1. WATCH, WAIT, AND WONDER:
An Infant-Led Intervention for Treating Troubled Parent-infant Relationships
Nancy J. Cohen
Hincks-Dellcrest Centre & University of Toronto
Swedish National Association for Child
and Maternal Health Care Psychologists
National Conference - Kalmar
September 24, 2009

2. COLLABORATORS:
Elisabeth Muir
Mirek Lojkasek

3. OBJECTIVES
Describe Watch, Wait and Wonder
Discuss the theoretical underpinnings of Watch, Wait, and Wonder
Explain and illustrate Watch, Wait, and Wonder technique and process

4. SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION: INFANT SYMPTOMS
4/6/2017
SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION: INFANT SYMPTOMS
Irritability and difficulty being soothed
Excessive tantrums
Sleeping problems
Eating problems
Clinginess
llllllllllllllllllllllll

5. SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION: PARENT SYMPTOMS
4/6/2017
SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION: PARENT SYMPTOMS
Depression
Anxiety
Complaints of not feeling bonded or attached to infant
Difficulty playing with and enjoying child
Not understanding what child wants or needs
Self endangerment
Risk for or allegations of abuse

6. THEORETICAL UNDERPINNINGS OF
WATCH, WAIT AND WONDER

7. IMPORTANCE OF ATTACHMENT
Attachment theory helps to understand how individuals:
manage (regulate) emotions
think and behave in relationships
organize inner experiences
manage separation & individuation

8. CONDITIONS FOR SECURE ATTACHMENT
Accurate perception of infant cues
Sensitive and appropriate response to infant cues
Acceptance of infant’s behaviour and feelings
Physical and psychological accessibility when infant is in distress or when exploring
Responses to infant that are consistent and predictable
Display of affection and pleasure

9. “GOOD ENOUGH” MOTHER Mothers cannot always be sensitively responsive
Misattunements can be adaptive because this helps infants to learn to differentiate themselves from their mothers & presents opportunities for repair
The critical aspect is a balance toward sensitivity, responsiveness, and accurate reflectivity over misattunement

10. IMPLICATIONS OF ATTACHMENT SECURITY
Engaging and relating
Curiosity
Initiative and exploration
Emotion and behaviour regulation
Reflective capacity
Resilience and coping skills
Trust, intimacy and affection
Capacity to relate to others
Cognitive and language competence
Capacity to parent

11. ATTACHMENT RELATIONSHIPS
INNER WORKING MODEL OF
ATTACHMENT RELATIONSHIPS
Through repeated interactions, infants form attachment representations or internal working models of self in relation to others. These include perceptions, thoughts, feelings, beliefs and assumptions
Inner working models of self in relation to others guide and filter attention and processing of experiences with regard to attachment. In this way, they impact on the course of future relationships

12. HOLDING
Meet the infant’s spontaneous gesture with a reciprocal gesture
Mother’s nonintrusive presence; being present without making demands.
(Winnicott)

13. “GOING ON BEING”
These maternal functions meet the infant’s need for “going on being” without impingements where the infant can experience his true self

14. CONTAINING
Accepting and tolerating feelings evoked by the infant and conveying through behavior and emotional response that the feelings are bearable and meaningful.
(Bion)

15. REFLECTIVE FUNCTION
Ability to envision mental states in self and others in a particular moment and to understand one’s own experience and that of others in terms of mental processes---desires, feelings, beliefs, intentions
Hypotheses used to understand why we or another might have thought or have done a particular thing

16. FAILURE TO KEEP THE CHILD’S MIND IN MIND
Failures in reflective function include misattribution, distortions, projections
Child takes on mother’s affect and own internal experience is distorted in an effort to adapt

17. REFLECTIVE FUNCTION AND ATTACHMENT
A secure attachment relationship is one where the infant’s signals are accurately interpreted by the mother, giving them meaning in terms of the mother’s response to the infant.
When a mother has a history of a secure attachment relationship she can observe her infant, explore her own mind and think about the mental state of her baby.

18. GHOSTS IN THE NURSERY (Fraiberg, Adelson & Shapiro)
“Unresolved mourning related to early privation restricts the mother’s own development, autonomy, and relationships. These mothers can be overwhelmed by an activation of disavowed feelings associated with those early experiences. These “ghosts” influence the mother’s relationship with her own infant affecting, in turn, the infant’s attachment security.”

19. GHOSTS IN THE NURSERY: KEEPING THE CHILD’S MIND IN MIND
Current views would add that the ghosts render the mother unable to keep her child’s mind in mind, that is, to think about the mental state of the baby.
These deficits lead to repeated failures to grasp the child's own effort to establish himself as an intentional being in his own right.

20. “You be this way or else you will cease to exist in my eyes
“You be this way or else you will cease to exist in my eyes.” The dilemma for the infant is that if he is himself he loses his mother. If he loses his mother he loses himself. Ironically, if he keeps his mother he also loses himself. The outcome of this experience is separation anxiety.

21. 4/6/2017
He/she only loves me if I am who he/she wants me to be. If I don’t go along with it, he/she is angry and cold toward me and I begin to feel as if he/she will leave me. That scares me because I need him/her. But if I am always going along with what he/she wants me to be, I lose sense of who I am. And that is terrible too. 21

22. UNDERSTANDING PROBLEMS IN INFANCY
Many problems in infancy can be understood as emerging when a stifling compromise occurs in the relational connection between mother and infant
Infant symptoms represent a way of simultaneously coping with and protesting against a relational and developmental dilemma related to attachment and autonomy

23. RELATIONAL PERSPECTIVE
Whether the problem resides more or less in the mother or the infant, it is how they negotiate their needs and fit with each other that determine whether a problem will develop.

24. GOALS OF WATCH, WAIT, & WONDER
Increase appropriate maternal sensitivity and attunement to her child and their relationship
Increase maternal responsiveness and reduce intrusiveness
Increase positive affect and pleasure within the relationship
Increase the chance for a secure attachment
Increase child competence observed through improved quality and complexity of play
Increase child self efficacy and development of a potential self and self-esteem
Possibly generalize positive effects within the family and in relation to the outside world (e.g., peer relations)

25. HOW DO WE INCLUDE THE INFANT IN PSYCHOTHERAPY?
Allow the infant to explore and show his curiosity about the environment through sensorimotor activity and play
Use observation of the infant’s spontaneous gestures as a reflection of his innate potential
Use a medium in which infants can seek and establish relatedness

26. THERAPIST IN WATCH, WAIT, AND WONDER
Creates a space for the Watch, Wait, and Wonder process to take place
Models curiosity. Watches, Waits, and Wonders about the mother and infant
Accepts and endures whatever happens (holding and containing). Models openness
Reflects on own feelings and uses these reflections as a guide to talking with the mother about her observations and her experience of herself and her infant

27. ASSSESSMENT

28. GOALS OF ASSESSMENT FOR WATCH, WAIT, & WONDER
Establishing therapeutic alliance
Gathering relevant information on concerns
Obtaining developmental and family history
Parent attachment history
Quality of parent relationship
Attempted solutions

29. COMPONENTS OF ASSESSMENT FOR WATCH, WAIT, & WONDER
Family meeting
Free play and WWW play
Developmental assessment
Formulating
Contracting

30. FREE PLAY AND WWW PLAY
Free play – play with infant much as would play at home
WWW play – instruction not to initiate but to follow infant’s lead. Consider:
Parent’s capacity to allow infant to initiate
Note activities parent finds most difficult to tolerate
Ask parent to make and reflect on observations
Ask about how this kind of play feels

31. FORMULATION Take into account how presenting problems relate to:
infant’s development
parent personality/mental health
parent history
strengths and weaknesses
Parents’ understanding of the problem
Pay attention to what feelings were stirred up
Use parents’ language and metaphor to link problem with recommendation of WWW
Explain how intervention and the problem relate to each other

32. CONTRACTING Initially arrange for a minimum of 6-8 sessions
Emphasize that therapist does not give advice
Reiterate the importance of play and activity (exploration, curiosity); the idea of play and infant activity as forms of communication
Rationale often has to be repeated Sometimes it helps to write out reason for this approach with particular dyad

33. POSSIBLE CONTRAINDICATIONS FOR WWW
Infant younger than 4 months
Preoccupation which prevents the mother from following her infant’s lead and becoming absorbed in play/activity
Poor spousal support
Mother is very depressed
Reflective capacity
Mother wants and insists on something else
Limited intellectual capacity of mother

34. WATCH, WAIT, AND WONDER SESSIONS
Infant-led activity
Discussion

35. INFANT-LED ACTIVITY

36. A relational connection cannot be directly taught in that it is emotional and experiential. The Watch, Wait, and Wonder process is not the same as teaching parenting skills. It is not a process that informs parents about ways to parent. Rather, parents are told that they and their infants will need to find their own way of relating with each other.

37. PROCESS OF WATCH, WAIT, & WONDER
Offers the mother and infant a safe uninterrupted play space
Releases the mother from pressure of her unresolved relational issues which can intrude upon and distort her relationship with her infants
Gives mother permission to become the observer of her infant and respond to her infant’s cues
Gives the mother the space to think about, rather than do to or for, her infant
Allows infant to experience himself through manipulating toys in the presence of an attentive observing mother
Allows mother to experience herself with her infant
Provides an arena where the mother is sometimes stimulated to talk about her conflictual past relationship

38. WATCH, WAIT, AND WONDER SUGGESTED LIST OF TOYS
New born baby anatomically
correct dolls with bottles and
diapers and blankets
Doll’s crib that is large enough for
child to crawl into, or set up a
space on the floor with a pillow an
blanket defining a bed
Bean chair
Two telephones
Mirror (shatter proof)
Activity board
Softball
Policeman helmet or some other
official hat
Undermatting for padding
Stacking cups
Blocks
Small cars including ambulance
Medical kit with stethoscope
Sets of vinyl family dolls (black & white
Set of tame and wild animals - large solid variety
Bowls and mixing spoons
Train set
Heavy duty blue vinyl (Pool manufacturers)
None of these toys are required. In Fact, WWW can be done with very few toys if necessary

39. INSTRUCTIONS FOR WATCH, WAIT, AND WONDER
Get down on the floor with your child
Follow your child’s lead; let him take the initiative
Do not initiate activities yourself
Be sure to respond when your child initiates but do not take over his activities in any way
Allow your child freedom to explore; whatever he wants to do is okay as long as it is safe
If unsure what to do, remember to Watch, Wait and Wonder

40. DISCUSSION

41. DISCUSSION What did you observe? What was your infant’s experience?
What was the play about?
What were your thoughts and feelings?

42. FUNCTION OF DISCUSSION
To deal with the mother’s anxiety evoked by WWW
To help mother be a better observer
To stimulate thinking about the child’s inner world (reflective capacity)

43. DIFFICULTIES THAT ARISE IN SESSION (1)
After initially observing, the mother becomes intrusive or detached
Mother becomes busy, bored or sleepy
Mother says she does not like to play
Mother wants to change WWW
Mother is uncomfortable with the therapist sitting in a chair and observing

44. DIFFICULTIES THAT ARISE IN SESSION (2)
Mother is impatient regarding solutions of problems/wanting advice
Mother wants to focus on events outside the session
Mother has difficulty making observations in the Discussion
Infant falls asleep, wants to escape the room, or otherwise acts out

45. DIFFICULTIES THAT ARISE IN SESSION (3)
Difficulties typically arise in sessions when strong feelings are stirred up in the mother
Often accompanied by the mother saying she does not know how to interpret child’s play and that she wants the therapist’s interpretations
Important to let mother know that children stimulate feelings and that this is one of the ways children communicate. Therefore it is important for the mother to talk about the feelings stirred up in her.

46. TRANSFERENCE AND COUNTER-TRANSFERENCE
Discomfort being observed
Wanting specific advice
Feeling contained (mother and infant)
Feeling acknowledged/accepted
Mother wanting mothering. Keeping the infant as the focus is problematic
Countertransference
Tension re conflict and danger
Feeling criticized, not doing anything for dyad
Wanting to focus on mother rather than dyad
Feeling of being in love

47. KNOWING WHEN TO TERMINATE TREATMENT
Reduction or disappearance of presenting problems
Shift in interactional pattern
Increased comfort in relationship
Infant signals readiness to stop