Presentation on theme: "WATCH, WAIT, AND WONDER: An Infant-Led Intervention for Treating Troubled Parent-infant Relationships Nancy J. Cohen Hincks-Dellcrest Centre & University."— Presentation transcript:
1 WATCH, WAIT, AND WONDER:An Infant-Led Intervention for Treating Troubled Parent-infant RelationshipsNancy J. CohenHincks-Dellcrest Centre & University of TorontoSwedish National Association for Childand Maternal Health Care PsychologistsNational Conference - KalmarSeptember 24, 2009
3 OBJECTIVESDescribe Watch, Wait and WonderDiscuss the theoretical underpinnings of Watch, Wait, and WonderExplain and illustrate Watch, Wait, and Wonder technique and process
4 SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION: INFANT SYMPTOMS 4/6/2017SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION: INFANT SYMPTOMSIrritability and difficulty being soothedExcessive tantrumsSleeping problemsEating problemsClinginessllllllllllllllllllllllll
5 SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION: PARENT SYMPTOMS 4/6/2017SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION: PARENT SYMPTOMSDepressionAnxietyComplaints of not feeling bonded or attached to infantDifficulty playing with and enjoying childNot understanding what child wants or needsSelf endangermentRisk 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) emotionsthink and behave in relationshipsorganize inner experiencesmanage separation & individuation
8 CONDITIONS FOR SECURE ATTACHMENT Accurate perception of infant cuesSensitive and appropriate response to infant cuesAcceptance of infant’s behaviour and feelingsPhysical and psychological accessibility when infant is in distress or when exploringResponses to infant that are consistent and predictableDisplay 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 repairThe critical aspect is a balance toward sensitivity, responsiveness, and accurate reflectivity over misattunement
10 IMPLICATIONS OF ATTACHMENT SECURITY Engaging and relatingCuriosityInitiative and explorationEmotion and behaviour regulationReflective capacityResilience and coping skillsTrust, intimacy and affectionCapacity to relate to othersCognitive and language competenceCapacity to parent
11 ATTACHMENT RELATIONSHIPS INNER WORKING MODEL OFATTACHMENT RELATIONSHIPSThrough repeated interactions, infants form attachment representations or internal working models of self in relation to others. These include perceptions, thoughts, feelings, beliefs and assumptionsInner 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 HOLDINGMeet the infant’s spontaneous gesture with a reciprocal gestureMother’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 CONTAININGAccepting and tolerating feelings evoked by the infant and conveying through behavior and emotional response that the feelings are bearable and meaningful.(Bion)
15 REFLECTIVE FUNCTIONAbility 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, intentionsHypotheses 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, projectionsChild 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 4/6/2017He/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 infantInfant 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 relationshipIncrease maternal responsiveness and reduce intrusivenessIncrease positive affect and pleasure within the relationshipIncrease the chance for a secure attachmentIncrease child competence observed through improved quality and complexity of playIncrease child self efficacy and development of a potential self and self-esteemPossibly 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 playUse observation of the infant’s spontaneous gestures as a reflection of his innate potentialUse 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 placeModels curiosity. Watches, Waits, and Wonders about the mother and infantAccepts and endures whatever happens (holding and containing). Models opennessReflects 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
28 GOALS OF ASSESSMENT FOR WATCH, WAIT, & WONDER Establishing therapeutic allianceGathering relevant information on concernsObtaining developmental and family historyParent attachment historyQuality of parent relationshipAttempted solutions
29 COMPONENTS OF ASSESSMENT FOR WATCH, WAIT, & WONDER Family meetingFree play and WWW playDevelopmental assessmentFormulatingContracting
30 FREE PLAY AND WWW PLAYFree play – play with infant much as would play at homeWWW play – instruction not to initiate but to follow infant’s lead. Consider:Parent’s capacity to allow infant to initiateNote activities parent finds most difficult to tolerateAsk parent to make and reflect on observationsAsk about how this kind of play feels
31 FORMULATION Take into account how presenting problems relate to: infant’s developmentparent personality/mental healthparent historystrengths and weaknessesParents’ understanding of the problemPay attention to what feelings were stirred upUse parents’ language and metaphor to link problem with recommendation of WWWExplain 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 adviceReiterate the importance of play and activity (exploration, curiosity); the idea of play and infant activity as forms of communicationRationale 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 monthsPreoccupation which prevents the mother from following her infant’s lead and becoming absorbed in play/activityPoor spousal supportMother is very depressedReflective capacityMother wants and insists on something elseLimited intellectual capacity of mother
34 WATCH, WAIT, AND WONDER SESSIONS Infant-led activityDiscussion
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 spaceReleases the mother from pressure of her unresolved relational issues which can intrude upon and distort her relationship with her infantsGives mother permission to become the observer of her infant and respond to her infant’s cuesGives the mother the space to think about, rather than do to or for, her infantAllows infant to experience himself through manipulating toys in the presence of an attentive observing motherAllows mother to experience herself with her infantProvides 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 anatomicallycorrect dolls with bottles anddiapers and blanketsDoll’s crib that is large enough forchild to crawl into, or set up aspace on the floor with a pillow anblanket defining a bedBean chairTwo telephonesMirror (shatter proof)Activity boardSoftballPoliceman helmet or some otherofficial hatUndermatting for paddingStacking cupsBlocksSmall cars including ambulanceMedical kit with stethoscopeSets of vinyl family dolls (black & whiteSet of tame and wild animals - large solid varietyBowls and mixing spoonsTrain setHeavy 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 childFollow your child’s lead; let him take the initiativeDo not initiate activities yourselfBe sure to respond when your child initiates but do not take over his activities in any wayAllow your child freedom to explore; whatever he wants to do is okay as long as it is safeIf unsure what to do, remember to Watch, Wait and Wonder
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 WWWTo help mother be a better observerTo 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 detachedMother becomes busy, bored or sleepyMother says she does not like to playMother wants to change WWWMother 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 adviceMother wants to focus on events outside the sessionMother has difficulty making observations in the DiscussionInfant 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 motherOften accompanied by the mother saying she does not know how to interpret child’s play and that she wants the therapist’s interpretationsImportant 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 observedWanting specific adviceFeeling contained (mother and infant)Feeling acknowledged/acceptedMother wanting mothering. Keeping the infant as the focus is problematicCountertransferenceTension re conflict and dangerFeeling criticized, not doing anything for dyadWanting to focus on mother rather than dyadFeeling of being in love
47 KNOWING WHEN TO TERMINATE TREATMENT Reduction or disappearance of presenting problemsShift in interactional patternIncreased comfort in relationshipInfant signals readiness to stop