What Can the Matter Be?

Therapeutic Interventions with Parents, Infants and Young Children

Elizabeth Bradley, Louise Emanuel

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429923791
• Subtopic: Developmental Psychology
• Index: Psychology

This book describes the particular approach to clinical work with under fives that has been developed at the Tavistock Clinic. It sets out new approaches in the understanding and treatment of psychological disturbance in children, adolescents, and adults, both as individual and in families.

Introduction

The Under Fives Service

The Under Fives Service was set up in recognition of the importance of prompt early intervention for families with babies and small children. The multidisciplinary team consists of a consultant child psychiatrist, child psychotherapists, family therapists, child psychologists, and a couple therapist. It offers quick-response psychoanalytically based interventions to families, carries no waiting list, and offers up to five sessions of focused work, which can be extended as required. The underlying approach requires the clinician to maintain a thoughtful and observant attentiveness when seeing families, without a set structure for interventions. This framework, combined with a flexibility of approach, may allow for a range of decisions to be made about frequency, duration, and the appropriate type of intervention, based on clinical judgement. This may also include some form of practical advice.

In addition to work undertaken in the clinic, the Under Fives team offers a service to families who are more difficult to reach, seeing them in outreach community settings. Group work and parenting skills courses are also offered both within the Clinic and in the community. A specialist perinatal project, focusing on pregnancy and the early weeks, offers support to families who have had fertility problems, miscarriage, premature babies, or a bereavement. Consultation to staff of nurseries and other day-care provision for infants and pre-schoolage children is also offered as part of the service, including telephone consultations. There is also involvement in consultation on policy issues—for example, what contributes good nursery care arrangements, and the separation of mothers from their babies in the prison population.

Referrals fall into three categories: babies under 18 months, toddlers, and children from the age of 3 to 5 years. Common problems in the first year are feeding, weaning, and sleeping difficulties, excessive crying, and “failure to thrive”. Later on separation anxiety, hyperactivity, aggressive behaviour, and temper tantrums are more common. Phobias and nightmares, sibling rivalry, as well as concerns about developmental delay or obsessional behaviours are common referrals. Psychosomatic symptoms—such as eczema, asthma, incontinence, and encopresis—lead to referral once medical investigations have ruled out physical problems. In the main the underlying issues tend to point to difficulties within the parent/infant/child relationship and within the parent/couple relationship. Sometimes separation difficulties or problems around attachment and bonding lie at the heart of the problem, both for parents and for child. In many cases, the parents bring to the parenting situation their own experience as a child and may repeat a cycle of neglect or abuse with their own children.

The brief five-session structure often brings into focus the key issues within a family. For example, in cases of babies with eating difficulties, the sense of urgency transmitted to the therapist may lead her to address the pressure placed on everyone by the five-session model. The need to “get something into” the parents quickly and resolve the situation may, paradoxically, contrast with their often limited capacity to “take in” a lot of what is offered. This may reflect their baby’s eating patterns—a very little at a time—and may indicate the need for longer-term work.

In many less urgent situations, the request for instant solutions and strategies is a constant one. Helping parents to recognize that we are not averse to giving advice but resist substituting thoughtfulness with action—we need to get to know and understand how the family functions first—is an important aspect of the work.

Some families may use the service for repeated brief consultations at points of difficulty, often at a new developmental milestone, relating to weaning, separation, and loss. This form of “serial” consultation (Stern, 1995) can be a valid way of using the service, although a question might remain about whether some underlying difficulty is being missed and brought back time and again for further work.

Audit and evaluation exercises over the years have indicated positive outcomes for the five-session model. However, the service has expanded to include longer-term work, reflecting the increasing complexity and greater levels of disturbance of referred cases, requiring multi-agency liaison. There are occasions when an initial piece of brief work may bring about change but may also function as an assessment for long-term work for one or more members of the family, including individual, group, or parent/couple work. It is often hard to ascertain from the initial referral the level of severity of the problem and the nature of the intervention that may be required.

Theoretical framework

The psychodynamic framework presupposes an awareness (for which we are indebted to Freud, Klein, and many others) of the power of unconscious processes, and the way in which they can be expressed through nonverbal and verbal communications in the consulting room. Such awareness involves an understanding of, for example, the concepts of unconscious phantasy, splitting and projection, projective identification, and transference and countertransference phenomena (see the Glossary). Also at the heart of the framework is the application of observational skills to clinical work with families with young children (Miller, 1992; Miller, Rustin, Rustin, & Shuttleworth, 1989; Reid, 1997; Sternberg, 2005; Waddell, 2006; see also all issues of the International Journal of Infant Observation and Its Applications). An understanding of attachment theory, child development, and neurosciences research offers multiple perspectives to the work, and ideas stemming from systemic family therapy may also contribute to clinical practice with under fives.

Of central importance is Bion’s concept of container/contained (1962a, 1962b) and his notion of “maternal reverie”. He recognized that the baby’s psyche is not developed enough to contain powerful feelings of any kind. Using the digestive system as a metaphor for the processing of emotion, Bion described how the infant requires an attentive carer, who is able to “take in” and think about his unbearable feelings of distress without becoming overwhelmed by anxiety. When the carer has made sense of the infant’s communications in her own mind, she is then able to respond appropriately to the infant and tend to his needs. This process of “containment” is achieved when the parent is able, in a state of “reverie”, to attend closely to the infant and to “digest” what the baby has put into her—the contained.

Gradually, the infant learns, through repeated experience of a thoughtful parent, how to make sense of his own experiences, to think for himself. This shift—from evacuation of overwhelming sensory data to a capacity to investigate his own feelings—is vital for a baby’s emotional and cognitive development. It is the beginning of his development of “symbol formation”—the ability to internalize a picture of helpful parents to whom he can turn in his mind in times of distress.

Excessively long periods of inattention or inconsistent unpredictable responses by the main caregiver may result in the infant unconsciously developing defensive forms of behaviour as a means of coping with this lack of containment. He may find ways of “holding himself together” through excessive muscular development, sensory stimulation, or kinetic activity, creating his own “second-skin containment” (Bick, 1968). By turning away from the carer and becoming prematurely self-sufficient, he may develop a version of Winnicott’s “false self” (1960). In attachment theory terms (Ainsworth, Blehar, Waters, & Wall, 1978), the child would manifest insecure or disorganized attachment patterns, which can often be observed in the clinical setting. At times, despite adequate attentiveness and attempts to contain the infant, his overwhelming states may be too much for the carer to process. This mismatch in the early parent–infant relationship may, therefore, be linked not only to the quality of parental care, but also to the infant’s temperament and responsiveness to the caregiver.

Much of the understanding of young children’s behaviour and communications, as well as that of their parents, is based on a recognition that these unconscious infantile defence mechanisms may be resorted to at times of stress or anxiety throughout their development. Symptoms such as sleep problems, tantrums, crying, biting, or hair pulling may originate in very early experiences in infancy, relating to the lack of an adequate container for the infant’s internal and external experiences that might become intensely persecutory.

The experience of a reliable adult thinking about a child’s feelings, struggling to make sense of and to understand them as a meaningful communication, enables him to gradually take into himself or internalize a model of thoughtfulness, attention, and curiosity. This, in turn, can help the child to be able to “say” what he is feeling and experiencing, as well as to play out “symbolically” his anxieties and preoccupations and can facilitate his emotional, cognitive, and social development.

When a young child projects his emotional states into his parents or carers, they may become filled up with the child’s feelings, making it difficult for them to think clearly. By “giving” his carers an experience of his emotional discomfort at first hand, via the mechanism of “projective identification”, a child conveys his states of mind nonverbally to those who are most likely to be receptive to his communications. The carer will hopefully identify with the child’s emotional predicament and, reflecting on it, understand the nature of his experience. Thus, the mechanism of projective identification can be used as a means of communicating emotional experience in a nonverbal yet powerful way. A clinician may make use of these unconscious projections (via the mechanism of projective identification) to consider their impact on her own emotional state, a helpful gauge of her clients’ state of mind.

Just as we recognize the “infant” in the child, we can notice the “child” in the adult, observing infantile feelings of rivalry, exclusion, envy, and anxiety relating to “not knowing” or feeling “small”. This is especially pertinent as parents often feel a failure by coming to the clinic in the first place, and they may be confirmed in this by their own parents’ views. The transgenerational transmission of failures in emotional containment may lead parents themselves to develop infantile defences, passing on these methods of coping to the child. Young children are at risk of becoming the “receptacles” (Williams, 1997) of their parents’ unprocessed projections. This can lead to disruptive behaviour as they attempt to discharge this burden through whatever means available to them. The tension between acknowledging infantile states of mind in parents whilst simultaneously supporting their capacity to function as adults is a recognizable feature of the work.

In addition to a psychodynamic framework, an awareness of neurosciences research can be of particular importance when working with children traumatized in infancy who are hyper-reactive and are prone to apparently unprovoked outbursts of aggression. An understanding of the autonomic conditioned fear response (Emanuel, 2004) offers us a framework for thinking about the bodily processes involved in infants’ responses to trauma, a heightened awareness of the body as the “theatre” for the emotions (Damasio, 1999). The trauma of chronic abuse and violence resulting in hyper-vigilance and an overactive bodily response to fear, triggered in the brain, can be recognized in the consulting room, and an explanation involving this understanding can offer relief to parents or carers who may be bewildered by their young child’s behaviour. This research confirms the importance of emotional containment for the infant’s social and cognitive development.

Intervention process

Access and acceptability have always been important features of the service. The aim remains to respond to referrals quickly, often by telephone, to arrange a mutually convenient appointment. Meetings are arranged on a regular basis, initially weekly or fortnightly, but the frequency may vary after the initial meetings, with longer intervals if this is felt to be the best option. In brief work the structure and the setting are important and need to provide a safe environment for both the therapist and the family.

In approaching the session the therapist has in mind the theoretical framework, a receptivity to observing all details of the way the family present themselves, and an awareness of the emotional impact of the family on her. The attitude is one of openness to exploration of all communications from parents, infants, and child, until a “selected fact” (Bion, 1962b) and focus for the work emerges. The therapist will attempt to make contact with the infant or child, observing his play and attempting to understand the meaning of his communications, while also engaging the parent. The way in which young children dramatically enact their predicament and that of the family through their play, their drawing, and their interactions with family members contributes to the “speed and spectacular nature of the therapeutic effect” (Watillon, 1993) in this work and enables a “slow unfolding” of the material within a brief time frame (see chapter 5). This is likely to include a gradual exploration of the parental background and its implications for the family. Detailed discussion about the daily routine of the family (Daws, 1989) can offer a valuable “port of entry” to understanding the nature of the difficulties and their impact on the family.

Although the therapist may be acutely aware of transference manifestations in the room, she is sparing in addressing this, unless drawing attention to it is likely to facilitate the development of a therapeutic alliance with the parents. A flexibility of approach, taking into account the unique needs of each family referred, seems to be important. This is possible when the therapist has an internal theoretical framework on which to draw, enabling her to provide a containing structure to the interventions.

Nearly all of the work of the Under Fives Service is done in the presence of one or both parents or carers, together with the child, and, on occasions, the parents on their own. Often the focus is on helping the parents to gain the insight and strength to function together as a benign parental couple, despite sometimes conscious or unconscious attempts by the child to split the couple. In other cases, work may centre on helping a single parent understand her child’s need for her to exercise both paternal and maternal functions: to maintain in her mind, and to cultivate in the child’s mind, the notion of a well-functioning parental couple. The role of the father and an ability to keep him in mind, whether absent or available to attend the clinic, is increasingly seen as essential to the therapeutic process (Barrows, 1999b; Emanuel, 2002b; Von Klitzing, Simoni, & Burgin, 1999).

Clinicians often offer a model of family work alternating with separate parent meetings. The latter enable parents to consider parenting/couple issues separately with the therapist, in parallel with family meetings in which they can observe, together with the therapist, how young children’s play and behaviour communicate their emotional preoccupations and often those of the family.

Therapists may work on their own or with a co-worker, depending on the nature of the referral. Co-workers ensure that there is a built-in opportunity to discuss the impact of the family’s projections on the therapists and how they are perceived in the transference. There may be requests to join other professionals in the network when there are concerns about parenting capacity, with a view to assessing whether an intervention from the Under Fives Service could help support parental functioning. Health visitors, who offer an invaluable service to parents with young children, make use of our services for referral and consultation purposes and, if practical, may accompany referred families to a first meeting.

Families who only want advice and instruction are unlikely to benefit from the service, which does require some interest in thinking about or exploration around the problem rather than a direct problemsolving approach. Medication is rarely prescribed for children and only very occasionally considered to be helpful for a parent, and this would then be discussed with the parent and the GP.

Finding explanations for children’s difficulties in early life is a challenge. Growing up involves developmental steps that can seem insurmountable at the time and may require careful understanding and help from the wider family or professionals. In the first years of life these steps come in rapid succession. Trying to work out “What the matter can be” is a joint project that the family and clinicians undertake together to come to a shared understanding of the underlying problem. There will always be further developmental tasks ahead, but each one accomplished gives more confidence and hope for the future.

Part I
Theory and Practice

Early developments

This section contains versions of three previously published papers written respectively by Isca Wittenberg, Lisa Miller, and Juliet Hopkins, who participated in the establishment and growth of the Under Fives Service and corresponding workshop. These chapters give a historical perspective on the developing influences and underlying theoretical framework informing the authors’ work with under fives, touching on major themes running through this book. They are “classic” in the sense that the authors illustrate clearly the underlying psychoanalytic framework gained through their training as child psychotherapists, while adapting this to the requirements of mainly brief interventions with parents and families.

The debt to Melanie Klein and her description of an infant’s primitive states of persecutory anxiety and “terror of annihilation”, later described by Bion as “nameless dread”, is evident in the way in which the authors capture the essence of a baby’s early experience, his states of persecutory anxiety and moments of fragmentation. The concepts of “containment” (Bion, 1962b), “holding” (Winnicott, 1963), and “second-skin containment” (Bick, 1968) underpin the clinical work. The capacity to reflect, to think rather than to act, to maintain an attentive presence in the face of overwhelming projections, is central to this work.

These early chapters focus on the younger end of the “under-fives spectrum”, with Isca Wittenberg describing work with parents of young babies, and Lisa Miller and Juliet Hopkins including clinical examples of babies and toddlers Perhaps this is not a coincidence, as so much of what follows in later sections and work with “rising fives” is rooted in early parent–infant interactions. Some themes when working with parents of young children seem to be universal, and many of us will have had an experience, as Isca Wittenberg puts it, of a mother exclaiming incredulously: “Do you really think that babies think?”! Differences in technique and emphasis in the work depending on the age of the child—infant, toddler, or “rising 5”—are explored in the latter half of the book.

Isca Wittenberg elaborates her technique of working psychoanalytically with parents of babies, within a brief time frame. Her suggestion that “we can best help the baby by the help we offer to the infantile aspects of mother and father” is convincingly supported by the case examples, although she also cautions against transference interpretations that only take account of infantile aspects of the parents at the expense of their adult capacities.

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Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• SERIES EDITOR'S PREFACE
• ABOUT THE EDITORS AND CONTRIBUTORS
• ACKNOWLEDGEMENTS
• FOREWORD
• PREFACE
• Introduction
• GLOSSARY
• REFERENCES
• INDEX