Continuing Trends

Journal of Infant, Child, and Adolescent Psychotherapy, 2.3

Kirkland C. Vaughns

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9781138416604
• eBook ISBN: 9781317706908
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This new issue of JICAP features some of the most engaging material yet on the subject of treating depressed mothers and their small children. It opens with "Video Feedback with a Depressed Mother and Her Infant," the presentation of an unusual collaborative individual psychoanalytic treatment written by Phyllis Cohen and Beatrice Beebe that is one of the most unique studies on the subject to date. This brilliant introductory article is followed up by a well-executed analysis of the treatment from Phyllis Ackman and a smart commentary by Anni Bergman.

The issue continues with a thorough examination of the changing role that play instruments have in child psychotherapy over the course of the analysis in a strong article co-written by Saralea Chazan and Jonathan Wolf. The active aspects of object relations are discussed next by Marcia Kaufman, followed by a special look at the influence of culture on therapy in Carmen Vazquez and Lorna Myers' piece "The Case of Alicia: Understanding Selective Mutism and Alopecia within a Cultural Framework." The issue continues with Debbie Hindle's take on the vagaries of self-help with "I'm Not Smiling, I'm Frowning Upside Down" and closes with Kate Henderson's account of a session with a group of latency children.

VIDEO FEEDBACK WITH A DEPRESSED MOTHER AND HER INFANT: A COLLABORATIVE INDIVIDUAL PSYCHOANALYTIC AND MOTHER-INFANT TREATMENT

Phyllis Cohen, Ph.D., and Beatrice Beebe, Ph.D.

We present a model of collaboration between two analysts, one (Phyllis Cohen) in the role of primary therapist of a severely depressed young woman, and the other (Beatrice Beebe) in the role of consultant for a concurrent mother-infant treatment. The psychoanalytically informed treatment of Linda, mother of a 3-year-old and an infant, was conducted on a three-times weekly basis. We report on the treatment during the infant’s first three years of life, during which time seven videotaped feedback intervention sessions with Dr. Beebe occurred. These sessions were used as an adjunct to the mother’s individual therapy with Dr. Cohen.

THE BEGINNING OF LINDA’S TREATMENT

Linda was referred to me (Phyllis Cohen) one month after the birth of her second son, Dan. She was feeling severely “depressed, nervous, scared, dizzy, and lightheaded.” These feelings had begun toward the end of her pregnancy, which was medically normal. She was afraid she had a brain tumor that would not be detected. She did not want to get out of bed. On the day that her sister first contacted me, Linda had called her older sister, weakly crying, “Please help me. I can’t go on any more. Please help me end it all.” Although her husband had been generally supportive of her, recently he had become impatient.

The sister brought Linda to her first session. Linda was in a very regressed state. She needed assistance to walk. She was lethargic and despondent, but she was able to ask, “Can you help me?” In lieu of hospitalization, the sister, Linda, and I together decided to try three-times-per-week individual therapy sessions. A psychiatric consultation yielded diagnoses of panic disorder and severe postpartum depression. Zoloft, Xanax, and Valium were prescribed. An M.R.I. ruled out any physical causes.

Linda began her sessions explaining that she was the youngest of four children. She had been very close to her mother, who had died of colon cancer six years earlier, three years prior to the birth of her first child. I later learned that the day Linda called her sister saying she could not go on had been the anniversary of her mother’s death. Linda explained that she was afraid she had a terminal illness, and she did not trust the medical profession that had failed to cure her mother. She had recently been clashing with her mother-in-law, whom she experienced as intrusive and controlling. She was anticipating a major loss because her older sister planned to move her family sixty miles away. She held onto the fantasy that if she were sick, weak, and incapacitated enough, her older sister would not abandon her the way her mother had. Linda described holding onto her 3-year-old son’s security blanket: “I smell his blanket to comfort myself. But he comes over and pulls it away, and I feel stabbed.” She lamented, “How could I have a baby without my mother here? I want to be the baby. I feel cheated.”

Although her husband worked long hours, several sessions were held together with him, in an effort to help him understand what Linda was going through, and the importance of her treatment. I tried to help him support her capacity for, and interest in, being a mother to her baby and her 3-year-old. It was also important for him to ensure that enough help was in place to keep the family afloat. A full-time baby nurse took care of Dan, which was facilitated by the fact that Linda was not nursing him. A nanny took care of her three-year-old son. Yet she felt there was no one to take care of her.

THE INTRODUCTION OF DAN AT 4½ MONTHS

Not until the second month of her therapy did Linda begin to talk about Dan. In retrospect, she had been preoccupied with her own survival, and I (PC) had also been so involved in her survival that I had failed to ask, “How is your baby?” It was her pediatrician who jolted Linda into a greater awareness of Dan. At a well-baby visit when Dan was 4½ months, the pediatrician noticed that the baby was delayed, not smiling, “inside himself.” When Linda told me about the pediatrician’s concern, for the first time she offered her own concerns: “Dan doesn’t smile without lifting him up in the air and jiggling him, and I’m not strong enough to keep lifting him.”

That very week, I recommended that Linda bring Dan into the next session. I suggested that we videotape the session, and she agreed. She did not “set the stage” to orient the baby toward her; instead, she placed the baby on her lap, oriented away from her. She strained her neck around as she attempted to speak to him. Her repertoire of play was quite limited. Only when she repeatedly lifted him up and down would Dan smile, but she kept saying, “You’re so heavy. I can’t do this.” Then she patted his hands, touched his face, and smelled him while speaking to him in a singsong voice. She explained to me, “He lets me do these things, but he shows no reaction. I guess he has a serious nature.”

Linda then complained, “Dan doesn’t even play with toys; he’s not interested in anything. Other kids his age smile all the time, but not him.” I tried to test out Linda’s statement that her baby was “unable to do anything.” I held a candy dish within Dan’s reach. Dan reached for the candy and then dropped the pieces on the floor. I said to him, “You can do something. You can reach for the candy if you want to.” Linda responded, “You think he wants to? I think he’s just flailing his arms by accident.”

In another attempt to assess the baby’s capacity, I asked Linda if I could play with him. I held him on my lap, face-to-face. I began to talk to him, but only when he looked at me. He, in turn, focused longer and longer. When my voice rose, he became more animated, and we moved higher and higher together, until Dan and I were both smiling and giggling. Through this interaction, I determined that this baby was capable of positive engagement.

Linda was watching our interaction, and she was giggling on the couch next to me, like a baby herself. She did this until she became self-conscious and said, “He never did that with me. He’ll never laugh with me, even if I stand on my head.” I joined her in her feeling that it was so painful to see that Dan laughed with me while he would never laugh with her. I told her that she needs to remember that the stranger, as a new person, usually has an advantage over the mother in interesting a baby at this age. We also discussed how painful it is to let someone else play with your baby, and how natural it is, but how painful, to feel inadequate.

I asked her if she’d like to try to do what I did. For the first time, as I coached her to wait for his cues, Dan responded to her by looking and cooing briefly. Her expectation of rejection seemed to be so strong, and she had been so sure that this could never happen, that as he was responding to her, Linda said, “He just wants to show me up to be a liar.” This assumption of negative intent was a salient aspect of her view of Dan.

At another moment when Dan became fussy, Linda offered him a pacifier. When he took the pacifier out of his mouth, she said she was thinking of cutting off the handle because … he uses it too much to pull it out of his mouth.” She did not understand her infant’s need to be able to regulate his own arousal by putting the pacifier in and out of his own mouth by himself.

In the session following this first joint one, Linda was different. Unlike all her previous sessions, she had little to talk about. I wondered to myself if she might be feeling embarrassed about having exposed herself with her baby to me. I worried that she might be feeling jealous of my interaction with Dan. I felt it was important not to push her to speak about the session with Dan until she was ready. Instead, I needed to be sensitive to her feelings of depression and vulnerability. We spoke about Linda feeling incompetent in many areas of her life, and then she expressed anger at Dan for making her feel so inadequate. I raised with her the possibility that she might be feeling angry with me as well, since it was so painful to see Dan laugh with me when she could not get this response from him. Linda said, “No, you were trying to teach me.” She could not bear to experience any negative feelings toward me at this point in the treatment.

Her depression was so strong at times that she completely relied on her household help to care for her children. She alternated between feeling anxious and totally hopeless. In sessions she often cried about her feelings of abandonment. She felt that no one was there for her, and that her husband, her mother-in-law, and her sister were all critical of her.

We did not focus on her baby again until a few weeks later, when Linda told me she was absolutely convinced that there was something wrong with Dan. She said, “He’s not doing anything. He’s not trying to get anywhere. He doesn’t seem sharp or with it. It feels like he’s somewhere else.” When asked to describe more of what had been going on, she responded, “I’m trying not to be critical. But I think it’s all in the name. He’s named after my father, and he’s serious, just like him.” She added, “My other child was perfect at that age, but Dan has turned into a big fat blob, and I’m not cut out to be his mother. I’m just not strong enough.” I asked her to bring Dan into my office for another joint session that we would videotape. Once again, I attempted to interact with Dan. Unlike the previous session, on this day he was totally uninterested in me. Although it was possible that his bad cold had played a role, at this point I began to be seriously worried about Dan. I told Linda that I knew someone who would be able to help us. With her permission, I asked Dr. Beebe, a psychoanalyst and infant researcher, to see the mother and baby together. I told her that I would come with her to the session with Dr. Beebe. I reassured her that our consulting with Dr. Beebe would not in any way replace our own relationship.

In order to more fully evaluate Dan, an early intervention evaluation was recommended by the pediatrician, and a neurological evaluation was recommended by both the early intervention services and Dr. Beebe. Interestingly, neither of these evaluations emphasized the social difficulty, nor was mother-infant treatment recommended. Instead, both the Early Intervention Services and the neurological evaluations recommended intervention strategies that addressed the infant, rather than the dyad and the potential interactive mismatch in the dyad.

EVALUATIONS OF DAN AT 5½ MONTHS

The Early Intervention Services evaluated Dan with the Bayley Scales, the Denver II, the Vineland Adaptive Behavior Scale, and the Early Learning Accomplishment Profile (E-LAP). Their diagnosis emphasized physical and motor delays. Although he was now almost 6 months, these tests all assessed Dan as functioning at a 3-month level of development. Moderate to severe delays were seen in fine and gross motor development, borderline functioning was observed in language and communication skills, and a moderate-to-high muscle tone in extremities and trunk were observed to prevent free movement of extremities for exploration and interaction. Affect was considered “low to normal.” The evaluation noted that no score could be obtained in the social/emotional sections of the tests, and interestingly, this dimension of Dan’s functioning was not explored or pursued. Therapy with a special educator, an occupational therapist, and a physical therapist was recommended.

Within the same few weeks, Dan was evaluated by a pediatric neurologist. Concerns related to hypertonia (constricted muscles in his upper body), delays in his gross motor ability, problems in socialization, and “peculiar affect and other abnormalities” placed him “at risk for subsequent developmental or behavioral impairments.” Physical stimulation was recommended, confirming a similar conclusion from the Early Intervention Services. Thus physical and occupational therapy services were organized for Dan. Although mother-infant treatment was not mentioned in either of the above evaluations, we decided to address the social/emotional aspect of his development in a collaborative treatment with Drs. Beebe and Cohen.

FIRST FACE-TO-FACE VIDEO FEEDBACK CONSULTATION WITH DR. BEEBE: DAN AT 5½ MONTHS

When Dr. Cohen requested a consultation with Dr. Beebe for a mother-infant evaluation, Dr. Beebe recommended that the roles be separated in the following way: Dr. Beebe would do the split-screen videotaping and initial evaluations of the interactions in the filming lab, with brief feedback to the parents. She would teach Dr. Cohen how to view the videotapes and do the actual mother-infant treatment using video feedback, while simultaneously continuing the individual treatment of Linda. Dr. Beebe recommended that Dr. Cohen, rather than Dr. Beebe, work with the mother around the video feedback, because the trusting relationship the mother had already established with Dr. Cohen would facilitate her ability to share all her feelings, both negative and positive.

Preparing the way to include a consultant in a psychoanalytic treatment is a delicate process. Linda needed to be reassured that I (PC) was not going to abandon her, and that she would not be criticized by yet a...

Table of contents

• Cover
• Series Page
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Video Feedback with a Depressed Mother and Her Infant: A Collaborative Individual Psychoanalytic and Mother-Infant Treatment
• Discussion of “Video Feedback with a Depressed Mother and Her Infant”
• Commentary on “Video Feedback with a Depressed Mother and Her Infant”
• Using the Children’s Play Therapy Instrument to Measure Change in Psychotherapy: The Conflicted Player
• Object Relations in Action, or “The Impossible Profession Revisited”
• The Case of Alicia: Understanding Selective Mutism and Alopecia within a Cultural Framework
• “I’m Not Smiling, I’m Frowning Upside Down”: Exploring the Concept of the Claustrum and Its Significance in Work with an Adolescent Girl
• Joining In: An Account of a Latency Group
• Information for Authors
• A Call for Papers