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What Can the Matter Be?

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This volume is the result of over twenty years of therapeutic interventions with families within the Tavistock Clinic's Under Fives Service. It describes in detail the process of understanding young children's communications and behaviour and the dynamics of family relationships within the consulting room in a lively, accessible style. It covers common themes in work with young children such as disruptive, angry behaviour, separation and sleep difficulties, and problems in the parent/couple relationship. This book is essential reading for all early years professionals hoping to gain a greater understanding of the technique, observational skills and theory which underlie a psychodynamic approach to work with the under fives.

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1 Brief work with parents of infants

ePub

My interest in brief work began when I was asked to spend a day a week at Sussex University Student Health Service as a Student Counsellor. Having so little time available and wanting to see as many students as possible, I offered a three-session consultation to each of the young people referred to me by the doctors. It proved a wonderful learning opportunity.

I was impressed by how clearly a core problem emerged not only from what the client said, but also from his or her behaviour during the interview and how the very difficulty that had brought about the present impasse sometimes became enacted. This enabled me to observe, feel, think about, and comment on what was happening between us in the here-and-now and how this might be a way of communicating what was also going wrong in other relationships.

The interviews were mainly unstructured, but I felt free to ask questions if some statement needed clarifying. Also, unless such information emerged spontaneously, I would usually within the first session enquire about the client’s family and what had prompted him or her to seek help at this particular time. I would be quite active in commenting on the feelings in the room and what seemed to be expected of me. On the basis of this, I might begin tentatively to formulate something about the nature of the underlying problem and how it might relate to present and past experiences. A great deal of work went on in my mind between the first and second session, especially an examination of the feelings and thoughts that had been aroused in me or appeared to have been lodged in me. These gave a clue as to the nature of the emotions and anxieties that were intolerable for the client to bear and hence had been projected into me. I encouraged the student to do some homework, too—namely, to think about our conversation and bring to the next session any further thoughts that had come into his or her mind in connection with it. The second (middle) session was the one where earlier hypotheses as to the nature of the anxieties and difficulties and their possible origin could be tested and new understanding take place. In the final session, I learnt how such understanding had been used and I summarized what we together had discovered. We would explore what the ending of our contact meant to the client and whether more help might be needed and desired, or not.

 

2 The relation of infant observation to clinical practice in an under-fives counselling service

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This chapter gives an account of a method of working and a service developed in the Child and Family Department of the Tavistock Clinic. It presents some thoughts on the use of observation in psychoanalytically orientated work.

I need to describe the services offered in the Child and Family Department under the title “The Under Fives Service”. We offer brief help—up to five sessions only, which may be variously spaced out over a number of weeks—to families whose concern is focused on anxiety about their baby or small child. For example, we have mothers and fathers with babies who will not sleep, who will not eat, who cry incessantly; we have couples where the mother is depressed; we have parents anxious about the effects of bereavement or divorce; we have babies who refuse to be weaned, toddlers who suffer tantrums and jealousies; and of course we have those who come with nameless and inexplicable anxieties. This service differs from the rest of the provision made in the department in so far as here we do not regard ourselves as having a referred patient. We have parents coming for counselling; they come to think with an experienced outsider about the problems they perceive in their child or their children. The worker comes from a multidisciplinary workshop where psychiatrists, social workers, psychologists, and child psychotherapists meet regularly to discuss some of these cases and other aspects of work with very small children.

 

3 Infant–parent psychotherapy: Selma Fraiberg’s contribution to understanding the past in the present

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Infant–parent psychotherapy was first named and developed by an American child psychoanalyst, Selma Fraiberg. She described the work in a ground-breaking book, Clinical Studies in Infant Mental Health, published in 1980. Since then many significant clinical and theoretical contributions (e.g. Stern, 1995; Lieberman & Zeanah, 1999; Barrows, 2003; Baradon et al., 2005) have been made to this field. The subject has expanded to include a wealth of complexities of interpretation and technique, but the value of Fraiberg’s original psychoanalytic insight remains unchallenged.

Fraiberg relied on the assumption that there is no such thing as individual psychopathology in infancy. This does not mean that babies do not contribute difficulties from their side of the relationship. It does mean that symptoms in the infant can best be treated by treating the infant–parent relationship, rather than by treating either infant or parent separately. Like all short-term therapies, infant–parent psychotherapy is focused, and the focus is on the development of the infant, who is always present in the sessions. The infant’s presence ensures that parental feelings towards him are readily available in the here-and-now for exploration and interpretation. Interpretation, as practised by Selma Fraiberg, utilized a combination of “object relations” and “attachment theory” to understand the ways in which the parental past interfered with relating to the baby in the present. The symptomatic infant was found to be the victim of negative transference, haunted by “ghosts in the nursery” (Fraiberg, Adelson, & Shapiro, 1975, p. 165). Infant–parent psychotherapy was the treatment of choice whenever the baby had come to represent an aspect of the parental self which was repudiated or negated, or when the baby had become the representation of figures from the past. The primary focus of the work was on understanding the parents’ negative transference to their baby, rather than on understanding their transference to the therapist.

 

4 The process of change in under-fives work

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The work described in this book is concerned with effecting changes in the relationship between parents and their infant. There is general agreement that the period of early infancy is one in which there is considerable potential for change and greater psychic flexibility than at other times, and hence it is a prime time for intervention.

In this primarily theoretical chapter, I would like to look more closely at the question of what it is that we are seeking to change in the kind of work illustrated elsewhere in this book, and how it is that we conceptualize those changes. As will be seen, this also has implications for the nature of that work, in particular whether it be brief or long term.

On the whole, previous accounts of the work of the Tavistock Clinic’s Under Fives Service (e.g. Miller, 1992; Hopkins, 1992) have emphasized its brevity. It offers up to five sessions, with change often apparent within the first few sessions, later sessions being provided to consolidate those changes. At times such accounts can seem almost magical: the therapist is perhaps left in despair or puzzled—the family returns next time and all is resolved! For example:

 

5 A slow unfolding—at double speed: therapeutic interventions with parents and their young children

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The title refers to what may seem to be a paradox, touching on the particular technique developed in the Under Fives Service, of working psychoanalytically, but often within a brief time frame. How can there be a slow “free-associative conversation” with parents (Watillon, 1993) and a simultaneous exploration of a child’s communications through behaviour, play, drawing, and interaction with parents and therapist, in what is often a brief therapeutic intervention? In exploring this paradox, I shall be developing Annette Watillon’s (1993) suggestion that “the ‘speed and spectacular nature of the therapeutic effect’ in work with under fives results from the ‘dramatization’ of experience in the therapeutic setting”. I describe how the dramatization of experience by children in the consulting room, or through parents’ narratives, can be effectively used by the clinician to facilitate the unfolding of material and lead to change. As will become clear, thinking with parents about the impact of their parental functioning on the child, and vice versa, plays a central role in this work.

 

6 A sinking heart: whose problem is it? Under-fives work in the surgery of a general practitioner

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This chapter focuses on the application of the Tavistock Under Fives model to work in a community setting, a GP’s surgery. Detailed case material is given from brief work undertaken with a 4-year-old girl and her extended family seen for four sessions, and we expand from this specific case to highlight key issues that arise in the application of this Under Fives model to a community context.

The pleasures and problems of working in a GP setting

An increased awareness of children’s mental health needs and the value of early intervention has developed as part of primary care provision. Child psychotherapists have a contribution to make in supporting primary health care teams, which include GPs, health visitors, and practice nurses, alongside child psychologists and other early years professionals. The child psychotherapist’s contribution to the GP service involves direct work with families with young children, as well as indirect work focused on supporting practitioners. This indirect work offers training, supervision, and consultation to help the primary care team extend their range of responses to these families. Parents will approach their GP with a number of problems for which they would never imagine needing referral to a psychological service or hospital department. The Tavistock Under Fives model is particularly well suited to a primary care context that offers help to these families, providing a “thinking space” in an easily accessible community base.

 

7 Anger between children and parents: how can we help?

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This is a chapter about angry people. In the caring professions we are confronted by people who are distressed and vulnerable. Consequently the question of negative feelings—anger, hatred, aggression, and hostility—affects all of us in our work, as an inevitable feature of our professional lives. We hear about and witness scenes of antagonism in families which we know must do damage to small children. Either this is upsetting or it makes us angry in turn; some response in us is inescapable. People who work with families where there are babies and small children lay themselves open to the experience of powerful and primitive anxieties. Families—and I recognize that a family can take many shapes, from one single parent and an infant to a complex grouping—that contain an infant or small child are in a labile emotional state, because babies, toddlers, and children do not consume their own smoke. Their distress has to be dealt with by the adults around them; they have not yet learnt to manage their feelings independently, and consequently they ask their parents to bear some of their feelings for them.

 

8 Disruptive and distressed toddlers: the impact of undetected maternal depression on infants and young children

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In this chapter I describe how the process of undertaking clinical work with toddlers referred because of disruptive behaviour and sleep difficulties revealed patterns of interaction between mother and child that suggested, retrospectively, that the mothers had suffered from undiagnosed post-natal depression during the period of their children’s infancy. These hypotheses were subsequently confirmed by the mothers during our discussions. Clinical work was undertaken in a community health centre, targeting families who were unlikely to find their way to a child and adolescent mental health service.

The recognition that a mismatch in attunement between mother and baby during infancy resulting from post-natal depression (or possibly contributing to maternal depression) is associated with impairments in infant cognitive and emotional development (Murray & Cooper, 1997) highlights the need for early diagnosis and intervention for mothers, within the adult mental health services, and for parents and their infants, within child and family mental health services. I first discuss the impact a mother’s post-natal depression may have on her infant’s development and then illustrate through clinical examples how patterns of relating between parent and toddler, which may have become entrenched since infancy, began to change through the relatively brief interventions offered within an under-fives community service.

 

9 Where the wild things are: tantrums and behaviour problems in two under-fives boys

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In his children’s classic, Where the Wild Things Are, Sendak (1963) describes how one day a small boy called Max donned his wolf suit and “made mischief”. His mother called him a “wild thing”; he threatened to eat her up and was sent to bed without any supper. In his imagination, Max’s room became transformed into a jungle and then the open sea as he sailed away to “where the Wild Things are”. Though they roared, gnashed their teeth, rolled their eyes, and showed their claws, Max tamed the Wild Things by staring into their eyes. He became their King, and all sorts of rumpus followed. Eventually Max tired of this. He sent these creatures to bed without supper. Then Max was lonely and “wanted to be where someone loved him best of all”. From far away, he smelled good things to eat. So he gave up being King, got back into his boat, and sailed back across the world. In his room, his supper was waiting for him, still hot.

As Raphael-Leff (1989) has noted, this story captures astutely some of the psychological challenges of parenting children under the age of 5 years. Judging from the illustrations, Max had been tormenting the dog, making holes in the walls, and shouting back at his mother. Behaviour problems at home and at school are among the most common reasons for referring under fives to CAMHS. The referred child is often described as a “Jekyll and Hyde”, delightful one minute and a monster the next. Alarm in parents and referrers may be exacerbated by public concern and media attention given to the question of the origins of violence and delinquency. Television programmes about ADHD and the interventions of a “super nanny” stress that it is urgent to intervene early for the family’s benefit as well as for the child’s. CAMHS referrals will generally implicitly if not explicitly highlight the risk of parents lashing out or harming the child, in reaction to their power-lessness and loss of control. These referrals commonly, but certainly not exclusively, tend to be of boys.

 

10 Locating the ghost in the nursery: the importance of the parental couple

ePub

Most of the authors represented in this book, and indeed many of the clinicians working in the Tavistock Clinic’s Under Fives Service, have been very influenced by developments within the Kleinian tradition of “object relations” theory. Within that paradigm, more recent thinking has tended to emphasize that it is the nature of the parental couple that the infant and young child internalizes that is central to successful psychological development. It is this couple, and its creativity or otherwise, that forms the core of the personality and, not surprisingly, is particularly influential in determining the kind of parent that the child will become in his turn.

It follows from this that in working with parents, infants, and young children, particular attention needs to be paid to the couple and to their relationship. In much of the literature on parent–infant work, however, this aspect has been rather lacking. As I have argued elsewhere (Barrows, 1999b), those working clinically with the under fives have all too often privileged the role of the mother’s “ghosts” (Fraiberg, Adelson, & Shapiro, 1975) at the expense of those the father brings to the nursery (although Fraiberg herself was very attentive to the father’s importance). This has been to the detriment of our potential therapeutic impact. This neglect has applied to researchers and developmental psychologists as well as to clinicians: most research papers still tend to be about mother–infant interactions.

 

11 Father “there and not there”: the concept of a “united couple” in families with unstable partnerships

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This chapter is based on clinical work carried out as part of the Tavistock Clinic’s Under Fives Service. As the brief nature of this work implies, it is necessary to focus on a few selected aspects of the problem, and addressing some areas of difficulty in the parental relationship can often provide relief to children and reduce their symptoms.

Nearly all of the work of the Under Fives Service is done in the presence of one or both parents, either with the child or 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. Work may also 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. Underlying this approach to work with parents and children is the idea that each parent embodies within him/herself both a paternal and a maternal function, a combined internal parental couple. This links with Bion’s (1962a, 1962b) concept of container/contained. Bion’s concept of a “container” incorporates both the maternal receptive and the paternal

 

12 Oedipal issues in under-fives families: creating a space for thinking

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This chapter addresses the feelings of exclusion and separateness commonly experienced by the young child as he moves away from the exclusive relationship with his primary carer, usually mother, and towards a triangular relationship, most notably with father, but also with siblings, and often a new baby. I shall describe therapeutic work with a family struggling with conflicts, anxieties, and defences associated with the triangular constellation of mother, father, and child—the oedipal situation. Attempts by the child and/or parents to avoid the natural feelings of anxiety and pain associated with this process can have a paralysing effect on the whole family. I hope to elaborate on the nature of these defences and show that one way of alleviating such paralysis is through the creation of a “triangular space” for observation and reflection by the therapist who can provide a “third position” (Britton, 1989) on the various points of view within the family. This is a space bounded by the three people within the oedipal situation and their potential relationships. It includes, therefore, “the possibility of being a participant in a relationship and observed by a third person as well as being an observer of a relationship between two people” (Britton, 1989, p. 86). This “space for thinking” allows the possibility of new ideas to be created within the therapeutic setting.

 

13 Spanning presence and absence: separation anxiety in the early years

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The realities of separation are part of all social relationships, including the earliest mother–infant bond. The newborn depends on the mother’s nurturing presence, but, being out of the womb and in the world, he is bound also to experience normal gaps in her care. The first separations in life might take the form of the baby coming to the end of a breastfeed, being put in his cot to sleep, or being handed over to another adult. O’Shaughnessy notes that: “The feeding infant does not have an association with the breast, like a strictly business association. He has a relationship to it, which spans absence and presence, which goes beyond the physical presence of the breast to the breast in its absence” (O’Shaughnessy, 1964, p. 34).

As the baby develops into a toddler, he becomes much more aware of the many small gaps in his care routine. The mother attends not only to him, but to his father and siblings. In an ordinary day, his parents concern themselves with their other children, with each other, with members of their extended family, and, more generally, with their lives.

 

14 Sleeping and feeding problems: attunement and daring to be different

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Attunement and autonomy

In psychotherapy we work with emotions, our patients’ and our own; this is most evident when we work with parents and infants. The first duty of parents of very young babies is to attend to their physical needs—to keep their baby alive. This requires knowledge, skill, instinct, and emotionality. As therapists, we may ask, how do new parents feel about this awesome task? How do they feel about their tiny helpless baby? Where do emotions connect with instincts? How do love and hate fit in to this life-and-death reality? Are parents developing the love and secure attachment that can grow from the proximity necessary in feeding a baby and keeping it safe? Or are the cues of infantile needs triggering hostility to their baby from parents who feel unable to meet his needs (Fraiberg, 1980)?

Our ability to work with parents and infants is drawn from our own experience, which, remembered or not, may lead us to empathize with the situations of others. But human experience is somatic as well as emotional. You could say that emotions are bodily reactions, which are at core an appraisal of self and environment. In parent–infant work, bodily realities are everywhere. Babies are fed in front of the clinician; their nappies are changed in the room. These basic bodily functions and the emotions that accompany them are experienced directly between the baby and his parents. The therapist who witnesses their activity may be the recipient of transference communications from the parents, but mainly she is in the privileged position of observing behaviour and emotion; she also observes the parents’ perceptions of their baby, influenced by their own past experiences—in other words, their transferences onto their baby.

 

15 Holding the balance: life and death in the early years

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The death of a child is devastating because it means the loss of so many hopes and dreams for the future. These may even have preceded the pregnancy; during the pregnancy they are elaborated and culminate at the time of the birth. Seeing families soon after the birth of a child, we are familiar with the many hopes for the future the baby can hold at this point. A new baby is experienced as reassurance that life goes on, and when things go wrong the repercussions can be debilitating and long lasting. The loss may continue to affect the family and the lives of future babies in a powerful but not necessarily obvious way (Reid, 1992).

Bourne and Lewis (1984, 1992) wrote about the effects of perinatal loss and the difficulties the next child may have. Women throughout the world continue to suffer from perinatal loss, and however many children parents may have, there is always a place in their memory for the lost babies. Some parents who lose a baby find it difficult to bond successfully with the next child and remain preoccupied with the dead child; this is a theme I shall explore in this chapter.

 

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