecution, and flight. It was developed from the psychoanalytically oriented FIRST STEPS program for migrant families in Frankfurt (Germany; cf. Burkhardt-Mußmann, 2016; Lebiger-Vogel et al., 2020; Leuzinger-Bohleber & Lebiger-Vogel, 2016) , which has also been implemented in Berlin since 2012 (for an overview of projects for migrants and refugees at the Kindergesundheitshaus, see Table 1 ). 2 Results of the empirical evaluation of the FIRST STEPS project show that psychoanalytically oriented prevention offered to migrants can also reach traumatized and severely burdened families and support the healthy development of their young children Lebiger-Vogel et al., 2020) . This appears to be of particular importance as we know that mothers who have experienced war and persecution are at greater risk of showing less sensitivity in the interactions with their infant than migrant mothers who have not experienced war and persecution ; see also van Ee et al., 2012 van Ee et al., , 2016 van Ee et al., , 2017 . Therefore, "Strong together!" particularly supports families who fled to Germany from war and crisis zones in 2015 and who cannot return to their country of origin. Like its preceding projects (FIRST STEPS, "Hand-in-Hand") "Strong together!" aims to provide preventive support for children's earliest relationship experiences. Mothers are supported both in professionally led, weekly mother-child groups as well as with home visits. 3 Currently seven groups take place, each with an average of seven women and their children participating and led by two female group leaders and a volunteer. Fathers have been invited to father meetings since the beginning of 2020, but due to the pandemic it was almost impossible to set up a new offering for them. In order to understand the effects of flight and trauma on the mother-child interaction and to be able to stay in emotional contact with the families, the professional group leaders receive weekly psychoanalytic supervision. As mothers called for help and more directive input on educational issues with their children at the beginning of 2019, we began piloting a new, additional offer, which takes place in the framework of the weekly mother-child groups: "Strong Parents-Strong Children" ("Starke Eltern-Starke Kinder", Rauer, 2009; Tschöppe-Scheffler, 2005 ), a parenting school well known and widely established in Germany. "Strong Parents-Strong Children" is being offered on 12 dates throughout the year within the weekly mother-child groups, facilitated by external parenting coaches. This offering aims to clarify questions about parenting and to provide new impulses for reflection for the mothers and thereby contributing to child protection and healthy child development. Research has shown that it is difficult to reach migrant families with such parenting schools, due to a lack of information about this offering, language barriers, racial discrimination, etc (Mühler & Spieß, 2009; Schmiade & Spieß, 2010) . Integrating this external parenting school into the well-established mother-child groups allows refugee mothers to also profit from this offering -in a more "contained" way. It also frees the group leaders from the task to "teach" and "tell" rather than to keep a more psychoanalytically informed stance. The trusting relationship with the group leaders allows for problems and difficulties to be discussed more and openly. All in all, "Strong together!" offers refugee families (a) a secure space to process feelings about war, persecution, and flight, (b) comprehensive (social) support in respect to the German health and social system, and (c) a place where they can enjoy social participation (for an overview of the concept of the project, see Figure 1 ). In summary, the focus lies on mitigating the risk of passing on trauma from the mothers to the next generation by supporting the mothers and their children in the phase of early development, and thus creating the necessary conditions for successful integration (Leuzinger-Bohleber & Hettich, 2018a , 2018b Leuzinger-Bohleber et al., 2017) . "Strong together!" is continuously evaluated (in cooperation with the International Psychoanalytic University, Berlin) to obtain information about whom we reach out to and how the external parenting school is being accepted. The formative evaluation allows us to improve the offering and to adapt it to the needs of the target group. Inventory (Körner & Betz, 2012) and include questions on flight and migration background, the Harvard Trauma Questionnaire (HTQ; Mollica et al., 1992) , the Parental Reflective Functioning Scale (Luyten et al., 2017) , as well as semi-structured group interviews and video recordings of mother-child interaction. Preliminary analyses (N = 40) provide information about the countries of origin and flight backgrounds of the participating mothers. Most of the participants came from Syria and other crisis areas in the Near and Middle East (Syria, followed by Iraq, Lebanon, Palestine, Jordan, Kuwait, Algeria, Egypt, Libya, Guinea, Cameroon, Eritrea) and arrived in Germany between 2014 and 2016. About half stated "war," "civil war," or "persecution" as their cause of flight. On average, passage to Germany took 65 days, with a great variance: 36% of the participating mothers traveled for 1 day and came by plane. Fifteen per cent of women reported that it took them more than 180 days (including duration of stay in refugee camps, i.e., in Turkey). Half of the mothers had to pay a smuggler and used various means of transportation (boat, train, car/truck, on foot) on the escape route. The findings on the causes of flight and the course of flight indicate highly stressful and potentially traumatizing experiences. Half of the participants stated that they had been strongly or very strongly stressed in the first 3 months after their arrival in Germany. Another 23% reported medium levels of stress after arriving in Germany. First evaluations of the Harvard Trauma Questionnaire (HTQ) show that 78% of our participants have experienced or witnessed at least one traumatic event. On average, five traumatic events were affirmed by the participating mothers (experienced or witnessed). Half of the mothers stated that they had experienced or witnessed "combat situations/warlike confrontations" or said that they have been close to death. About half of the participants reported having been forced to separate from family members. The most frequently mentioned trauma-associated symptoms included "recurring thoughts or memories of the painful or frightening events," "feeling nervous and easily frightened," and "feeling people do not understand what happened to you." However, in total only six participants qualified for acute posttraumatic stress as assessed with the HTQ (mean score for all participants on the HTQ symptom scale was 1.61 [SD 0.69]). The news of an unknown virus with no known cure, that had symptoms so common to parents of young children, yet was so deadly, particularly to the elderly, lead to intensive reactions in the families of our project. Panic reactions, psychosomatic symptoms as well as persistent attempts to deny the acute danger could be observed. Within the course of a couple of weeks the group leaders, who also had to come to terms with their own fears for themselves and their families, had to react creatively and flexibly to the changed conditions of the pandemic in order to maintain contact with the families, which they noticed already had a heightened level of anxiety. With their supervisor, Bernd Räde, the group leaders decided to continue their weekly supervision online. This allowed them to reflect on the situation of the participating families and to state the following problem constellations and questions, to which they sought solutions in order to maintain an improvised holding environment for the refugee families. Since the outbreak of the COVID-19 crisis in February 2020, the project has focused-in what can be called a state of emergency-on the following questions: How can a trusting contact be established via messenger services so that relationships with participating mothers can be maintained? Is it possible to offer mother-child groups via online platforms? Will offering more one-on-one contacts support staying in contact better? By phone? Outside? How will the isolation caused by the pandemic affect the psychological well-being of the participating families? What attempts can be made to alleviate participants' fears, anxieties, and the impact of strict self-isolation? How can cases of re-traumatization be identified from a distance? And how can participants, who are particularly suffering, be supported? The group leaders' task was first and foremost to listen closely to the mothers' concerns and fears about the pandemic and to continue to be available as reliable contacts. This also allowed for practical questions to be answered, like how to organize everyday family life while schools and day-care centers were closed and how could children be entertained at home. The heightened level of insecurity among the group participants during the first COVID-19 wave was striking. Although there were no curfews in Berlin at any time, most of the families did not leave their homes for several weeks. Selective home visits by the group leaders gave reason for great concern. Many children were pale and overweight-they had not played outside for several weeks. Depressive moods in both mothers and children were observed. The children's physical inactivity had effects on motor skills and led to a poorer ability to concentrate during play. The group leaders had to urgently encourage the women to leave their homes for walks with their children. Finally, we asked the head of the children's department of the associated hospital to give a brief video message to send to the mothers stating that they can and must leave the house for their children to get fresh air. One of the group leaders wrote in her report: "We kept encouraging the women to take their children outside for a walk in the fresh air. It was especially important to help the mothers separate fake news from accurate news and information. They had heard that they mustn't open the windows as the virus was spread in molecules in the air-they had understood that the aerosols would enter their homes if they opened the windows. Time and again, panicinducing messages were shared in the group chats, which needed to be broken down and countered with reasoned news." The group leaders described that the external threats experienced by the mothers and families led to an increase in traumatic memories and heightened levels of vigilance as a result of unprocessed fears due to their experience of persecution, war, flight, and further threats to their lives and that of their loved ones. Close ties to family members, who had been left behind in their countries of origin, may have also led to mothers having difficulties differentiating between the COVID-19 restrictions and situation in Germany and the restrictions and situation in their mother country. If, for example, there were poor medical care and overcrowded hospital wards in their country of origin (Syria, Iraq, etc.), they perceived this to also be the case in Berlin, or at least behaved accordingly. The panic buying and temporarily empty shelves in Germany at the beginning of the pandemic were a painful reminder of wartime conditions in their countries of origin. Accordingly, some families isolated very strictly, possibly feeling more connected to their family in their mother country when doing so (see similar observations in the contribution of Leuzinger-Bohleber & Montigny in this volume). Some women were affected by domestic violence which was a particularly stressful and difficult issue to deal with as our experience has shown that-even though it is being silenced-the children also experience violence in times of familial distress. Many others were enormously concerned about family members in their countries of origin. There were losses and deaths to mourn, related to civil wars, persecution, and the pandemic. For all this, the group provided a "potential space" (Winnicott, 1973 (Winnicott, /2015 , where emotional comfort could be sought-even when it could only take place online. The group leaders maintained close telephone contact and established weekly online group meetings to offer the families support and orientation. This proved difficult at first, as many women were unfamiliar with the technology. Some women seemed to be too disappointed that groups could no longer take place in person. Therefore, at the beginning, only a few women took up the offer. The initially irregular meetings via zoom were perceived as an effort-often the women could not understand each other at all, the noise level with the children was simply too great. However, with the current ongoing second wave, habituation has set in and dealing with the digital meetings works much more smoothly. The women are able to handle the digital offerings and are participating regularly again. The noise level in their homes has decreased because they have all learned to turn on their microphones only when they are talking, and so very personal group conversations can take place. One difference from the group meetings taking place in person is that no private two-way conversations can form, and rather everything has to be shared in the large group. This has had a positive effect on the coherence of the group feeling while we also understand that it frustrates wishes for more intimate private conversations, which we try to compensate with more one-on-one telephone calls. In the summertime-between the first and second wave/lockdown, group meetings and outings could take place in person again, sometimes in the group room at the Kindergesundheitshaus or sometimes on the Kindergesundheitshaus' front lawn. That this could be re-established in summer seems to contribute to a more optimistic perspective that it will be possible to meet in person again after all. Fortunately, the external parenting courses were also able to take place online throughout the period. Not only could they provide direct support during these emotionally stressful times, but we assume that continuing the parenting school also contributes to a sense of continuity, a most precious value and utmost need to refugees at the verge of re-building their lives. The following two case studies shall illustrate some of the observations reported above in respect to the complex interaction of effects of persecution and flight and the pandemic-in individual refugee mothers, in one-onone relationships, and in the mother-child groups. Case study 1 Regressive child development and the potential of more intimate relationship building through more frequent one-on-one video calls. With their supervisor, the group leaders try to understand the unconscious dynamics of the group participant's increasing radicalization and to work out ways of intervening to buffer the traumatic experiences marked by numerous losses and the associated feelings of helplessness, accepting current forms of defense mechanisms that fight the yet again loss of self-agency. In this process, special attention is paid to the countertransference feelings of the group leaders, who have different professions, but no analytic training. This allows the group leaders to maintain empathic understanding while also confronting splitting. As a result of the COVID-19 pandemic, fears and insecurities among refugee mothers are extremely heightened and feelings of powerlessness are reactualized, pressing to be soothed with what we call most primitive forms of defenses. While clear, reliable, and continuous instructions for action are lacking for pandemic control, the Koranic school provides support, identity, and clear rules of conduct. It can be surmised that turning to religion provides a sense of security for some of the women: giving meaning to meaningless events. At the same time, it provides anchor points of orientation and identity that can be lost in exile: Ideologies, especially those characterized by friend-enemy thinking and clear-cut attributions of good and bad, can help to deal with unsolvable inner conflicts by externalizing them. In addition to existing ideal and good objects to which one also belongs, the weak and fear-driven aspects of the self are projected onto socalled objects of hate. The resulting split in both internal and external reality is not unique to the mother in this case study but affects the entire group (Bohleber & Leuzinger-Bohleber, 2015) . Allowing this process to take place and to not exclude those women who react in this way from the group poses a great challenge to the group and the group leaders but can have a stabilizing effect if it can be held. We hope the groups can meet in person, rather sooner than later. The reported findings on the causes and courses of flight are indications of highly stressful and traumatizing experiences of the mothers' participating. The prolonged and diverse stressful experiences can be understood in the sense of sequential traumatization processes (cf. Keilson, 1979 ; see also Becker, 2006; Zimmermann, 2012) . We are only at the beginning of understanding the effects of the COVID-19 pandemic. However, as described in other contributions in this volume, it is evident that those severely traumatized are particularly endangered by the reactivation of their traumatic experiences as their traumatic histories have not been sufficiently internally integrated. The current situation may already be understood as yet another potentially traumatic phase in the sequence of the mothers' experience of persecution, flight, and post-migration stressors (poor economic living standard, lack of privacy in camps as well as lack of the experience of self-agency; c.f. Leuzinger -Bohleber & Hettich, 2018b; Schouler-Ocak & Kurmeyer, 2017) . Our observations not only support findings of preceding projects, where mothers who were persecuted and who are cut off from returning to their country of origin in order to "emotionally refuel" are more at risk to show less sensitivity with their infants, leaving their children at greater risk to develop attachment disorders or further developmental delay . Our findings alsoworryingly-support findings of a recent study by Ravens-Sieberer et al. (2021) which found that the children and adolescents of immigrant families, with a low socioeconomic status, and living in crowded housing conditions, are already particularly and significantly burdened by the COVID-19 pandemic and the restrictions it imposes. Case study 1 provides important insights into the consequences of COVID-19-induced isolation and lack of social contact for young children and indicates the great necessity to provide support to parents in exile. It is the group leaders' task to focus on reducing the risk of transgenerational transmission of trauma from the mothers (and fathers, who we also reach out to) to the next generation, by supporting the mothers and their children in the early development phase. Here, it is central to the success of the work that both mother and child are kept in mind, that difficulties in the child's development are recognized as early as possible and that the mother and child receive adequate and prompt support. A baby or toddler cannot "wait" for the mother to recover or stabilize at her own pace. This may contribute to preventing ghosts in the nursery to threaten mother-child dynamics by becoming entrenched in the long term, permanently repeated, and thus possibly further intensified (Fraiberg, 1980 (Fraiberg, , 1982 . However, as of now, it remains unknown whether these tasks can be sufficiently achieved under the conditions of COVID-19. Nevertheless, projects such as "Strong together!", which are always threatened by the loss of financial support, must not give in to xenophobic tendencies, which are activated during such times, as we already observe the birth of splitting and radicalization processes among some of the women-a danger not only to the development of children, but also a threat to societies. Our thanks go to Gina Gröning and Annina Dittmann for their help compiling the case studies, to our supervisor Bernd Räde, and the entire team of "Strong together!" for their tireless commitment in these difficult times. 1 The project "Strong together!" has just been awarded the 1 st IPA community prize by the IPA Violence Committee (to be announced at the IPA conference 2021). 2 FIRST STEPS is a subsequent project of the FIRST STEPS project set up by Patrick Meurs and his team in Belgium (see e.g., Meurs & Jullian, 2015; Meurs et al., 2006) . In cooperation with the Belgian research team, Marianne Leuzinger-Bohleber and her team at the Sigmund Freud Institute, Frankfurt, developed a modified pilot and research project in Frankfurt and Berlin (see e.g., Leuzinger-Bohleber & Lebiger-Vogel, 2016) , which started in Frankfurt in 2008 and in Berlin in 2012 (see Table 1 ). 3 For a detailed description of the development of the FIRST STEPS programs in Belgium see Meurs and Jullian (2015) . Its modified aims, theoretical framework as well as further description of practical work see also Lebiger-Vogel et al. (2020) , Lebiger-Vogel and Leuzinger-Bohleber (2016), Rickmeyer et al. (2015) . 4 For anonymization, all names in the case studies have been changed. Die Erfindung des Traumas: Verflochtene Geschichten Processes of political and terrorist radicalization in late adolescence -some case examples. 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Repräsentative Untersuchung von geflüchteten Frauen in unterschiedlichen Bundesländern in Deutschland (final report Unterstützungsangebote zur Stärkung der elterlichen Erziehungsverantwortung oder: Starke Eltern haben starke Kinder Attachment representation and sensitivity: The moderating role of posttraumatic stress disorder in a refugee sample Relational patterns between caregivers with PTSD and their nonexposed children War trauma lingers on: Associations between maternal posttraumatic stress disorder, parent-child interaction, and child development Vom Spiel zur Kreativität Migration und Trauma. Pädagogisches Verstehen und Handeln in der Arbeit mit jungen Flüchtlingen Ghosts in the nursery in exile-Supporting parenting in exile during the COVID-19 pandemic