New thoughts for a new land

Frances Thomson Salo

I shall talk about developments in perinatal mental health and start by acknowledging that my title reflects in part the way that the early psychoanalysts saw Australia – as a new land - whereas the indigenous Aboriginal culture is the world's oldest surviving one. While there are worldwide cultural differences in views about infants, I think that some ideas are generally applicable. I shall first try to show how clinical work in infant mental health that was rooted in the analytic culture of Europe, specifically object relations theory and Esther Bick’s infant observation, has been shaped in Australia.

When I began work at the Royal Children's Hospital 20 years ago after training in the British Society, the culture in Melbourne was one where the therapists were strongly influenced by Winnicott - seemingly the culture of the ‘old country’. The infants were referred in their own right for psychosomatic symptoms to the Hospital infant mental health therapists which is likely to have contributed to the therapists extending Winnicott's thinking. This was different from the way that I had been trained in England where the work was primarily with the parents to try to bring about change in their representations, and the infant if present, was not directly engaged so as not to undermine the parents. I realise that in trying to put some points succinctly I may misrepresent them. To return to Winnicott (1941)’s ‘spatula’ paper - he described interacting with an infant who suffered from fits and once she could bite his knuckles without being overwhelmed with guilt, she was able to play, and her relationships and symptoms dramatically improved. So the Children's Hospital therapists developed a way of working that engaged jointly with the parents and the ‘baby as subject’ entitled to an intervention as a person in their own right. The central therapeutic mechanism seems to be trying to understand the infant’s experience from the infant's point of view, and then conveying to both parents and infant the understanding that the infant has a mind of their own with their own history. Parents usually welcome this approach, which aims to increase their reflective capacity about themselves and their baby. In 90% of out-patient cases, gains were maintained relatively long term.

Simultaneously I began running, with my colleague, Campbell Paul, an open-ended weekly mother-baby therapy group that ran continuously for 8 years, mainly for infants under 12 months and their parents. The infants led to a change in our thinking about using principles of adult group work, as we saw that they had relationships with the other infants, the other parents and above all with the leaders. The infants initiated interactions with us, and in our trying to respond in an attuned and contingent way we seemed to make non-verbal interpretations which became part of group life.

I now want to turn to infant observation in the analytic and therapy trainings in Europe, with its broad focus since the 1970s of focusing on the observer’s countertransference. Infant observation in Australia can trace its roots from the 1970s, when Patricia Kenwood, of the Australian Society and who also trained in England, started infant observation at the Children's Hospital, in the Esther Bick tradition. Some infant observation in Australia, while also focusing on the observer’s countertransference, has been shaped as a result of the increasing awareness that very young infants often seek a relational encounter with the observer and show curiosity about the observer's mind. To be aware of how the active infant relates to the observer, making - and shaping relationships - so that the infant’s sense of self changes is a shift in infant observation. Infants enjoy being watched by the observer who becomes important to many of them. At times, however, an infant who faces challenges in their environment may reach out emotionally to the observer, and then is keeping the traditional non-responsive observer role entirely ethical? In ‘Still Face’ studies, some babies become distressed within seconds by a violation of what they expect. It sometimes seems no longer acceptable to just keep observing the baby without, for example, empathic mirroring and in complex families perhaps more than this is indicated. Debbie Hindle and Trudy Klauber (2006) from the Tavistock raised similar ethical issues when they wondered whether there might be ‘a potential tension between what we as teachers want our students to learn from observing in a family, and the family’s experience of the observation’. (One development in the field uses infant observation as a therapeutic modality so that perhaps a spectrum of observer response needs to be considered.)

Drawing on the short-term Hospital work, the long-term therapy group work and infant observation material from about 45 seminars I have run, I formulated some principles in this work: the therapist aims for mindfulness and secure attachment for the family from the triple perspective of psychological holding, communicating with the baby and playfulness in the infant-professional interaction.

  1. Psychological holding. Nonverbal ways of relating contribute not only to the parent feeling safe in the setting but also the infant feeling safe. When infants feel emotionally held, they sense that the therapist’s mind is available to help contain their affects.

  2. Communicating with the infant as a person in their own right

Therapists try, above all, to understand and communicate with the infant, and with very young infants by gaze, gesture, vocalisation and words.

  1. Pleasurable playfulness in the infant-therapist interaction

Trevarthen (2001) suggested that infants want to matter to those who look after them, and above all to be enthusiastically enjoyed. Even tiny infants can feel sad and ashamed when they do not feel meaningful to their carers.

I think that even very young infants contribute to the therapeutic process, including those who are insecurely attached - their sense of immediacy; their positive and negative emotions and moral capacities such as compassion; their wish to know and be known in a truthful experience and lastly, their wish to be creative and to have the experience of an uninterrupted process. To sum up, I want to suggest something quite radical - that responding to the infant as subject promotes reflective function. Nothing would be more convincing to a parent that their infant has a mind that reflects and can be reflected on than the therapist authentically doing this with their infant. Videotaping can show very young infants making an invitation to the therapist, as the third, to engage with them.

I think that interacting with the infant helps reflective function develop in a fourfold action.

  1. Changing infant representations and behaviour

When infants experience their mind existing in the therapist’s mind, and are responded to in a new way, this offers a possibility for responding differently. When they are with a therapist who is interested in understanding the meaning of their experience, the infant gets this mirrored back in a way that he or she can feel bodily with changes in behaviour and representations.

  1. Changing parental representation through exploring and making links, concurrent with seeing their infant differently

This re-presents the infant to the parents who then have the possibility to see the infant as less damaged than they had feared, the infant whom they had at some level hated for not being perfect.

  1. Changing infant-parent interaction with the infant taking the changed ways-of-being into the relationship with the parents

  2. Changing parental ways-of-being with the infant

When the therapist interacts with the infant from a position of finding the infant intentional, understandable and potentially enjoyable, the parents are likely to have mirrored in themselves a similar experience. The therapist-infant interaction can begin shaping the parents’ representations and implicit memories of relational behaviours. In the relational encounter with the infant these could be modified faster than at other times.

Currently, with evidence-based practice, the public health sector is moving towards short term programs which may last only 1–5 sessions. We need to find ways to maximise brief therapeutic interventions at the ‘hard’ end of infant mental health – infants of parents who have serious mental illness, borderline personality difficulties or use alcohol and drugs. Also in the case of some very premature babies as up to 75% of their parents may experience Post Traumatic Stress. Using the clinical learnings I have described above, I developed some short-term group models:

  1. For parents who have contact with child protective services.

  2. For women and infants who had experienced violence in the first year of life, to help with the mothers’ guilt, shame and depressive feelings in thinking about their infant’s mind responding to the violence. Developmentally delayed infants ‘sponged up’ the enjoyment and made rapid progress.

  3. For pregnant teens, using group discussion of video clips, and an infant mental health intervention at birth and 6 weeks focusing on the infant's capacity for gaze, interaction and consolability.

  4. We may develop this further with indigenous communities.

Turning to individual work, I am interested in applying psychoanalytic thinking to the brief therapeutic work in a maternity hospital, in a tiny window of opportunity around pregnancy and birth. I shall focus on adolescent mothers, many of whom find it hard to look after and empathise with their babies. But having a baby can be a force for change like no other. One teen mother[1] could only allow herself half an hour to talk to me about her baby whom she could not bear to visit in Neonatal Intensive Care Unit. But in this ½ hour, making the link that she feared this baby would die, like with the baby’s sibling who had also died, allowed her to start visiting.

The context may not always prevent the possibility of some response. One young mother, with a past history of violence using a knife, was referred and I saw her with her community support worker in the room and a security guard sitting outside. I tried to find some connection between her and her baby who had to be in hospital for a month while she withdrew from the drugs that her mother had used; her mother was likely to lose custody. I watched a feed, and talked to her about what I saw of her baby’s experience of being calmed by her mother whom she did at some level know, to try and help the mother feel she had given her baby something, that something of her lives on in her daughter, so as not to have to immediately start another pregnancy to replace this baby.

Let me finish with a vignette that, while it is still early days, we can see something of working fast while working containingly, and with the infant as a therapeutic partner. A 16-year-old adolescent, living in a refuge, with a possible diagnosis of antisocial personality disorder, was referred for difficulty bonding to her unborn baby. Her use of marijuana, ice or cocaine had increased in pregnancy. She was said to be mechanical and to not look at her baby. She was interested that I talked to the baby but then told me she did not have a clue what was going on in her baby’s mind. However in the fourth session she unselfconsciously began talking motherese very easily to her daughter, so we had reached some good implicit memories behind the difficulties. There were many issues I did not take up. In 4 hours of work it is unlikely I touched the depression below the addiction or the Personality Disorder but the mother-infant relating is better. The infant does her bit, trying so hard to respond to me, and being responsive at home. Her mother is clean of drugs. She seemed to feel that I can help with something that she wants help with and she did seem to be thinking her baby might have a mind that she could be curious about. She makes enormous efforts to come on public transport to see me.

In conclusion, parallel with these clinical developments, the emerging developmental and neuroscience research confirms that very young infants are available for a relational encounter. Clinical trials also showed that even when the mother recovers quickly from postpartum depression, if the mother-infant relationship and the baby are not helped, they are likely to continue to have difficulties (Forman, 2007). This suggests to me that the approach that I found in Australia 20 years ago and which sometimes felt like going out on a limb has been validated. But then, as Peter Fonagy and Mary Target (1998) said, I would think that, wouldn’t I? And there are now other therapists interested in exploring aspects of this direct interaction with infants. In conclusion, I think that when the focus is on helping new parents who are having difficulty with parenthood, it is probably most helpful if the infant is included in the work as a way of contributing to reflective function.

References

Forman, DR, O'Hara, MW, Stuart S, Gorman, LL, Larsen, KE, & Coy, KC (2007). Effective treatment for postpartum depression is not sufficient to improve the developing mother–child relationship. Development and Psychopathology, 19, 585−602.

Hindle D, Klauber T (2006). Ethical issues in infant observation: Preliminary thoughts on establishing an observation. International Journal of Infant Observation, 9: 7-19.

Fonagy, P, Target M. (1998). Mentalization and the Changing Aims of Child Psychoanalysis. Psychoanalytic Dialogues, 8: 87-114

Trevarthen C. (2001). Intrinsic motives for companionship in understanding: their origin, development, and significance for infant mental health. Infant Ment Health Journ, 22: 95-131.

Winnicott, D. W. (1941). The observation of infants in a set situation. In Collected Papers: Through Paediatrics to Psycho-Analysis. London: Tavistock Publications, 1958, pp 52-69.