Containment and Reciprocity

Integrating Psychoanalytic Theory and Child Development Research for Work with Children

Hazel Douglas

• Publisher: Routledge
• Year: 2007
• Print ISBN: 9780415396974
• eBook ISBN: 9781134154104
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Containment and Reciprocity shows how the psychoanalytic concept of containment and the child development concept of reciprocity can be used together to inform clinical work with young children and their families. Using extracts of mother/child and therapist/child interactions, Hazel Douglas explores, for the first time, the relationship between these concepts, and shows how they underpin the quality of an attachment.

Using clinical examples from the author's own psychoanalytic work with very young children as well as her recent research, the book explores these two concepts with important implications for psychotherapeutic technique. Containment and Reciprocity will make valuable reading for all those working in the field of infant mental health.

1 Both/and, not either/or

All over the world, those of us working with very young children and their families are having to perform mental gymnastics, climbing out of our favourite theoretical box in order to integrate concepts from different fields. Working with infants means that we need to work quickly, so that valuable developmental time is not lost. This requires us to try new approaches. In addition, a baby and his family present many facets at the same time: the baby himself, his relationship with his mother, his relationship with his father, his relationship with his parents together, the parents’ relationship, each parent’s mental health and its relationship to the parents’ own previous parenting, the way the family functions, and the way the extended family functions, the presence or not of support in the community. This represents many different theories all at the same time. I am going to take two influential concepts from different areas, describe them and their relationship, and then show how they can inform clinical work when the practitioner is aware of the phenomena which the concepts try to describe. The two concepts are containment (Bion, 1959) from the psychoanalytic world and reciprocity (Brazelton et al., 1974) from the child development research community. These two concepts, together with behaviour management from learning theory, comprise the Solihull Approach, a model of working with infants and their families, which is described elsewhere (Douglas, 2004a). These concepts have proved to be helpful both for professionals (Douglas & Ginty, 2001; Whitehead & Douglas, 2005) and for parents (Douglas & Brennan, 2004; Milford et al., 2006). This book provides the space to explore the concepts in more detail, extending both theory and practice.

Describing and naming the relationship between the two concepts allows the interplay to be seen and used with greater clinical precision. Wittgenstein suggested that naming within language, constructing a name for something, allows it then to be thought about: ‘what we cannot speak about we must pass over in silence’ (Wittgenstein, 1921/ 2001: Proposition 7, p. 89). Although both these concepts have names, these names are used mainly within their own discipline, and each is not generally used within the other’s field. This means that each community is missing out on using the rich explanatory concept of the other. This situation is exacerbated by the fact that containment as a concept has been created and mainly used in the UK, whereas reciprocity has been described and mainly developed within the USA. By bringing both these concepts to awareness at the same time, it should be possible to extend our understanding of the interrelationship.

In order to examine the concepts in more detail, I will first attempt to define them. The curious situation exists that, although containment is one of the most influential ideas within British psychoanalytic circles, it is not defined in any of the psychoanalytic dictionaries. Nor have its theoretical ramifications been explored in any detail. I will also define reciprocity and, in addition, look at its relationship with the three linked ideas of attunement, intersubjectivity and mutual affect regulation. The concepts of attunement, intersubjectivity and mutual affect regulation have all developed from reciprocity, but there has been little work carried out in describing their subsequent relationship.

I think that containment and reciprocity are fundamental in human society. They are the basic building material of the architecture of human relationships. I think that they are therefore also the mechanisms through which the quality of an attachment is created. I will examine both research and therapeutic interventions to show that both containment and reciprocity are involved in the creation of the quality of an attachment.

It will probably be difficult at times for psychoanalytic psychotherapists and for child developmentalists to read this book, because each will feel at times that I have not done justice to ‘their’ concept, especially as I shall be looking at each concept from the perspective of the other. Each concept has grown within a particular literature that I shall only be able to present a small proportion of. I therefore apologise in advance for when I have been unable to represent the full richness of the idea, but hope that you will bear with me during the exploration.

Containment and reciprocity: a first look

At this point, I will introduce the concepts by providing a definition the result of my examination of some of the literature on containment and reciprocity. Material will be provided later to show how the following definitions of containment and reciprocity have been arrived at. ‘Emotional communication’ includes anxiety, fear and terror.

Containment is thought to occur when one person receives and understands the emotional communication of another without being overwhelmed by it and communicates this back to the other person. This process can restore the capacity to think in the other person.

Reciprocity initially describes the sophisticated interactions between a baby and an adult when both are involved in the initiation, regulation and termination of the interaction. Reciprocity applies to the interactions in all relationships.

Both containment and reciprocity are involved in the interrelationship between two people. However, within the mother/baby relationship, the mother is portrayed as much more active in the concept of containment, whereas both mother and baby are portrayed as active within the concept of reciprocity.

The process of reciprocity has been captured by video, through a frame-by-frame analysis (Brazelton et al., 1974). It can be observed directly in the behaviours of the participants. It is both a conscious and unconscious process. Containment tends to be more of an unconscious process, although one can also consciously act to contain another. The process of containment has not yet been studied by analysis of videotape, although it may be possible in the future. Judith Trowell (2003) has suggested that it may be possible to perform a microanalysis of eye movements and other eye-related phenomena to examine containment. There may be other observable concomitants as well, such as other facial responses and body posture. At present, however, containment tends to be inferred from the end result, where the other person quietens/becomes calmer or is able to change their behaviour. Further similarities and differences will be outlined later.

Clinical experience, theory development and the Zeitgeist

For me, the idea of using containment and reciprocity, two concepts from disparate fields, has grown in a space defined by three different lines of thought. Britton (1989) suggested that creativity occurs within a thinking space originally occurring in childhood within the Oedipal triangle created by the triangulation between the father, mother and child. Here, the triangulation is provided by the link between the following three lines of thought. The first is clinical experience. The second is from a step in the natural evolution of theory. The third is the prevailing international Zeitgeist around work in infant mental health.

Clinical experience is the first contributory factor. Two types of clinical experience influenced my thinking. The first was the process of working to understand my clinical experiences in the therapy room with an individual young child and suspecting that current psychoanalytic theory was not sufficient to explain my experiences. The second was in listening to health visitors discuss their work with infants and their families, and in thinking about my own work with families with very young children.

In my individual clinical work, the therapeutic method that I used was psychoanalytic psychotherapy based on object relations theory. This theory is prevalent in the UK. The essence of object relations theory is that human beings are not simple nuclear selves: we are all in a constant relationship to ‘objects’ or internal representations of other people or aspects of other people (Hinshelwood, 1991). These internal representations may be based on actual external relationships, but they are also affected by our own inner constructions of them. Although Klein herself emphasised that both internal and external reality were important, there was sometimes a tendency in early psychotherapeutic work with children to minimise the importance of the outside world. Although this was useful in developing the theory, current practice now tends to incorporate a better balance between knowledge of the external reality of the child and working with the internal world of the child in the therapy room.

The method of psychoanalytic psychotherapy based on object relations theory is that the therapist is constantly attempting to understand and interpret the internal world of the child as it becomes manifest in the therapy, both in the relationship with the therapist and with the play material in the room. The ideas around containment and reciprocity in this book first crystallised around the experience of working with this psychotherapeutic method with a little girl whom I shall call Kylie. The initial ideas about these concepts were first discussed in a paper (Douglas, 2002). Kylie was about three and a half years old when we first met for twice-weekly psychoanalytic psychotherapy for six months, progressing to thrice-weekly therapy for three years. It is typical of this type of therapy that it is possible to gain a glimpse of the child’s infantile aspect; that is, there were times in the sessions when it was like working with an infant or very young child, and I began to think about the relationship between the theory of reciprocity from child development research (Brazelton et al., 1974), which had been developed from the observation of mothers with their infants, and the theory of containment. The concept of containment was first suggested by Bion in 1959 in response to a deeper understanding of the counter-transference. This will be expanded upon later.

Kylie was an engaging but very anxious little girl. Internal doors in the house had to be kept shut or she would become extremely anxious if she walked past an open door. She felt compelled to change her clothes six or seven times a day and would wash her hands many times after going to the toilet or if they became dirty. She had other obsessional rituals, which she performed to lessen and control her anxiety, becoming extremely upset if she was prevented from doing so. This was distressing both to her and to her parents.

The background to this was that, before Kylie was born, her sister Mary was seriously injured in a traffic accident when Mary was three years old. Her parents struggled to keep Mary alive, but, although there were times of hope, eventually Mary died seven months later. Kylie was born five months after Mary’s death. Kylie’s parents were still grieving for Mary when Kylie was born and no doubt were recovering from seven months of physical and emotional strain. Kylie also had a brother, Connor, who was six years older than her.

There was evidence that her parents’ ability to provide the containment needed by Kylie was compromised. Her parents were, understandably, often preoccupied with their own distress, making it difficult for them to attend to Kylie’s moments of distress. This process is not uncommon in this type of situation and has been documented by Reid (1993). The parents’ grief was still very evident four years later.

In the parent sessions, tears were never very far away whenever Mary was mentioned. Although this was very understandable, this contributed to the situation described by Bion (1959), where the child is left with their own terror, overcome with nameless dread, which the child has to try and control or defend against. When parents are grieving in this type of situation, it can be difficult for them to offer all the requisite developmental support. Such preoccupations may interfere with parents’ availability to be involved with the surviving infant in a reciprocal relationship. However, in this case, Kylie’s parents recognised her plight and sought help for her, arranging their lives around bringing Kylie to therapy three times a week, no small feat within a busy family life.

The inferred result of these external events was that Kylie’s inner world was peopled by depressed, dead or unresponsive objects. As the therapy progressed, I became aware that she was often stuck in a very persecuting world, in psychotherapeutic terms, a paranoid-schizoid mode of functioning (Klein, 1946/1988), frightened that she had killed off her sister and her functioning parents and frightened that her aggression would rebound on her as the debilitated objects redirected her projected anger back on her. She would then try to control this vicious circle with external rituals, having few inner containing resources of her own. At other times she would ‘disintegrate’ within the session, something that was very distressing to behold, the session descending into mess and chaos.

Details of Kylie’s clinical material will be considered later in order to identify where the concepts of containment and/or reciprocity were utilised within the reciprocal interaction with Kylie in order to explain the behaviour of the patient and the therapist. Neither by itself seemed adequate. The experience of working with Kylie was pivotal in developing my understanding of both these concepts and led to my questioning of how reciprocity was involved within the practice of psychoanalytic psychotherapy and how the psychoanalytic concept of containment related to the child development concept of reciprocity. This was an example of ‘learning by doing’ (Kolb, 1985), where the actual experience provided the impetus to integrate mentally different theoretical concepts. This case also represented more than itself. The experience within this case helped to integrate the experience of my own analysis, my learning from my training as a child psychotherapist and experience from my work with other individual cases. It also provided the platform from which to question my understanding of my work with families and health visitors’ work with families.

Health visitors are a professional group working within the UK. They are initially trained as nurses and then specialise later as health visitors. Every family within the UK has access to a health visitor. They increasingly try to visit every family antenatally, and then carry out a primary visit when the baby is around ten days old. Some areas provide further visits for every family; others provide further visits for those in need. They also run well-baby clinics, antenatal groups and post-natal groups. In many areas, health visitors are available to the family for the first four years; in some areas, for much longer than this. For many families, health visitors provide the first contact point when difficulties arise between parents and children. As I had trained as both a psychologist and as a child psychotherapist, when I worked with health visitors to think about what concepts might be most useful to them in their work, my experience led me to suggest the use of containment together with the behaviour management that they were already familiar with. However, it soon became apparent that these two concepts together were not enough to illuminate and direct the work with infants and their families. A concept was required that would focus on the active relationship between the parents and child. I knew of Brazelton’s concept of reciprocity, and when we applied the understanding from this concept together with containment, the work leapt forward and continues to do so in the form of the Solihull Approach (Douglas, 2004a). Although we use other ideas as well within the clinical situation, the concepts of containment and reciprocity seem to be robust enough to provide the foundation for work with families that enables families to change and in doing so, to solve some of the difficulties that arise.

The evolution of theory is the second influential factor in the genesis of the ideas within this book. Concepts go through a time of defining themselves, usually against other concepts, where the emphasis is on difference, as in the relationship of teenagers with their parents. It may be that theories mature a little like people, in that during adolescence the person moves towards separation and individuation in order to prepare for making a relationship with another. As the concept develops and people become more confident in their application, it becomes more possible to examine interrelationships.

This may be linked to, but not completely comparable with, the philosopher Hegel’s dialectic process, which is a very interesting idea. Hegel thought that whenever there was a thesis there was also an opposite antithesis and that eventually a resolution would be formed out of these opposites, which would be the synthesis. The concepts of containment and reciprocity are not exactly opposites, but they are different and can seem to have less of a relationship than opposites (in that opposites are related to each other by the fact that they are opposite). Containment and reciprocity are not entirely antithetical, but they are different enough to require a synthesis. Hegel’s view was that ideas evolve within a dynamic tension between them (Magee, 1998). Thus, within this book, a similar process of development may occur of defining the thesis, antithesis and synthesis, that is, by first defining containment and reciprocity and then examining how containment and reciprocity are similar and how they are different, and then how they can both be used in work with young children (the synthesis).

Alan Shuttleworth (1999) has written about the evolution of psychoanalytic theory. He has outlined the development of psychoanalytic thinking, about the causes of ‘serious, complex and persistent child mental health disorders’ (Shuttleworth, 1999, p. 1), through three phases. He emphasised the use of the term ‘phase’ rather than `stage’, because all three forms of theory are in use today, although each phase needed its predecessor from which to evolve. The first phase was the early theory of Freud where disorders were thought to arise from conflicting states of desire, especially infantile sexuality and aggression. The second phase was the later theory of Freud and Klein where disorders arose from ‘disordered states of identification, understood as internal states’ (Shuttleworth, 1999, p. 2). The third phase of theory was developed between 1958 and 1962 by Bion, Bowlby and Winnicott. They postulated that childhood disorders arose from ‘damage to the intimate early processes of interaction between a child and her or his parents’ (Shuttleworth, 1999, p. 3). Shuttleworth names this as the theory of attachment-holding-containment. This is not to say that each component theory is the same. Differences exist, but there is an overlap between them. Shuttleworth suggests that a fourth phase of development of theory will need to reach beyond psychoanalytic theory so as to integrate theoretical developments from other disciplines. Hopefully, the ideas outlined in this book may contribute to this fourth phase of development, in that I have attempted to define and integrate two different concepts from two different disciplines, one from the psychoanalytic world and one from the child development research world.

The third influence is the current Zeitgeist (spirit of the times) within the field of infant mental health, which appears to be a move towards integration. ‘Zeitgeist’ is also a term developed by Hegel, one aspect of which is that the development of ideas occurs within a historical context. There are many examples now of individuals arguing that it is important to integrate theories. Douglas and Brennan (2004) pointed out that Scavo (2000), a child psychiatrist working in Italy, thought that psychoanalytic, interactional and behaviourist models converge in working with parents and young children, because of the demands of this particular type of work. It may be that the therapists working with young children and their families are using ‘combined theory’ in their work because the situation demands interventions at different points in the system all at once. The therapist is faced with a mother, a child, and the interaction between the mother and child, which is further complicated by the relationship between the mother and father, family and grandparents, and the father and child, all at a time when the needs of the child demand rapid change. Scavo described the different emphases of the different theories as follows:

The psychodynamic model focuses primarily on maternal representations, the behaviourist model focuses primarily on interactive behaviours, and those who observe the meaning of affective changes from a dynamic point of view, focus on the nature of the relationship. Finally, infant psychoanalysts and developmental psychologists focus on the child’s qualities and the developing construction of his /her inner world.

(Scavo, 2000, p. 2)

Another example of working towards integration comes from the work of adult psychoanalysts. The school of relational psychoanalysts in New York have been writing for some time about the importance of the relationship in psychoanalysis (Skolnick & Warshaw, 1992). Object relations theory is an important part of `relational theory’, but relational theorists have perhaps been rather more specific about the importance of external relationships. ‘Relational theorists have in common an interest in the intrapsychic as well as the interpersonal, but the intrapsychic is seen as constituted largely by the internalisation of interpersonal experience mediated by the constraints imposed by biologically organized templates and delimiters’ (Ghent, 1992, p. xviii). The school is looking to integrate different perspectives and was set up with that objective in mind. In the UK, a move to emphasise the relational in object relations theory can be seen in the work of Alvarez (1992), although she keeps the emphasis on internal object relations. Her work will be examined further in Chapter Two, because within her work on object relations theory (in which the concept of containment is embedded), she also uses the concept of reciprocity in her work with children with autism.

Dilys Daws was one of the pioneers of the Under 5’s clinic at the Tavistock Clinic. The method underlying the work at this clinic can be seen in her book Through the Night (1993). Although this was written by a child psychotherapist working in a child psychotherapy clinic, the method described used containment, but also included a consideration of attunement. Daws did not use the concept of reciprocity as such, but she did use Stern’s derived concept of attunement (Stern, 1985). Attunement was thought about in the later section of the book on the development of a sense of a separate self for the baby, rather than being posited as a core concept for the work, but Daws was very clear that the presence of the baby together with the parent/s is necessary for the work. She explained that this was required in order that she could observe the relationship between them, and it is difficult to imagine how this could not include a consideration of how ‘in tune’ the parents ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Foreword
• Acknowledgements
• 1 Both/and, not either/or
• 2 Has anyone else looked at integrating these two concepts?
• 3 What is containment?
• 4 What is reciprocity?
• 5 Can reciprocity be seen in psychotherapy sessions with children?
• 6 Does containment occur in child development research?
• 7 Are containment and reciprocity linked?
• 8 What are their differences and similarities?
• 9 How does reciprocity link to therapeutic theory and technique?
• 10 How does attachment relate to containment and reciprocity?
• 11 Integrating containment and reciprocity in work with children
• References