Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=riob20

Download by: [The University Of Melbourne Libraries] Date: 13 November 2015, At: 21:55

Infant Observation

ISSN: 1369-8036 (Print) 1745-8943 (Online) Journal homepage: http://www.tandfonline.com/loi/riob20

‘Free to be playful’: Therapeutic work with infants

Frances Thomson-salo , Campbell Paul , Ann Morgan , Sarah Jones , BrigidJordan , Michele Meehan , Sue Morse & Andrew Walker

To cite this article: Frances Thomson-salo , Campbell Paul , Ann Morgan , Sarah Jones , BrigidJordan , Michele Meehan , Sue Morse & Andrew Walker (1999) ‘Free to be playful’: Therapeuticwork with infants, Infant Observation, 3:1, 47-62, DOI: 10.1080/13698039908400854

To link to this article: http://dx.doi.org/10.1080/13698039908400854

Published online: 04 Feb 2008.

Submit your article to this journal

Article views: 122

View related articles

Citing articles: 7 View citing articles

FREE TO BE PLAYFUL

‘Free to be playful’: therapeutic work with infants

Frances Thomson-Salo with Campbell Paul and Ann Morgan and Sarah Jones, Brigtd Jordan, Michele Meehan, Sue Morse and Andrau Walker

In this paper we will describe the kind of direct therapeutic work done with very young infants at the Royal Children’s Hospital in Melbourne, Australia, by the Infant Mental Health Group. It represents a different emphasis from currently accepted thinking in infant mental health work in that a core principle of our approach to infant-parent psychotherapy is to be with the baby, in Winnicott’s sense, to make a link with the baby, as well as the parents. This shifts the emphasis from working primarilywith the parents’ representations or behaviour. The quotation in our title is also taken from Winnicott (1971) who observed, ‘Children play more easily when the other person is able and free to be playfd’ (p.44), and this idea very much informs our approach.

Winnicott described a kind of direct work in his paper ‘The Observation of Infants in a Set Situation’ (Winnicott, 1941), with the infant girl who suffered from fits. After observing her, he offered her the experience of an interaction with him and once she could bite his knuckles without being overwhelmed with guilt, she was able to play and there was a dramatic improvement in her relationships and symptoms.

Observation of infants as developed by Esther Bick underpins our thinking and our work, and we view the development of the work done in the hospital as having evolved from trusting in the power of reflective observation. Observation in which the observer is attuned to the infant’s experience and active in thinking about it is therapeutic and often may be sufficient in itself, as with the infants whom Winnicott observed in the set situation of his consulting room. So why did Winnicott move with the little girl from attuned observation to a position encompassing participation and action? We will try and answer this in connection with our own work in the course of this paper. We are interested in trying to elucidate those occasions when to do so is in the furtherance of the therapeutic aim and is not about abandoning an analytlc framework.

We will make some theoretical points about direct work and illustrate these with clinical examples. We ask the question: in whose interests would we be acting if we continued to wait while hoping for change when the situation is urgent and the parents’ representations are very fixed? We will then discuss the principle of being with the baby as well as with the parents.

0 Tavistock Clinic Foundation ISSN 1369 8036

47

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

THE INTERNATIONAL IOURNAL OF INFANT OBSERVATION

The Royal Children’s Hospital Infancy Group This paper represents more than two decades of the thinking of the infant mental health workers at the Royal Children’s Hospital. The first Coordinator of this Group was Ann Morgan, a paediatrician from Wales who very much followed in Winnicott’s footsteps. She joined the hospital Department of Psychiatry, which over time had a number of London-trained analysts on its staff including Bill Blomfield, George Christie, Neil Martin, Eve Richards and Pat Kenwood. Ann Morgan was succeeded by the current Coordinator, Campbell Paul, an infant and child psychiatrist. The Infancy Group is a multidisciplinary group drawing on the disciplines of psychiatry, psychoanalysis, psychology, social work, nursing, speech pathology and child psychotherapy. It is made up primarily of members of the Consultation-Liaison team which provides mental health services to inpatients and outpatients. The psychoanalytic background was important in providing a matrix in which the work with infants could be thought about. While other hospitals also specialise in the care of the physically sick infant, we are not aware of any where the focus on the mental health of the infant has led to such a specific development in the clinicians’ thinking and work with the infant.

The Royal Children’s Hospital patients The development of our ideas has been influenced by the serious symptomatology of some of the babies referred to the Infancy Group. The Royal Children’s Hospital is a large paediatric hospital with generalist and specialist units, and has an international reputation. The majority of the children admitted are infants aged 3 years and under. Victoria, where the hospital is sited, while it is the smallest of Australia’s five states is the size of England and Wales and a few children have to be admitted without their parents who live long distances away or are only able to visit occasionally. Many parents also have significant health or social problems. In the Southern Hemisphere the hospital has the largest concentration of infants who are literally in life-ordeath situations, or suffer tertiary stages of illness, or depression. This has an enormous effect on the work and its conceptualisation. Whereas in the past the paediatricians woiild have worked only with an illness or trauma model there has been a cross fertilisation with their becoming more aware of infant mental health issues.

I t may help to give some case material before continuing with the discussion.

Ahout 20 years ago Ann Morgan was consulted about a seven-week old gaze avoidant girl, Alana, whose parents thought she was blind, deaf and autistic. The mother had previously worked with autistic infants. The father thought there was some response to him although he was losing hope because of the baby’s withdrawal. Ann said, ‘Mien I first saw the infant she was wrapped in her blanket and cocooned, her hands lying very passively on the blanket, her eyes closed and sucking on the dummy, very unresponsive with all of us standing around the cot. The first thing I did was to talk to her very quietly, barely above a whisper and she stopped sucking immediately. Then I held onto her hand and stroked it a bit while I was talking to her. Unbelievably, she began to stroke my finger and then her own finger and it was as if she could feel both fingers, and she kept stroking her own finger and stroking my finger. All the time I was talking to her 1 was certain she heard me, that she was in fact aware of the other but also was making the other aware of her. I think it meant a great deal to the mother when we talked about

48

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

FREE TO BE PLAYFUL

the fact that her daughter could hear perfectly well, that she was very aware of me and was, I think, both thinking about i t and being very separate and thoughtful.’

In considering this vignette, we think it would have been difficult to have worked only with the parents’ representations when the parents’ difficulties were already having such an effect on their interaction with their daughter. Ann was aware of the ambivalence which the mother brought into her relationship with her daughter, but the full extent of her difficulties only became clear later when the parents gave the staff a video which the father had made of his daughter having a bath. Alana, who had always been unable to look at her mother, had rolled over so that she was looking at the camera but the water was lapping over her face which her parents were totally unaware of and she was not struggling. What Ann did in connecting with the infant was to switch off the projections enough so that the mother could see her daughter more realistically.

The second example is from Campbell Paul’s work (for a hiller account see Paul, and Thomson-Salo, 1997).

Tom, at seven months, was an inismiling boy who had held his arms out rigidly at right angles to his side like scaffolding for several weeks until a short playful sequence with the therapist helped undo this His mother. Brenda, had lost her first child, a daughter, when she was a year old and in her anger about this she had found it difficult to mourn her death. When she looked at Tom she saw her daughter’s face and her relationship with him was not easy; she had never been able to play with him. When Campbell wiggled his own fingers Tom watched them. Campbell then touched Tom’s hands and talked to him and gradually Tom could bring his own hands, which Campbell was still holding, to his own mouth and explore Campbell’s thumb. Gradually his arms relaxed and, still holding Campbell’s hands, he was able for the first time to bring his own hands together. As he did so, he smiled. His mother then played with him for the first time, smiling at him.

In reviewing the videotapes it looked as though there was a protective aspect to Tom’s rigid arms, bracing himself as if frightened by the anger he could read in his mother’s face. The sequence with Campbell helped change Tom’s behaviour and representations, and as he stopped being so frightened his mother could also change. Again, in thinking about this more direct infant intervention, we justify it on the grounds that we had tried working with the mother’s representations for a number of weeks without change. As there was about to be a long break from therapy the situation was urgent for the child.

Direct work in relation to other infant-parent work We want to place direct work with the infant in relation to three other main methods of working with infants and their parents. In infimt-parent psychoth~rupy, while sessions are generally with the parents and infant together, traditionally the therapist focuses on trying to change the ‘ghosts in the nursery’, that is, the parents’ internal representations of themselves and the child. In this way the child can be freed from the effect of distorting projections from the parents’ own past. In into-ucfion guidance the therapist uses video recordings of short periods of play between parents and child, which are replayed with the parents, so that the therapist can reinforce positive aspects. The therapist does not play with the infant as this is thought to undermine

49

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

THE INTERNATIONAL JOURNAL OF INFANT OBSERVATION

the mother’s already low self-confidence. In Watch, Wait and Wondermother and child are also video-taped in short play sessions in which the mother has been instructed to follow the infant’s lead as much as possible. This instruction, as well as exploring with the mother during discussion of the videotape what she thought the infant was feeling, is thought to switch off the projections and effectively make the parent the therapist. All these methods are effective. But we think that there are times when direct work with the infant is indicated as a central part of infant-parent psychotherapy.

We are arguing for an area of work which seems to have been relatively neglected. As long ago as 1976, Ferholt and Provence wrote that, in their experience, no infant is too young to be engaged in direct therapeutic work. However, we think that the implications of this view have not been fully explored. We are not minimising the importance of work with the parents. Within the framework of working with the parents’ representations we include a range of techniques to help the parents understand their infant’s response, and to facilitate how they might help their distressed infant.

But how often do we relate to infants in their own right, convinced that this is therapeutic? Lebovici (see Cramer, 1995) has often advocated a recognition of the infant as a subject who is capable of highly complex representations, as in his experience the therapist can have a direct effect on the baby. When Stern (1995) wrote about the infant’s representations, as the therapist imagines them to be from her observation of parent-infant interaction, itwas from the standpoint ofusing them as a port of entry to change the parents’ representations. Recently Norman (1999) has described an approach which has some similarity to ours, although our examples would show a difference in emphasis in verbal interpretation and also in how we ofTer ourselves to be used in an experience of interaction with the infant. Norman describes how in the first session with an extremely depressed mother and her 6 month old gaze-avoidant daughter, Lisa, having assessed that the mother’s depression is so severe that it will take too long to help her become available to Lisa, he interprets to Lisa that she is afraid of and avoids her ruined mother. Lisa immediately returns his gaze and begins to reconnect with her mother, turning to her and mouthing her.

Reasons for direct work In advocating direct work we do not have in mind those situations where the parents may be unavailable for practical reasons, for example when they live several hours’ drive away from the hospital. Rather, we think that direct work is particularly indicated where parents seem unable to use their thinking to make links. Where parents seem unable to think about their infant, there has often been a very early fixed identification with the infant, rather than an empathic one, with the result that the parents’ relationship is notwith a subject and, in consequence, no transitional space is possible. The resulting pathology can be very profound, and can be extremely difficult, if not impossible, to treat later on, whereas even severe pathology can be treated very quickly if the treatment is undertaken sufficiently early. We particularly want to make a case for direct intervention when the infant’s symptomalology is so urgent, particularly if it is linked with physical deterioration, that we have to act quickly. (It is important to remember the pressures of the hospital context. We do not have the luxury of engaged

50

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

~

FREE TO BE PLAYFUL

parents ready for mental health help.) We also want to make a case for those situations where the infants’ difficulties have more to do with their internal world and their own contribution to a problematic interaction.

We think most readers will be familiar with the evidence and reasoning in support of intervening quickly. As Perry (1995) states, ‘The simple and unavoidable result of this sequential neurodevelopment is that the organizing, sensitive brain of an infant ... is more malleable to experience than a mature brain (p.276) ... the brain changes in a usedependent fashion and mgunizes during development in response to experience (p.283) .’

This suggests that any intervention of ours has the potential to alter the situation in a positive way. On the other hand, the longer negative experiences remain unmodified for the infant the greater the certainty that there will be organic changes in the brain which may mean that later therapeutic work cannot ameliorate the early deprivation. It may mean that even very early we can miss the boat.

In our work we create a space in which thinking can start again. Our direct work makes a bridge across which the parents can re-find the infant. Clinicians generally hold that if the parents’ representations change there will be a change in interaction and symptom. We are proposing that we examine change in the other direction, when the infant’s representations are altered and this affects their parents. A central point is that in doing therapeutic work with infants even in the first year we change the infant’s representations with significant effects on interaction and symptoms.

We do not refer here to such physical care of the infant as settling the infant in order to get her into a routine, nor to modelling. It is true that from our observations meanings arise that we can convey to the parents, and often we act as eyes for them when they miss the infant’s cues. But we are referring to something different when we talk about direct clinical work with the infant. We also want to stress that direct work can be very subtle and very little may appear to be done. Some of the interventions seem to be slight, but when they are captured on video with the sequence repeatedly observed on film, such as through the use of a video jog-shuttle, the evidence is very compelling.

One example of this comes again from Campbell Paul’s work. He did a consultation on a 2-month old boy who was failing to thrive.

Since birth, various hospital admissions meant that he had only been at home a total of 3 weeks. The boy w a s slumped and floppy in his mother’s arms and she was patting him very vigorously while his grandmother looked on anxiously. Campbell then asked to hold Stewart. Campbell sat him facing his mother, his hands around Stewart’s chest, with his fingers holding him firmly across his back. Campbell talked to Stewart and on video it can be seen that as he did so Stewart became more erect, with tone, smiled at his mother for the first time and talked vigorously to her and she instantly related in a more alive and warm way. She took him back and instead of being restless in her arms he settled into a comfortable sleep as mother and grandmother tearfully talked for the first time of a family trauma. Thirty years ago the grandmother had lost a three-month- old baby son and had never been able to mourn him and Stewart had come to repre- sent the dead child. Subsequently the mother rang to tell Campbell that Stewart had won two baby competitions.

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

THE INTERNATIONAL JOURNAL OF INFANT OBSERVATION

Being able to contain very powerful feelings while thinking about them and not rushing into action is very important in the work. Davis (1999) reports Beatrice Beebe, videotaped with babies in despair, saying that she felt that, in order not to fail the baby, she had to sit and do nothing, just to be with the baby and not encourage her to be something other than what she was, in despair. With this attuning the baby feels ‘met’ and can become hopeful again. We are aware that we are open to the criticism that we may be substituting too active an intervention for thinking, or are intervening to relieve our anxiety or, more seriously, are acting out a rescue fantasy that we could succeed where the parents have failed, and rescue this child. We think, however, that these are not the motivations for direct work, as we will elaborate, and that it is unclerpinned by a recognition that infants may not be able to afford to wait for change in the parents.

Above all we recognise that direct work is usually embedded in a total situation in which we work with the parents as well, and alter their representations, which in turn also has its effect on the infant.

The parents’ feelings We think that in the field of infant-parent psychotherapy there may previously have been too much anxiety about the effect on the parents of our interventions. A major concern was whether parents would feel we had taken over from them as some one who can parent or play with their child better than they can. It has not generally been our experience that mothers resent our relating directly to their infant. Rather we think they welcome it on a number of levels. We think that they find it therapeutic that we are trying to understand the experience from inside the child’s world rather than looking from outside as if it were inexplicable and could not be understood or known about. The parents see that, whatever the baby’s presenting difficulties, we respond to a live person and the baby responding to us feeds back to them in many ways but perhaps most importantly that there is an undamaged part of the child.

We share Winnicott’s belief that if parents can help their children this is the best outcome. But in some cases the parents’ thinking is stuck. It may then be that, if there is change in the infant, change can come about more quickly for the parents; when we do something relieving with her infant the mother in turn feels mothered and a good internal object can be experienced again. One example, where the mother’s response seems to be one of unequivocal pleasure, comes from an occupational therapist, who was referred a one year old girl, Jane, with cutislaxia (loose skin) syndrome, who used to scream all the time. The occupational therapist sat her on her lap and bounced her and talked to her. She stopped screaming and looked deep into the worker’s eyes. Her mother said the sessions were wonderful. ‘You were the first person who talked to Jane.’ All week the mother looked forward to the session. Jane is now aged 20 and she and her mother still keep in touch with the occupational therapist as someone whose intervention they valued, and Jane presents as happy and engaged with life.

We struggled in particular with the concern about whether we would increase the mother’s guilt if we interacted, say, with the depressed baby of a depressed mother

52

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

FREE TO BE PLAYFUL

and the baby perked up quickly. But for the infant’s sake we need to find ways to work with the mother’s ensuing guilt or envy. Sarah Jones, Psychiatric Social Worker, worked with Tim, who had r e i d problems, and his mother, from the time Tim was 12 months. (Some of the following case material appeared originally in Thomson-Salo, and Paul, 1997).

Tim was growing at a slower rate than the nephrologists thought was attributable to his physical problems. His mother had had a deprived childhood and it seemed that this small sick hoy made her feel special. She put a lot of pressure on Sarah for help to play with him and eventually Sarah suggested she allocate 10 minutes a day to play. ‘That sounds pathetic, I should he able to do much more than that.’ The following week the mother said it was a complete disaster - what sort of mother was she that she couldn’t do this? Sarah felt she had made a mistake and left the area of play. After a few months’ work there was an attack on Sarah playing with Tim. Tim brought a difficult jigsaw puzzle over to Sarah, who said, ‘Sometimes it’s hard and sometimes you can’t get the right piece,’ and because Sarah was not anxious about his achievement they could play with quiet pleasure. It took 3 minutes in all. His mother turned to Sarah and with a touch of concealed anger asked. ‘Have you got children?’ and when Sarah gently que- ried why she was asking now she said, ‘ I can’t bear the way you play with my child. I can’t play at all.’ Sarah said that perhaps she was asking now because it seemed as if Sarah could do something she could not do. Being able to express her anger and hav- ing it accepted was an enormous relief for the mother and subsequently her capacity to play with her children changed. She could begin to do so with some pleasure.

A number of seriously depressed infants are referred to us. The neonatal nurses call it ‘boredom syndrome’ - where the infants no longer smile - although in fact it is rather because they have given up hope, not because they are bored. The infant feels that life is not worth living because of the painful, frightening experiences they have had. Sometimes a single session with a clinician from the Infancy Group, in which an alive meaningful contact is made, is enough to reverse the cycle of despair and start the infant’s development moving forward again. We think that these interventions allow hope again for the parents, for them to feel that the baby is more resilient than they had thought.

Joseph was referred to Campbell Paul as a last resort by the medical staff, who nevertheless thought it was likely that the infant’s listlessness resulted from something organic such as terminal cancer. He was 2-years old and after a liver transplant had had glandular fever and for 4 months had inexplicably lost appetite and weight, and begun scratching himself. For a video taped session with Campbell, the mother came with Joseph and his lively 3-year old brother.

Campbell listened to the mother, while Joseph lay draped motionless across her for half an hour. Joseph was close to death and defensively disconnected from himself, and his mother, while she cared for him well physically. had also disconnected psychically from him. Gradually Cdmphell tried to engage ,Joseph. It was striking how, almost out of Campbell’s range of vision, Joseph reached out to him hut when Campbell responded he would not engage. But then the infant. enlivened by the contact with Campbell, started to reach out to his mother, with the faintest of whispers, ‘mum, mum’. She did not notice and he had to call five times before he was heard. It was as though no one in the room quite believed he was alive. Joseph then started to play. When Campbell sug- gested to his mother that he was depressed she said, ‘I hadn’t thought of that ever but now you mention it, of course.’ It seemed that once there was live play she was able to hear and think about her son again..[oseph’s lovely smiles to Campbell were observed at the end of the session.

53

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

THE INTERNATIONAL JOURNAL OF INFANT OBSERVATION

The power of gaze and play We want here to say something about the power of gaze and of play to have a therapeutic effect on the infant. Mothers describe how, after delivery, their baby fastens on to them with their eyes from the moment of being handed to them, trying to take in with sight someone who was already known long ago in a different way. This cross- modal perception contributes enormously to the emerging sense of self. Genevieve Haag and her colleagues (1994) describe observers watching premature babies and, after the observation, the readings showing that the oxygen saturation had significantly improved, as the infant feels held in the observer’s gaze. Observation is also used by Margaret Cohen (1995) with premature babies, and the nurses tell her, ‘The babies like you coming.’ Infants are aware of the special quality of the clinician’s gaze, with its thoughtfulness and playfulness. Looking in order to understand the infant’s experience is felt differently from simply looking at the infant. ‘Looking thoughtfully at’ an infant, whether as part of an infant observation or as part of clinical work, will most often be enough for the infant to feel that they have received something of value, something to introject as a good object. When the infant knows someone has come to look at them, trying to understand them, gaze becomes tremendously important in the development of self and other. Current research (Schore, 1994, 1996) bears out the infant’s need to be in contact with a thinking mind for optimal development.

Winnicott, in Playingand Reality, described playing itself as a therapy. There he wrote, ‘it is play that i s the universal, and that belongs to health: playing facilitates growth and therefore health’ (Winnicott, 1971). In the area of overlap between the child’s playing and the therapist’s playing the therapist is concerned with removing the obstacles to development. ‘Where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play.’ Reading Winnicott’s case examples what comes over is how much of his own playfnlness he contributed to the playing. As already noted he wrote that, ‘Children play more easily when the other person is able and free to be playful.’ And he thought that it is only in playing that the child is able to be creative and only in being creative that the child discovers the self. We think that when the infant realises she is imitated by us as adults who are not under her control butwillingly submit to this game, herjoy becomes part of the experience and self-knowledge.

We think of our interventions as a flow of communication, backwards and forwards, between all those taking part. We receive the projective identifications from the infant as well as the parents, and are free to be playful and to think about all of the child’s experience, which is so often compartmentalised in hospital. To put it in Ann Morgan’s words, ‘in the intersubjectivity between the child and myself, I know that the infant understands that I understand, and she knows that what she is getting is communication.’ In this way the child has the experience of being seen and related to in an integrated way. When the parents see the child playing there is a continued interactional effect in that as they respond, the child in turn responds to the changes in them.

54

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

FREE TO BE PLAYFUL

Clinical illustrations We will give three illustrations of cases where the infants’ parents cannot use their thinking to make links and we sense in the countertransference that the infant can use us. In the first example the difficulties were less entrenched.

Michele Meehan, Maternal and Child Health Nurse, was consulted about an 11-month old boy who was furious that his mother wanted to wean him.

She had been trying to introduce other food from 6 months of age but he had refused any food other than breast milk. The constant breastfeeding was tiring her. Once she started to wean him from the breast, he refused the bottle and all food, refused to be held by his mother when she did not let him feed, hit her and pulled her hair. He screamed and threw things at her when he woke in the morning; he did not accept any of her overtures. His mother was distraught about his distress, and became tearful when he behaved like this. Michele talked this through with his mother but it made no differ- ence. While Michele was talking to her, he wanted to feed and his mother refused, putting him in the cot with some toys. He reached out and hit her. She commented to his mother ‘He’s really angry with you.’ He then picked up a soft ball, and flung it, yelling, at his mother, and then clenched his lips. Michele caught the ball and, attuning to his anger and matching it, she flung the ball hack to the foot of the cot. He was instantly engaged, recognising the communication, smiled and returned the ball to Michele for them both to play a throwing game. It developed gradually into a quieter tossing and catching game which he let his mother join in. With his next feed it was noticeable that his anger had gone and he was able to accept food from his mother and the previously good relationship returned. We can see here how the internal meaning to the infant of the loss of the breast had contributed to the mother’s difficulties in thinking. Michele intuitively knew that in play the infant’s rage at the breast/mother could be accepted and survived and when the mother could not break the deadlock Michele was able to reconnect them.

In this more dramatic example, Brigid Jordan, Psychiatric Social Worker, was called to see a 7-month old and her mother. The baby was on the 3rd percentile for weight, and a brain scan was hooked because i t was thought likely that there was very serious neurological deterioration in process. Her mother had been extremely depressed and abused tranquillisers. For the previous 6 weeks the baby had refused a bottle; since admission she had been tube-fed at night and had pulled the tube out four times. Her mother used to spend an hour trying to get the bottle into her until the baby was hysterical with shock, her face white and her eyes wide open.

When Brigid arrived the mother was sitting slumped away from the cot; the baby was scrunched up and crying. Her mother said nothing helped. There was no response when Brigid said hello to the baby, made soothing noises or talked to her. In the face of them both being unreachable, Brigid picked up the baby; her hands flapped loosely. It was very hard to get eye contact with the baby and there was a lot of eye shutting. Brigid talked to and held her, and listened while her mother talked about being depressed. Then after 15 minutes the baby grabbed Brigid’s earring, held on and calmed. Later, when Brigid put her in the cot. the baby tried to go to sleep but became miserable and with arms outstretched repeatedly clutched at the blanket with her fingers opening and shutting in an odd way. Brigid suggested giving her a toy and unexpectedly her mother produced a teddy, and the baby took her dummy out and looked a t the teddy.

Several hours later Brigid returned and found a nurse had tried t o feed the baby cus- tard she did not want and could only manage when she could alternate putting the dummy in her mouth with accepting a spoonful, and the nurse had not persisted. When,

55

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

THE INTERNATlONAL JOURNAL OF INFANT OFSSFRVATION

however, Brigid held her she spontaneously opened her mouth so Brigid gave her six spoons ofcustard. She still refused her bottle although her hand brushed against it and she looked intently at Brigid as Brigid talked to her about her bottle. The following day her mother had makeup on and was more smartly dressed. The baby looked at Brigid, and was talking to her, and looked intently at her mother and smiled at her. Brigid talked to the mother about how she could give control back to the baby. The following day she began to drink from the bottle, and mother now ‘knew’ when to feed her. The mother held her and sang in an attuned way and the baby grasped the bottle instead of her hands splaying out to the side.

The baby began a steep trajectory of improvement. This intervention took place after there had been 3 previous hospital admissions that had not achieved such change. The brain scan was cancelled as the clinical indications were no longer present.

The following is a longer case which shows how the Infancy Group would try to foster the child’s optimal long-term development. Belinda was an &month old girl who had spent her whole life in hospital. The Intensive Care Consultant referred her to Sue Morse, Speech Pathologist, as she had never eaten proper food but he felt it was probably too late. Belinda was born with an exomphalous, with her intestines in an exposed mass. The stafFdid not expect that she would live. There were several attempts at surgical repair but she had a respiratory arrest and at 7 months was transferred to the Intensive Care Unit where the surgeon immediately did a tracheotomy, which resulted in her having a permanent tube fixed at the base of the throat. Sue noted that she had done more observation of her than intervention with her, partly because she did not want to intervene until she had met with the mother. However, despite her attempts to do so, she did not meet her for 6 days.

Sue stayed in the background and observed Belindawith the music and play therapists. Belinda did not search the world around her. When she was overwhelmed she looked through the person and averted her gaze. She did this at first with Sue. ‘She knew I was a new person, she didn’t particularly want to talk to me at first.’ Sue talked a lot with the nurses about her observations, musing ‘what do you think she felt then?’

She set up the intervention with the different systems before working with the child. Partly this was to help the staff ‘see’ the child differently so that they could work collaboratively with Sue. She shared her observations about Belinda’s quality of life with the ICU Consultant, and queried the need for continuous nasogastric feeds. He agreed that there be 3-hour gaps between feeds and for the first time Belinda began experiencing a range of different body states.

Sue assessed Belinda’s readiness for eating as well as her communication. She had noticed Belinda was doing a lot of blurts and was not sure whether she was calling people. Belinda had not had many experiences with her mouth apart from sucking her dummy, blurting and pushing things out. Her mouth was repeatedly suctioned. Her oral experiences were relatively unintegrated. In the beginning Sue went frequently to help Belinda with eating. As Belinda got to know Sue, she would greet her and was very relaxed and Sue no longer sat back but played with her, matching what Belinda did. Once when listening to her music she blurted gently and pleasurably and Sue thought ‘she’s singing’, and that she had a bigger range than Sue had thought. As Belinda did not have a voice because of the tracheotomy she could not vocalise in

56

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

FREE TO BE PLAYFIJL

the ordinary way with her mother. Sue observed she could make the sound tst, copied her and Belinda did it again. Sue had made it into a reciprocal game.

Simultaneously, she worked to help the parents and staff understand Belinda’s cues so that they would see eating as an interaction and that when Belinda said no people would respect that. (So often long-stay children lose their sense of agency and become unnecessarily passive.) Sue also suggested they use words to make sense of her world, not to just blurt back at her or talk to her as if she were a younger infant.

Sue suggested that as there were no picture books illustrating her world in the ICU, a world so different from that outside, i t would be helpful to make one. Sue took photos of her daily life and the parents were very positive and, in choosing which photos to include, they could talk about what they had noticed. Sue titled the book ‘I SeeYou, Boo’. (She also thought it would be helpful for Belinda when she was older to have this time in her life recorded so it could not be glossed over.) At the end of the book Sue described some of Belinda’s cues such as ‘If her blurts get fast and she waves her hands around and has a set expression on her face - she is not impressed’. She also included those she did not understand such as ‘I don’t know what sucking her tongue means, if you have an idea let me know’. The nurse whisked the book off to the tea-room where everyone read it. Her parents noticed the reciprocal ‘babbling’ and became reflective about what Belinda was saying.

When Belinda was leaving for an overnight stay at home Sue went down to ICU and found that Belinda’s oxygen was falling but the alarm was not working. Belinda was very panicked and distressed, Sue herself was frightened. Belinda took Sue’s finger and would not let go and fixed on Sue’s eyes while staff boosted up her oxygen. They talked and Belinda finally relaxed again. Here we see Sue being open to the infant’s projective identification.

Sue thought that another reason why she observed Belinda’s facial cues so much was because the exomphalous was so shocking, with its leaking scabs, that it was unbearable to look at. There were however times when Sue wanted to sit her up and as there wdS

no nurse available Sue had to hold the exomphalous herself. We suggest that the fact that Belinda could see Sue struggle with her sense of shock, whilst remaining available to the child and thinking about her, would represent a powerful communication.

Sue reduced her visits because she felt Belinda was only happy eating for her mother. Six weeks after the intervention began, the nasogastric tube was removed as she was totally orally fed. Overall the parents and nurses became more observant and understanding of Belinda. As well as her first hand experience of the contact with Sue, she also now possesses a book where she can observe what Sue has observed about her.

Returning to the question of whether, in each of these cases, we should have relied on working only with the parents’ representations in infant-parent psychotherapy, or have made use of interaction guidance, we think it will be clear how urgent some of our cases were. With many of the parents where thinking is frozen with the trauma, it would not work to only model playing with their infants. We therefore ask what is, to us, the essential question: in whose interests would we be acting if we continued to wait while hoping for change in the parents’ representations?

57

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

THE INTERNATIONAL JOURNAL OF INFANT OBSERVATlON

Some thoughts about infant-parent psychotherapy

Lieberman and Pawl (1993) acknowledge Selma Fraiberg’s legacy in the field of infant- parent psychotherapy. There they describe that a possible pitfall lies in not working equidistantly from the parent and the infant, from which we can extrapolate that working equidistantly is a main principle in infant-parent psychotherapy. We have come to feel, however, that a core principle is to be with the baby, to make a link or a connection with the infant, and to do so without over-identifymg or pathologising.

To be with the baby is also to be with the mother or the parents. Ann Morgan describes engaging with the infant, usually with gaze and voice, often with touch as well, usually the fingers. What is important, she believes, is that by the second or third visit, something is repeated which the baby recognises and that the baby has a feeling that she is there in her own right. The baby has a contact that is not through her mother, which in turn helps the mother realise that there is some separation between her and the baby. There is a look of relief on the baby’s face and the mother’s, and this can be seen as early as 4 months. Ann noted, ‘The baby makes contact with me and is fascinated because I am fascinated with her. I am with another human being as with an adult and that is as powerful a recognition as possible and the infant recognises that in me’ (personal communication). The purpose of the link between the eyes (of infant and worker) is to allow a gap to appear. The mother seeing it, allows space so that something else can appear: in her a thought, in the infant a connection with another. With Joseph, there was no gap to let Campbell in, no gap in which the mother might think that it might be better if he died, and therefore no gap in which the child could think his own thoughts. Without this space, there can be no integration.

Ann works actively at making a connection. She often offers her bracelet to the infant, even to a very young one. When the infant takes hold of it Ann can gently pull on it. The baby then has an awareness of the other, of someone who recognises the baby’s agency, and as a result she can begin to sense her own agency. Winnicott thought that for an infant the world is an impingement unless she has a sense of agency in what she does. It is a very powerful experience for an infant to know that they have captured the gaze of the other. Babies use gaze and touch to explore their mother’s face and the world around them - they need to know they have a part in the knowing. In offering ourselves or a symbol of ourselves, we are giving them the possibility to be active in their knowing. We are acknowledging the child as a subject with their own sense of agency, which is a hugely significant acknowledgement.

We suggest that it is important to work with the baby, as well as the parents, because otherwise the therapist can get caught up with working with the infant in the mother, and the real baby can get lost. One mother put her baby in the pram so expertly that she did it without looking at him and then fed him with his face covered with a cloth, obliterating his face. When they arrived for the following session Ann talked to him in the pram and he was eager to come out of the pram into the room. Ann asked if the mother thought it made a difference when Ann talked to the baby. She said, ‘Yes, because somehow I feel that things change; if he’s not in the room then I’m stuckjust repeating a story whereas I can see him differently if you are talking to him.’ When the therapist works with the infant as well as the mother, the mother can shift focus

58

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

FREE TO BE PLAYFUL

from her own infantile needs to hold more onto the thought that she is going to be able to parent and is an adult, ever1 though she does not altogether want to be one.

An additional reason for working with the baby and notjust with the parents is that it is important not to work with the mother’s hatred prematurely. The parents’ ambivalence is much more complicated in those situations where their babies are sick or damaged. With direct work with the infant the parents can see more easily that their fantasies of having totally damaged or killed off the infant are not reality. In the case of Ann’s intervention with Alana, the father understood immediately when she said that the baby could hear and see Ann, and the mother was able to take in what had happened even if she did not initially fully understand its significance in relation to her ambivalence.

Convinced of the applicability of this thinking to most infant-parent psychotherapy, Ann Morgan has taken it into outpatient work. She was consulted about a 5-month old girl and her mother who had been prescribed 3 different antidepressants. The mother felt the baby had ruined her life; she had not thought about the baby during pregnancy. The baby had withdrawn from her, and was flat and cautious. The mother wondered whether she should not have had the baby. In the first consultation, the baby made a good contact with Ann, and the second time she looked at Ann with a beam of recognition. By the third there was an undoubted shift in the mother. She looked with pleasure at her baby and the haby looked much more at her and at Ann. Initially the mother had wanted an immediate solution, whereas after three sessions she wanted to think. The way the mother held and looked at her baby had changed as she felt less trapped, with the baby having made a contact with Ann. In the fourth session the baby came off the breast, smiled at Ann and settled back to feed. When the mother was talking critically about the father the baby bit her, looked at Ann and gave a smiling nod. Ann said, ‘She was pulling you into line,’ and the mother laughed. The baby leaned back arms outstretched, beaming. Her mother had said if only they could always stay like this, a ‘divine couple’, but the baby wanted the third person involved. The work with the infant frees the mother to start thinking in a wider way. (Several years later this mother said that if she had not been seen with her infant they could not have survived and she, the mother, might have gone mad.)

When a core principle is to hr with the baby as with the parents, we see this as communicating with the infant as a subject in her own right. Dilys Daws (1999) sees the worker as taking the third position, that of the father, representing the internal father in the mother’s mind. We have in mind a more active role, that the worker offers the baby a particular kind of experience, which many parents can permit even when they may be quite imniobilised psychologically.

Many of the examples given have included a physical connection with the infant. Touch, as in infant massage, is generally acceptable whereas holding the infant in order to interact with her has been more questioned with respect to the parents’ feelings. But as emotions are experienced both in the mind and the body at the same time, when a clinician holds an infant there is a dialogue of feelings in the first ‘language’ of the infant, which the clinician takes part in in a receptive and containing way. Consider the example of Campbell taking the floppy, failing-to-thrive baby Stewart on to his lap and, as he is held, his becoming more erect, smiling at his mother for

59

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

THE INTERNATIONAL JOURNAL OF INFANT OBSERVATION

the first time and talking vigorously to her. What do we think might have heen comniunicated in Campbell’s physical holding and interacting, in addition to hi5 overall emotional holding of the family and the verbal explorative work? We could think of him as having been receptive to the infant’s tremulous fear and, in turn, communicating safety back to Stewart, emotionally as well as physically by touch.

Infant-parent psychotherapy is usually described as the therapist trying to make conscious the links with the past, whereas in the way of working described in this paper, this does not necessarily have to take place. The aim of the therapeutic contact is that there is an experience in which consciously or unconsciously the difficult feelings are shared and the therapist’s thinking about them is in some way communicated to the parent and infant, Parent and infant can then see themselves differently and can then reconnect and relate to each other in a new way. Emotional thinking restarts. The communication by the therapist is often verbal but need not be spoken and can often he communicated through interaction or play. Where the parents’ thinking seems to he halted or there is a marked contribution from the infant’s side to the presenting difficulties, direct workwith the infant as part of the workwith the parents is particularly indicated.

Therapeutic work with infants and their parents needs to he solidly grounded in being able to observe reflectively. Because of this conviction, in 1996 we made Infant Observation a central subject in the University of Melbourne Graduate Diploma/ Masters in Infant and Parent Mental Health, which developed out of the work that is done at the Royal Children’s Hospital. Many of our staff, as well as a wide range o f workers in the community, have done these courses.

The following vignette illustrates how observation informs the clinical work. Andrew walker, Neonatal Social Worker, was asked to assess possible supports for an immigrant family with poor English whose &month old boy, Colin, had been re-admitted with severe failure to thrive. His head lag was like that of a neonate. The medical staff attributed the failure to thrive to organic factors of unknown aetiology. The mother was keen to wean hut Colin would not allow this. He had had three previous admissions to an Early Parenting Centre and to the Royal Children’s Hospital which had not helped with the difficulties. Within 20 minutes of Andrew talking to the parents and Colin he had such a conviction that this was a mental health case that he spent an hour persuading the medical staff to refer to the Infancy Group.

What was it he had seen that led him to speak with such conviction on behalf of the infant? We think this is a knowing based on having had Observation skills refined through following an Infant Observation, a knowing that is not always at a conscious level. Andrew had seen that Colin, while not looking at his mother’s worried eyes, was keen to engage with his mother, reaching out a little anxiously to her, touching her, smiling and vocalising a little. Andrew saw her waving a small toy in front of his face to tiy and distract him so that she could turn away and Andrew felt that all she wanted was to get Colin off her breast hut that she did not allow him appropriate play opportunities. She did not understand why he could not hear to be on his own and she had no clear idea what to do.

The referral came to Brigid Jordan. In turn she observed Colin sucking a torn vinyl strip on his pusher and therefore found him a toy which could bc looped onto his

60

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

FREE TO BE PLAYFUL

pusher with a plastic strap. Her thinking, which she explained to the parents and the nurses, was that before he could give up the breast he needed to create symbolic links to the breast and his mother, as the breastfeeding was his only way of relating to his mother. There was an immediate improvement in Colin’s capacity to play and in the mother-infant relationship, and he rapidly made lip much of the physical delay.

We think this is an example of what Bill Blomfield (personal communication) describes as looking at an infant with knowing eyes while knowing absolutely nothing about the infant in front of you - you bring all your experience to bear yet suspend it in order to meet the family afresh.

Conclusion We think that through direct work, by responding thoughtfully to an infant and contributing our own playfulness, we impart on the baby’s representations. Elizabeth Loughlin, Social Worker, put it poetically when she pointed out that the baby caii sense so quickly who is alive and caii use that aliveness to re-create it in herself and reach out to the parents. When the parents see that there can be hope, and can move internally, we think that this, in Cdlllpbe~~ Paul’s words, enshrines the baby as therapist.

What is important is that the therapist’s response is one that comes out of being mindful of the infant and the parents. We think that there is a place for direct work in infant-parent psychotherapy to help the infant’s sense of self and agency as well as helping the parents’ thinking restart. Perhaps in answer to the question we asked, ‘in whose interests would we be acting il‘we continue to wait while hoping for change in the parents’ representations?’, we can reply ‘why would we deny a more immediate relief to the infant when this is also wanted by the parents?’.

REFElUNCES

Cramer, B. (1995) ‘Infant creativity’. Irf‘nt Mrnlal Hralth Journal, 16 ( 1 ) : 21- 27.

Cohen, M. (1995) ‘Premature twins in a neonatal intensive care unit’.Journal of Child Psychothmafi, 2 1 ( 2 ) .

Davis, M. (1999) ‘Mind, body, or self the analysis of a 16-year-old girl with a hysterical psychosis’. Association Jbr Child Psyc~honna1~siJ.s N n u s l ~ / t ~ ~ June 1999. United States of America.

Daws, D. (1999) ‘Parent-infant psychotherapy: reniembering the Oedipus complex’ Psychoanalytic Inquity, 19 ( 2 ) : 267-278.

Ferholt, M. and Provence, S. (1976) ‘Diagnosis and treatment of an infant with psychophysiological vomiting’. l‘rychonndvtic S1udy of lhr Child, 31.

Haag, G. rl ol. (1994) Presentation at Esther Bick Conference, Toulouse, France.

Lieberman, A. and Pawl, J. (1993) ‘Infant-parent psychotherapy.’ In Zeanah, C. (ed.) Hundbook o f h fant Mental IfraBh. London & New York: Giiilford Press.

61

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15

THE INTERNATIONAL IOURNAL OF INFANT OBSERVATION

Norman, J. (1999) ‘To talk with infants - the baby analysand as a starting point for understanding the mother-and-baby-relationship.’ Paper presented at the Discussion panel on ‘Mother and Baby’, IPA Congress on Affect in Theory and Practice, Chile.

Paid, C . and Thomson-Salo, F. (1997) ‘Infant-led innovations in a mother-baby therapy group’. Journal of Child Psychotherufi, 23 (2): 219-244.

Perry, B.D. el (11. (1995) ‘Childhood trauma, the neurobiology of adaptation, and “usedependent” development of the brain: how “states” become “traits”’. Infmt Mrntnl Health Journal, 16 (4): 271-291.

Schore, A. (1994) Aflect Regulation and the origin Erlbaum Associates.

Schore, A. (1996) ‘The experience-dependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology.’ Ilrrtelnpm,end and Psychopathology, 8: 59-87.

Stern, D. (1995) The Molherhood Constellation. New York: Basic Books.

Thomson-Salo, F. and Paul, C . ( 1997) Letter to the Editors.Journalof~/~iM Psychotheraj?,

the SelJ: New Jersey : Lawrence

2s (3): 470-476.

Winnicott, D. W. (1941) ‘The observation of infants in a set situation.’ In CollPctd Puprrs: Through Puediafrirs to Psycho-Analysis. London: Tavistock Publications, 1958.

Winnicott, D.W. (1971) Playing and Reality. London: Tavistock Publications.

62

Dow

nloa

ded

by [

The

Uni

vers

ity O

f M

elbo

urne

Lib

rari

es]

at 2

1:55

13

Nov

embe

r 20

15