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WATCH, WAIT, AND WONDER: An Infant-Led Intervention for Treating Troubled Parent-infant Relationships Nancy J. Cohen Hincks-Dellcrest Centre & University.

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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 Relationships Nancy J. Cohen Hincks-Dellcrest Centre & University of Toronto Swedish National Association for Child and Maternal Health Care Psychologists and Maternal Health Care Psychologists National Conference - Kalmar September 24, 2009

2 COLLABORATORS: Elisabeth Muir Mirek Lojkasek

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

4 SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION: INFANT SYMPTOMS  Irritability and difficulty being soothed  Excessive tantrums  Sleeping problems  Eating problems  Clinginess

5 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 Engaging and relating Curiosity Curiosity Initiative and exploration Initiative and exploration Emotion and behaviour regulation Emotion and behaviour regulation Reflective capacity Reflective capacity Resilience and coping skills Resilience and coping skills Trust, intimacy and affection Trust, intimacy and affection Capacity to relate to others Capacity to relate to others Cognitive and language competence Cognitive and language competence Capacity to parent Capacity to parent

11 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 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 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 INNER WORKING MODEL OF ATTACHMENT 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.” 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 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.

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 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 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 appropriate maternal sensitivity and attunement to her child and their relationship Increase maternal responsiveness and reduce intrusiveness Increase maternal responsiveness and reduce intrusiveness Increase positive affect and pleasure within the relationship Increase positive affect and pleasure within the relationship Increase the chance for a secure attachment Increase the chance for a secure attachment Increase child competence observed through improved quality and complexity of play Increase child competence observed through improved quality and complexity of play Increase child self efficacy and development of a potential self and self-esteem 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) 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 Creates a space for the Watch, Wait, and Wonder process to take place Models curiosity. Watches, Waits, and Wonders about the mother and infant Models curiosity. Watches, Waits, and Wonders about the mother and infant Accepts and endures whatever happens (holding and containing). Models openness 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 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 Establishing therapeutic alliance Establishing therapeutic alliance Gathering relevant information on concerns Gathering relevant information on concerns Obtaining developmental and family history Obtaining developmental and family history Parent attachment history Parent attachment history Quality of parent relationship Quality of parent relationship Attempted solutions Attempted solutions GOALS OF ASSESSMENT FOR WATCH, WAIT, & WONDER

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

30 FREE PLAY AND WWW PLAY Free play – play with infant much as would play at home Free play – play with infant much as would play at home WWW play – instruction not to initiate but to follow infant’s lead. Consider: 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: 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 Parents’ understanding of the problem Pay attention to what feelings were stirred up Pay attention to what feelings were stirred up Use parents’ language and metaphor to link problem with recommendation of WWW Use parents’ language and metaphor to link problem with recommendation of WWW Explain how intervention and the problem relate to each other Explain how intervention and the problem relate to each other

32 CONTRACTING Initially arrange for a minimum of 6-8 sessions Initially arrange for a minimum of 6-8 sessions Emphasize that therapist does not give advice 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 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 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 Infant younger than 4 months Preoccupation which prevents the mother from following her infant’s lead and becoming absorbed in play/activity Preoccupation which prevents the mother from following her infant’s lead and becoming absorbed in play/activity Poor spousal support Poor spousal support Mother is very depressed Mother is very depressed Reflective capacity Reflective capacity Mother wants and insists on something else Mother wants and insists on something else Limited intellectual capacity of mother 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 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 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 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 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 infant to experience himself through manipulating toys in the presence of an attentive observing mother Allows mother to experience herself with her infant Allows mother to experience herself with her infant Provides an arena where the mother is sometimes stimulated to talk about her conflictual past relationship Provides an arena where the mother is sometimes stimulated to talk about her conflictual past relationship

38 New born baby anatomically New born baby anatomically correct dolls with bottles and diapers and blankets Doll’s crib that is large enough for 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 Bean chair Two telephones Two telephones Mirror (shatter proof) Mirror (shatter proof) Activity board Activity board Softball Softball Policeman helmet or some other Policeman helmet or some other official hat official hat Undermatting for padding Undermatting for padding WATCH, WAIT, AND WONDER SUGGESTED LIST OF TOYS Stacking cups Stacking cups Blocks Blocks Small cars including ambulance Small cars including ambulance Medical kit with stethoscope Medical kit with stethoscope Sets of vinyl family dolls (black & white Sets of vinyl family dolls (black & white Set of tame and wild animals - large solid variety Set of tame and wild animals - large solid variety Bowls and mixing spoons Bowls and mixing spoons Train set Train set Heavy duty blue vinyl (Pool manufacturers) 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 After initially observing, the mother becomes intrusive or detached Mother becomes busy, bored or sleepy Mother becomes busy, bored or sleepy Mother says she does not like to play Mother says she does not like to play Mother wants to change WWW Mother wants to change WWW Mother is uncomfortable with the therapist sitting in a chair and observing 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 is impatient regarding solutions of problems/wanting advice Mother wants to focus on events outside the session Mother wants to focus on events outside the session Mother has difficulty making observations in the Discussion Mother has difficulty making observations in the Discussion Infant falls asleep, wants to escape the room, or otherwise acts out 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 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 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. 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 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 KNOWING WHEN TO TERMINATE TREATMENT Reduction or disappearance of presenting problems Reduction or disappearance of presenting problems Shift in interactional pattern Shift in interactional pattern Increased comfort in relationship Increased comfort in relationship Infant signals readiness to stop Infant signals readiness to stop


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