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Engaging Infants: Embodied Communication in Short-Term Infant-Parent Therapy

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The book begins by describing, within a psychodynamic approach, some traits an infant may bring to an intervention, followed by descriptions of interventions in several specialised perinatal settings. Several chapters focus on parent-infant families who have experienced considerable anxiety and depression, and those who have experienced trauma and lived borderline experiences or of mental illness. An innovative intervention which successfully engaged young parents and their infants so that most of them felt they could understand and relate to their newborn infant is next outlined. Turning to most parents of an infant in a neonatal intensive care unit who feel traumatised which may impact on the emotional relationship with their infants, there is often a need for psychodynamic exploration before these difficulties can be modulated. With such interventions the staff become more containing and may more likely seek an intervention for a premature infant in their own right, attuned to the meaning of his or her mood and behaviour. Infant-parent therapy in paediatric contexts, infants in groups, and relating to infant and parents in the context of family violence are briefly described. Interventions where something seemed missed are detailed to guide thinking about how a therapist listens to countertransference and to guide in intervening. The book concludes with the importance of what therapist factors such as authenticity and playfulness in the therapist-patient relationship contribute to the therapeutic alliance, including an infant's alliance and transformational moments, as well as the transference that infants develop to a therapist, and review of factors contributing to this approach being effective.

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Chapter One - Recognising the Infant as Subject

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This book describes a therapeutic approach with a focus on interventions that are infant-led. Engaging infants engages the change processes. The therapeutic interventions I describe are mostly short-term when infant and parent are referred in the perinatal period and the first three years. The infant is viewed as a person in his or her own right and is involved in the intervention, in an approach that upholds the rights of infants. In recognising an infant's intentional self from birth (Stern, 1985), this interactive approach with awareness of the infant's theory of mind is likely to contribute to developing the infant's sense of self even if in a small way. An early sense of self crystallises around an infant being treated as a psychological being who possesses a mind so that the infant develops a sense of self and identity through interactions with an adult carer who reflects on his or her mind. Even a single meeting with a therapist can contribute to this.

When describing the interventions, I try to convey the transformational nature of a therapist's embodied communication (Shai & Belsky, 2011) with an infant. In the infants becoming meaningful to the therapist, they usually become more meaningful to their parents; parents often need to first see change in their infants before they can become more reflective. (Reflectiveness is here used as a thoughtful and open way to appreciate feelings and intentions in others as well as in oneself.) Seeing an infant responding to a therapist often triggers a reflective moment for the parent. This way of interacting with an infant can also be successful on those occasions when a therapist needs to intervene with an infant alone, when a parent is not available (see Dee, Chapter Six). What also has the possibility of being transformational are certain aspects of therapist engagement, such as at times accepting being used as needed (Chapter Nine), or at times trying to find a sense of acceptance for parents (in the face of evoked hateful feelings in the therapist), and may be particularly needed in longer term work arising out of evoked childhood hurts that a parent has experienced.

 

Chapter Two - What an Infant Brings

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Here I describe the active contribution that even young infants make to the therapeutic encounter and their therapeutic alliance. I take for granted their expectable endowment of their capacity to communicate from birth, including triadic intersubjective communication, and their resilience. I highlight some emotions (Thomson-Salo & Paul, 2009), while aware that these concepts may not apply in all cultural contexts, beginning with a sense of immediacy, with both positive and negative emotions, and potential for playfulness and humour. An infant's moral capacities emerge quite early, along with the wish to know and be known in a truthful experience. Infants bring a willingness to enter the therapeutic process and often take a risk to do so. They look at the therapist so attentively that they seem to have an awareness of being in an emotionally meaningful encounter, gazing at the therapist to find out how available for interaction they are. They also bring a wish to be creative, free, integrated, and “alive”, and a capacity to pace their engagement. Even infants with an insecure attachment seem prepared to take this risk in the therapeutic process.

 

Chapter Three - Infants and their Parents in the Perinatal Period

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Many women struggle with transition to parenthood for several reasons, and with the conflicting feelings roused by love and regression. They may have considerable ambivalence about pregnancy, birth, and child rearing, such as child abuse, or difficulty facing the dependence of a needy infant, or trauma (from any point in her life including a difficult pregnancy). Anxiety symptoms are one of the commonest complications of pregnancy, and include a reactivation of past trauma, particularly the stress of lack of partner support, and the lived experience of mental illness in one, or both, of the partners. Parents may be caught up in old conflicts with their own parents, and childhood experiences of deprivation are triggered in looking after their baby. Some mothers find the changes to their body during pregnancy, birth, and breastfeeding frightening, disgusting, or traumatic and feel the need to take their body/privacy back. A mother may feel that if her infant is “bad”, she is bad. Infants in the first year can show difficulties in every physical and emotional domain including post-traumatic stress disorders. The mental health needs in vulnerable women with borderline personality difficulties or with symptoms of anxiety and depression, substance use, intimate partner violence, and/or psychotic disorders, unstable accommodation, and contact with protective services, multiply difficulties for them and their infants, and rapid discharge from hospital may exacerbate bonding difficulties.

 

Chapter Four - Infants with Young Parents

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While many adolescent mothers use their pregnancy as a catalyst for positive change, about half may struggle as this population carries disproportionate risks, presenting considerable developmental challenge for many infants and their mothers. The risks include generations of poverty, mental illness, and sometimes a history of neglect and abuse, depression, substance use, and coercive partner relationships. For the infants, there is a risk of developmental delay and later of conduct disorder and depression. Targeting the relationship that the mothers have with their infants is a window of opportunity for intervention in that the infants are less likely to be securely attached at one year of age. A young mother is negotiating herself through the adolescent process as well as the new experience of becoming a mother. She needs support so that she can participate in some teenage life, with professionals seeing some health in rebellious behaviour, mindful that an adolescent mother may hardly be cognitively ready to be a parent. She may use less mind-related comments in interaction with her infant. She may find it hard to empathise with her infant, as she may be hardly out of childhood herself, and may at times be rough. When her infant cries, the helplessness and terror may remind her of her own helplessness and if she feels very persecuted, she may walk away abruptly, increasing her infant's anxiety and anger.

 

Chapter Five - Infants and their Parents in Neonatal Intensive Care Units

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Working as an infant therapist in a NICU could be subtitled, “Finding the baby whom parents do not feel able to interact with”. Parents with an infant in NICU face many stresses—the total experience and their anxiety about their infant's physical and emotional struggle to survive contribute to most parents suffering symptoms of post-traumatic stress. Many parents are terrified to attach to their baby in case he or she dies. I try to suggest meaning in how their baby is and in his or her behaviour. Some parents need to care for a surviving infant when they are simultaneously grieving the loss of a dead twin. Parents may want to talk about unbearable and unmentionable feelings of rejection for a baby with a disability, or previously undisclosed family violence.

With advances in medical and neurodevelopmental care, premature or seriously medically ill babies may have admissions of many months’ duration and there is increased awareness that the quality of social interactions between parents and babies in NICU can lessen adverse effects of preterm birth and guides therapeutic interventions. A multidisciplinary team works in partnership with families to understand the complexity of the needs of baby and family, to increase sensitivity and bonding, and decrease parental stress, and an infant therapist particularly contributes an infant perspective: I may do a consultation with a baby, for example, whose parents are not able to visit or engage in therapeutic interventions with infants and parents in the parent–infant relationship, and families of a long stay infant may need specialised help. While much work is with the staff, and it is often helpful to be around for staff to talk with in an informal way, I have focused here more on direct interventions with babies and their parents. Many parents and staff attribute intentionality and a thinking mind to babies from the first day so that babies may from the beginning have a sense that their experiences are thought about by others interested in them.

 

Chapter Six - Infants and their Parents in Paediatric Settings

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The clinical pathway in a paediatric hospital shapes the therapy, out of the need to find interventions for distressed infants who are often in a medical crisis with chronic or severe problems (Paul, 2014). Emotional and psychological difficulties may arise with infants in connection with their own physical health, some of whom are near to dying. Sometimes hospital admission alone is not enough to reverse, for example, when an infant is refusing to eat for no ascertainable reason and with life-threatening symptoms cannot be discharged home. Infant mental health intervention varies according to the specific context of the referral. Many infants in hospital are under three years of age and in the tertiary stages of illness or depression or have experienced a traumatic event with serious psychological consequences. Many parents have significant health or social problems. Infants may be referred when they are in intensive care, or failing to thrive, or need a specific area of expertise such as speech pathology. Depression in infants is often overlooked and seen in medical terms such as sleep problems, feeding difficulties, and irritability and restlessness: further indications are withdrawal from play and family, constant sadness, and loss of interest in everyday activities. Infants are referred for disturbances in their relationship with their parents, or in their relationship to their own mind or body. In hospital referrals, a proportion of the population experiences emotional and physical deprivation and a primarily verbal approach would not soothe a dysregulated or dying infant. There is usually an urgent clinical imperative as infants often do not get better without intervention and this is crucially needed, yet time constraints may mean there is only time for a single session. The intervention is shaped by time constraints—whether an infant is admitted for thirty-six hours or for a week, whether the family lives locally or hours away. Despite the severity of an infant's symptoms, this approach has the potential to quickly begin to ameliorate an infant's representations and those of the parents.

 

Chapter Seven - Infants and their Parents in Therapy Groups

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I describe first a long-term therapy group for mothers and infants that created an environment that maximised the potential for infant-centred interactions. As co-leaders, Campbell Paul and I were interested in exploring how mothers and infants negotiated these processes as they came to understand themselves better. Infants can engage with each other soon after birth and they contributed enormously to the group in which the therapists responded to the infants as entitled to a therapeutic intervention in their own right. I discuss some powerful interactions that occurred, and that seem likely to contribute to change particularly between the infants: infant–infant interaction and the infant as therapist, which may constitute moments of meeting for infants and their mothers. I illustrate with a vignette of a depressed seven-month-old boy and his mother, and then describe some short-term groups.

A long-term therapy group

We explored what happens in a group for both mothers and their infants, combining principles of psychodynamic group therapy with infant–parent therapy. This mother–baby therapy group model included engaging with the infant in the mother's presence. We provided a space for the mothers to project their internal world, which was also a physical space where they could watch the play of their infants together unfolding, and offered ourselves as responding in a different way to their infants. We verbalised what we thought was the infants’ experience, and interpreted group themes and processes and, sparingly, the mothers’ negative transferences towards the infants.

 

Chapter Eight - Relating to Infant and Parent in the Context of Family Violence

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Here the needs of infants who have witnessed family violence are explored in therapeutic encounters with them and their families: experience of the effects of violence exposure depend on factors such as the infant's age, proximity of the violence, and relationship with the perpetrator. The vignettes are of infants who have experienced violence towards their mother by her partner as that reflects the presenting population (while recognising that some infants experience violence from their mother to her partner). What I describe refers more to infants exposed to family violence rather than suffering extreme violence themselves, although some have witnessed such extreme levels of violence that they may be challenged in managing their own emotional responses to their parents’ violence. A therapist would tune into the terrified world of a very young infant who is surviving in the best way he or she knows how, by freezing. The infant being present when his mother's issues around family violence are appropriately explored seems to help both mother and infant move forward rather than becoming marooned.

 

Chapter Nine - Countertransference in Infant–Parent Therapy

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Here I explore in particular, difficult countertransference feelings such as anxiety, guilt, and shame as well as those cases where I felt I may have missed something, or felt I failed. Countertransference phenomena illuminate how unconscious processes may enhance or interfere with the therapeutic relationships between infant, parent, and therapist, as containing in the countertransference transmutes the transference. Use of countertransference is widely seen as the single most important guide to the therapeutic experience, as possibly the most significant source for understanding. This includes the feelings and associated insights of therapists, as well as attunement to the emotional and psychological needs of infants and their parents. Countertransference shapes the therapy in that increased awareness of it shapes the therapists’ stance and their interpretive comments.

I touch on the experience of rupture and repair (Benjamin, 2009). Currently a major model for thinking about countertransference is one of co-creation by therapist and those with whom a therapist engages. Feelings evoked in therapists are a major way of understanding others. Therapists need to be thoughtful about the feelings triggered in them, particularly those they are resistant to, and continuously process a tendency to be critical and disapproving. To understand an infant involves looking at oneself.

 

Chapter Ten - The Therapeutic Alliance, the Presence of the Therapist, and Transformational Moments

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Therapeutic alliance: in infants

The quality of the therapeutic alliance is a robust predictor of therapy outcome and includes variables such as the life histories, personalities, and attachment styles of infant, parents, and therapist (Barber et al., 2012). What does a collaborative therapeutic alliance look like in an infant? Infant research highlights that in the early stages of the infant–mother interaction the infant is the initiator and the primary architect of reciprocity while the mother (and the therapist) is the follower (Call, 1980). An infant may, more than we realise, initiate the therapeutic encounter and the therapist follows, which may turn out to be a transformational moment. Yet it could be so subtle, it may be hard to justify as therapeutic alliance. This would be so in the vignette illustrating transformational moments (Natalie, this chapter), when I thought I made the move but the infant had already signalled to me. Therapists who communicate their intentions clearly and empathically to frightened infants, by, for example, tone and touch, contribute to the infants developing trust in the therapeutic alliance.

 

Chapter Eleven - Responding to Infants and Interpreting Transference

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I now consider interpreting infants’ transferences, with vignettes illustrating moments of affective communication and shift, when intervening at the level of emotional connectedness with the infant. I will first outline some ways when a therapist may respond and talk indirectly to the infant, in which I wonder if this subtly makes the infant an object, and then discuss engaging with infants. While play is not the same as a verbal interpretation in not revealing what is “behind” whereas interpretation does, for infant and parent it may nevertheless usher them into a transformative process.

Aims and ways of engaging infants

The aim of engaging infants and their parents is not primarily about improving parent–infant interaction but to communicate with the infant to understand the meaning of the symptom so as to relieve distress. However, in several different kinds of responses, the therapist may not truly be talking with the infant. If the quality of engagement with which a therapist interacts with an infant is not always contingent, appropriately attuned mirroring, it may matter less if a therapist speaks with sincerity, when it is not authentically to the infant, especially if, as in “speaking for the baby”, this intervention is often effective in having an almost immediate effect on the mother and then on the baby who improves rapidly. When a therapist comments to parents about his observations of the infant's behaviour and mood in the session, even young infants have a sense that he is talking about them. Lieberman and van Horn (2009) report a therapist saying to an infant whose mother was at that point hostile towards him, that he had tried to help her when labour started but was too little to do so, and she softened immediately in response to this and able to bring that she felt a failure. Such comments are undoubtedly containing for both parent and infant. Sometimes an interpretation directed to the infant is a way of talking to the parent in a gentle way, although it seems more truthful if a therapist could find a way of saying it directly to the parent. However, in making a more adult and sometimes long type of verbal interpretation to the infant, it is hard to be clear what sense the infant makes of it (apart from the sustained attention), in that current views of an infant's cognitive functioning do not support a view of an infant understanding such interpretations, and it cannot therefore be interpreting to the infant.

 

Chapter Twelve - Revisiting Mechanisms of Change in Infant–Parent Therapy

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As a result of therapeutic intervention, parents and infant each create a slightly changed self. Here I summarise what has emerged of the therapeutic factors. An infant-focused approach sees the infant as an active participant in the therapeutic process and a therapist using embodied communication intervenes in the infant–parent relationship, where the intervention needs to take place. With an accommodating infant, a therapist would engage to reignite a sense of expectation that the adult world will look after and excite her; with an infant who has less capacity to be accommodating, this would need to be more titrated. The power of enacted reflective moments is impressive. The new relational experiences infants and parents have with a therapist are likely to aid their internalising of the therapeutic relationship and facilitate affective communication as well as enhance their capacity for containment.

Relatively serious pathology can change quickly with the developmental push in infants, in the capacity for self-righting in the first year, as well as the chance that parenthood offers to rework difficulties, and change can also act as a foundation on which a parent with early deficits may risk engaging longer and further. The key to bringing about deep change is mourning for what has been lost or never been, with an often powerful resistance to mourning. With more fragile parents and infants the gain is more developing the capacity for self-reflectiveness.

 

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