Elsa brought her 18-month-old son George to see me with the typical concern, “He hits when he doesn’t get his way.” I resisted the pull to offer advice or behavior management, instead opening up the space of not-knowing. Soon this story emerged. Following the birth of her now 8-year-old daughter, Elsa explained, she and her husband had experienced years of infertility. The lilting seemingly effortless flow of the narrative suddenly stopped. She paused to compose herself. I waited. She began to wipe away tears that I could not yet see. When she began to speak again her voice cracked. They had lost a baby— he was stillborn— shortly before she became pregnant with George. The pregnancy was filled with fear that she would lose this baby too. She told herself that she would be so grateful if this baby survived that she would give everything to him. Now her tears began to flow in earnest as she confessed her deeper feelings. Alone all day with an intense active toddler who—unlike her quiet, easygoing daughter— demanded engagement at every moment, she found herself longing to have a moment away from him. She felt lost; craving time alone to rediscover herself. But these thoughts filled her with overwhelming guilt and shame.

I thought of this story when in preparation for a meeting with an infant mental health interest group we read Alicia Lieberman’s article Angels in the nursery: The intergenerational transmission of benevolent parental influences. The title alludes to Selma Fraiberg’s classic paper Ghosts in the Nursery. In it Lieberman writes:

“A therapeutic stance that gives equal importance to supportive early memories and to memories of conflict, abuse, or neglect should be established at the outset of treatment because the initial therapeutic sessions shape the client’s perception of what the therapist considers worthy of attention. Cultivating a frame of mind where experiences of joy, intimacy, pleasure, and love are considered to be as worthy of therapeutic attention as negative experiences can be of great assistance in promoting momentum toward psychological health.”

This model of actively seeking out positive relational experiences has been applied in pediatrics and other settings including in the HOPE (Healthy Outcomes from Positive Experiences) framework developed by Bob Sege and colleagues at Tufts university

In my clinical experience I have found that far and away the most powerful agent of change is the process of grieving loss. When I open myself up to what I call “playing in the uncertainty” allowing the visit to unfold without setting an agenda, I’m consistently surprised and amazed that this stance takes parents through feelings of profound sadness to powerful moments of connection with me, with their child, and with themselves.

The Muslim Sufi poet Rumi famously said, “the cure for the pain is the pain.”

These two perspectives offer a “both/and” possibility. The research offers evidence that memories of positive relational experiences can lessen the impact of adverse early relational experiences. But more than “attention to negative experiences” is the need to protect time and space to grieve loss.

Frontline practitioners who work with infants and parents often find themselves in intimate contact with stories of seemingly unbearable pain . An intentional focus on positive experiences, while helpful for the client/patient, can also serve to protect the practitioner from the intensity of the client/patient’s distress. We all feel better when we listen for what pediatrician Barry Zuckerman named “Angels and Kisses.”

Preparing for this meeting also brought to mind an experience as faculty of the UMass Chan Medical School Early Relational Health fellowship when Marva Lewis spoke with our group. Many activities of the weekend asked fellows and faculty to dive into their own personal history. One exercise called on us to share positive experiences of cooking that aligned with our particular cultural background. We heard beautiful stories of magnificent flavors and powerful loving connection. But many of the group, I soon discovered, were suffering in silence. The question brought up painful reminders of such things as mothers too overwhelmed by depression to prepare meals, or harsh mothers who, perhaps as defense of their own experiences of loss, exercised rigid control of any meal preparation. I only learned of this hidden suffering when I made a conscious decision to share with the large group my own emotional pain in connection with the question. Afterwards, in the break between presentations, many of the fellows thanked me in one-one-one conversation. They shared similar personal stories. Only after they could express their pain did they gained access to more positive memories in the context of other relationships.

So, while I embrace the spirit behind the concept of angels in the nursery, I wonder if we need to exercise caution in intentionally guiding interactions in any one particular direction. We might unintentionally bury an opportunity to grieve loss. When instead we convey to parents an openness to receive whatever they choose to share, we may help release them from the iron grip of unmourned loss. Blocked mourning can lead to a downward spiral of missed cues and disconnection. The process of grieving itself may help to— as psychoanalyst Norman Doidge wrote— transform ghosts into ancestors.