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

COLLABORATORS: Elisabeth Muir Mirek Lojkasek

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

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

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

THEORETICAL UNDERPINNINGS OF WATCH, WAIT AND WONDER

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

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

“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

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

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

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

“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

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

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

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

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.

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.”

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.

“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.

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

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

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.

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)

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

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

ASSSESSMENT

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

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

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

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

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

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

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

INFANT-LED ACTIVITY

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.

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

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

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

DISCUSSION

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

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)

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

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

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.

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

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