The Baby as Subject

Frances Thomson-Salo, Paul Campbell, Frances Thomson-Salo, Paul Campbell

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367101473
• eBook ISBN:
  9780429920172
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

This book is a collection of papers by clinicians united in their conviction about the importance of directly engaging and interacting with the baby in the presence of the parents whenever possible. This approach, which draws on the work of Winnicott, Trevarthen and Stern, honours the baby as subject. It re-presents the baby to the parents who may in that way see a new child, in turn shaping the infant's implicit memories and reflective thinking. Recent neurobiological, attachment and developmental psychology models inform the work. The book describes the underpinning theoretical principles and the settings and forms of direct clinical practice, ranging from work with acutely ill babies, to more everyday interventions in crying, feeding and sleeping difficulties, as well as infant-parent psychotherapy. Clinicians at The Royal Children's Hospital Melbourne from the disciplines of psychiatry, psychoanalysis, psychology, nursing, speech pathology, child psychotherapy, paediatrics, and music therapy describe their work with ill and suffering babies and their families.

CHAPTER ONE


What I am trying to do when I see an infant with his or her parents

Ann Morgan

Reginald Lourie’s message at the 1978 International Association for Child and Adolescent Psychiatrists and Allied Professions conference (IACAPAP) in Melbourne was that “you need to go upstream”. Yet to experience the infant as subject may open up unbearable situations. What do we mean by intentional relating to the infant as a subject? What I think we are struggling to do when we are involved with babies and families is to keep the baby in mind, and if we take time and effort to get to know and relate to the baby in the presence of the parents, we are making a definitive statement. We are saying that the baby is a crucial member of what we are trying to do—that the baby participates in his or her own right in the session and that this active involvement of the baby, which really may be quite difficult not only to initiate but also to sustain, can make a difference to the way in which we all think about the problem in hand.

The baby does make a difference to all experiences and relationships within the family, the baby changes things because essentially now the family has changed from one, to two, to three. One of the things this can offer to each member is that they can be the observer, they can observe the other with the baby, and this is true not only for the mother and the father but also for the baby. It gives a time when the baby can reflect on being the observer and you can see this in working with infants as young as three to four months. When one is engaged in talking to the baby, the baby can look intently at the therapist and then look at the mother, look back at the therapist and there is some work being done by the baby. One feels that the baby is really interested in how the therapist and the mother and the father are alike, but are also different. That difference, and the capacity to be aware of that for all of them, can offer them a gap, a gap in which they can allow something to emerge, and what can emerge may be a thought, an opportunity to feel that there are other ways of being.

Wherever therapeutic work with a baby and parent is done, how do we conceptualise the work? There is a constant movement between who is in the foreground and who is in the background. I think that if one privileges the baby by seeing the baby as participating in this then we can allow others to take the foreground, so that we can allow the mother to come forward and her narrative to be heard while at the same time still acknowledging and connecting to the baby, so that there is the possibility of offering to the family a suggestion that each member is of equal significance, that each member must be heard, each member must be kept in mind while the other narrative is being spoken. Why I am emphasising that the baby is part of the narrative is because it really is extremely difficult not to listen to the spoken word and our contact with the baby is often unspoken, although that is not altogether the whole story because when one contacts the baby, although a lot may be given through the gaze and the physical contact, nevertheless we all speak to the baby so that there is some talking and the baby knows this. The baby listens, the baby looks, the baby connects to the voice, the baby connects to the expression on our faces which change with each word that we speak. That is the element of the baby’s narrative and what we are suggesting is the importance of including all the narratives.

In using our professional knowledge it is constant that we come to the baby with our preconceptions of the work that we do and the knowledge that we have. We know a great deal about parents, we know a great deal about babies, yet how important it is to understand that we know nothing about this baby, we know nothing about this mother and this father, but we give them our full awareness, our thinking, our knowledge, so that somehow something new can emerge for all of us who are involved in the work, for the baby, the mother, the father and for the therapist. Furthermore, it is that I think, which makes the work the challenge that it is, but also what is so rewarding, because it can be so creative.

The three things that I think are essential are that the environment must be safe, reliable, and truthful. This is what I am trying to do when I see infants and their parents.

Safety

One of the most significant things that parents do is to protect the child. We are all very aware of protecting the child from external influences. One element of what I am trying to achieve is help the child feel that her internal world is safe, and real protection for the child is to be able to feel that. We can help defend the triangle (the father, mother, and baby) to feel in touch with what the infant is trying to do so that the mother is more able to protect the infant’s emerging thinking, imagination, and sense of self. What it means that an environment is safe is that the infant can experience violent, strong feelings but there is no retaliation—the adult sees behind what that experience might mean to the infant. The infant’s facing the reality of her own experience can only be done in a safe environment because if we do not understand what is happening in their mind that can make it unsafe.

I was seeing a nine-month-old boy and his mother who had been severely depressed but the difficulty in the relationship between them had been missed by the mental health professionals looking after her. He needed to be constantly at the breast as if he was desperate to get it, which she said was extremely uncomfortable. When he crawled, he clasped a toy car in each hand as well as something in his mouth as if to feel complete and wipe out a desperate injury or absence. I had been gently exploring my relationship with him over some weeks and he had made good gains. I was sitting quietly and he came up to my chair; I smiled and talked to him and as he was trying to stand I put my arm around him without touching him. His mother said something that took my attention and at the moment I turned to her he fell like a tree with a bang. Then he was frantic, rushed to his mother, did not look at her face but went straight to the breast, pulling at her clothes and sighed with relief as his mouth went around the nipple. It was an extreme panic in him that he had fallen and “come to bits” and the only thing to put him together was to have the nipple in his mouth. I was quite shocked, wondering if my turning away had led to an acute feeling of his being on his own. Despite having begun to lock himself into a paralysing state, he was able to use the intervention and did well socially and cognitively.

Making a safe place for a baby is very important and needs active thinking and work to make it so.

Reliability

Secondly, in protecting the child’s inner world, it provides somewhere for the child to have a sense of going on being, through our relationship with the child, especially if it is over time. The sense of remembering is a continuous thread. We share the experiences, and there is the sense of continuity and going on being within the baby. Protecting the baby so that he feels that his internal world is safe is related to the sense of going on being. These are important ideas when there are problems because we can get drawn in by pressure from the parents and forget to allow the child a sense of space. We are not there for the referral problem—we are there for the space, and for helping the child feel that his internal world is safe, and for the sense of going-on-being and to help if they do not feel attached. I do tend with the baby, to do some things over and over so that the baby knows what is happening. While I am doing things with the baby, I am asking the mother to think about what is going on for the baby. Mothers are often preoccupied with how they are as mothers, and I try to help them see the baby by helping them see what goes on for the baby with me. Many professionals prescribe advice, others educate. Sometimes I do translate, for example, saying, “She doesn’t understand, she wants to look at you, she’s wondering who I am because I’m not you but something like you.”

I had seen Bea with her mother since she was six months old and thought that her mother had been unavailable throughout Bea’s life as she was extremely fragmented psychologically, and could not give her a sense of protecting her inner world. She did not speak to her baby in case she used the wrong words, and Bea did not speak for a long time. In sessions, Bea wanted a sense of history. When I sometimes changed what I did, she indicated how we did it, saying in effect that I was to be in her internal world. When there was a break she wanted the games we had played early on, and hide-and-seek. As Bea’s mother doubted her own judgement, she felt that she had to “know” in all that she did for her baby. She only wanted help with the kind of little girl that Bea was to be. She would say, “I know she’s happy”, whereas I tried to go behind and allow Bea space. For example, when Bea’s mother thought Bea was hungry, she persisted in trying to feed her when she would not take it. As the parents and I talked, Bea’s mother forgot about feeding her, relaxed and became enlivened, and Bea ate the food. She felt that as a good mother she was there to see that her baby ate and this became a concrete task. To think about and play with her infant felt as if she was abrogating her duty as a mother. The baby was overwhelmed by a sense of uncertainty, a difficulty in letting go and a difficulty taking in—all aspects of an unheld and powerful anxiety. Bea felt tension and her eyes were huge and over-alert, she would laugh but something was not right. I had never seen Bea take in anything with pleasure. With a very ill mother, the baby is lost and has a profound experience of catastrophe. If the baby thinks that he or she will die and the mother thinks so too, the baby is in great distress, exacerbated if there is an awareness of the parent’s rage or anxiety. Bea’s mother was devastated, thinking that her baby would die, and I was caught by the fear of Bea failing to thrive. As long as I thought that, we did not get anywhere; once I was over my anxiety things got better.

I am concerned that we take seriously what will happen later and often we do not. In it lie the roots of future mental disturbance. We should change how we work. Instead we see the referral problem as something that happens now, which we want to relieve now, and if there is a biological aspect we get hooked in to not look at other aspects. Our aim is to protect the child from that—to get across to the child something different—and it is about the child, something we can help with about the child’s own experience and not only just through the parent.

Truthfulness

The last thing I think is important is truthfulness. Truthfulness is based on respect, being aware of one’s own thinking, being aware of the baby’s thinking and working towards understanding it, however young the baby. A relationship has to be truthful, because truthfulness is what gets through to the baby, not the words. That is an important point, when you are telling people how to be with babies—they have got to allow themselves to feel and to be with the baby. It puts a different meaning to the words that you say if you have that truthfulness and are truthful in your response—it matters to validate the baby, and I learnt this from being with babies: it is not the verbal response but the truthfulness of it, which underpins all interpretations and countertransference.

A three-month-old baby who came with her mother always played the same game with me each week, the same routine in our relationship, and I felt that she knew me. She would look at her mother and me and see that we were alike but also very different. After about fifteen minutes the baby would give the signal to be put to the breast to feed. On one occasion, her mother was very upset and could not wait to pour out her distress, anger, and fear. The baby gave the signal and without looking at the baby, her mother picked her up and put her on the breast and the baby bit her hard. When I said, “I wonder what she’s telling you”, her mother immediately understood and apologised to the baby. She settled her and the baby went back to the breast and to my amazement, turned round, looked at me and smiled and went back to the breast. The point of the work was to help the mother and the baby be in a threesome. Having the baby lit up enormous rage in the mother to the father, which she knew was irrational but could not stop. It was the importance of the third, and the baby really experienced that, and experienced her relationship to me, to the other, and there was a place and a time for all three of us.

I think the key to where work with the baby as subject is different to other ways of working, is that elsewhere the doctor can say the baby is fine because the baby does not have an illness, but the baby may be suffering which is not recognised in this culture. I think that time and time again we should reiterate that because it is often missed as there is not an awareness of what the baby and the parents are suffering, because it is not diagnosable. This is the awareness that the therapist holds about the experience that is so often missed when the doctor says, “This baby won’t die, is not seriously ill”, and while that is an important message, the real message is that there is something that has not been understood which is the suffering and if the baby is suffering the adult is suffering.

CHAPTER TWO


Engaging with the baby as a person: early intervention with parents and infants

Frances Thomson-Salo

This chapter outlines The Royal Children’s Hospital, Melbourne (RCH) approach to therapeutic interventions with parents and their baby. After describing some capacities that an infant brings to therapy, the underlying theoretical framework is outlined. Containing powerful, often distressing feelings, which become known in the countertransference through projective identification is often extremely therapeutic in the short-term, as is engaging with the infant in the parents’ presence, with psychological holding, communicating with them as a person in their own right and pleasurable playfulness in the infanttherapist interaction. With infants in vulnerable families, increasing the parents’ capacity to think reflectively about their infant’s mind is significantly therapeutic. Worldwide an increasing number of interventions with infants and parents, individual and group, short and long-term, psychodynamic and behavioural, are reported to be effective and the task ahead is to become clearer about the mechanisms for change. Here I shall focus on short-term infant–parent psychotherapy. Sometimes because of time pressures this may be no more than a relational encounter informed by psychoanalytic thinking (such as containment of feelings and thoughts at a time when unconscious meanings, conflictual or early implicit ones, distort a parent’s’ relationship with their baby), and while there are cultural differences in views about infants, ideas about the importance of sensitive parenting and attachment seem universally applicable.

The baby as “subject”

Respecting “the baby as subject” entitled to an intervention in her own right is an approach which informs the work at the hospital, where the paediatricians have for about twenty-five years referred babies with emotional and psychological difficulties to the infant mental health therapists. This follows Winnicott’s (1941/1958) way of working in his paper on the spatula game. The central therapeutic mechanism is thought to lie in trying to understand the infant’s experience from the infant’s point of view, and conveying to parents and the infant that the infant has a mind of their own, with their own understanding of their experience. This intervention usually takes place in the presence of the parents, who generally welcome this, and it aims to increase reflectiveness in them and in their infant, that is, the capacity to be reflective in a thoughtful and open way to emotional communication from others and from oneself. Responding to the baby as a person shifts the view of the baby as an object towards seeing the baby as intentional and seeking to be in a relationship. Many infants can modify interaction and behaviour in a single session with an infant mental health therapist.

We generally do not find that parents resent therapists engaging with their infant. They usually describe it as helpful that the therapist responds to their infant as more intentional than they had done. If they indicate that they feel the therapist has taken over from them as someone who could parent or play with their infant better than they could, this can usually be verbalised and worked with. Therapists try to be aware of possible resentment and jealousy in parents and to protect the parents’ dignity and self-esteem. (When this approach was previously described as direct work with the infant in the parent’s presence rather than as one of engaging with the infant in the parent’s presence, this may have contributed to the view that the parents were not addressed, and that there was less emphasis on verbal interpretation and more on handling the infant and providing developmental help (Dugmore, 2011)).

There are a number of capacities that we think a baby brings to therapy (Thomson-Salo & Paul, 2008), including the wish to know and be known in a truthful experience. In the presence of a therapist who is trying to understand their experience, infants sense this and it usually brings containment and relief. They may look at the therapist so attentively that they seem to have an awareness that an emotionally meaningful encounter is taking place, gazing at the therapist to find out if they are available for interaction. An infant may lock on with their eyes as a seven-month-old boy did for for...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• About the Editors and Contributors
• Introduction
• Chapter One What I am trying to do when I see an infant with his or her parents
• Chapter Two Engaging with the baby as a person: early intervention with parents and infants
• Part I: Interventions in Acute Health Settings
• Part II: Interventions in Crying, Feeding, and Settling Difficulties
• Part III: Infant–Parent Therapy
• Part IV: Interventions with Infants with Problems of Relating
• Part V: Interventions with Infants Exposed to Family Violence
• Part VI: Reference Papers
• Epilogue The spare room: a father confronts his fatherhood
• Index