Report: Psychotherapeutic Interventions in Infancy

Mary Morrissey reports on a recent meeting hosted jointly by the Irish Institute for Integrative Psychotherapy and the Irish Forum for Child and Adolescent Psychoanalytical Psychotherapy, at which Dr. Margaretta Berg Broden from Sweden spoke on “Psychotherapeutic Interventions in Infancy”.

“Sarah was a tense child always on her guard. She was attentive to what happened in her surroundings and never relaxed for a second. Her tension required a great deal of energy and she was far below normal weight. She was an abandoned child in need of being held. When her mother after treatment was able to take an interest in her child and started holding her, walking around with her and showing affection, Sarah gradually let go of her upright posture, her stiffness disappeared and her appearance changed drastically. She appeared to be a normal 3 month old baby with arms and legs slightly bent and curled up.” (Berg Broden 1992)

Dr. Berg Broden divided her presentation into two main areas: Treatment Concept and Treatment Intervention.

Treatment Concept

New knowledge of the infant’s capacity and ability to participate in relationships has led to a view that the infant is much more complex, compe­tent, resourceful and unique than previous theories of child development have indicated. She is supportive of research findings which claim that a sense of self is present in the infant already from birth. (Stern 1985). In the early days of her work she commented that her therapeutic team worked with 2-3 year olds in the hope that they would reach them early enough to be able to work in a preventative way. However, it transpired that the children’s problems were deeply rooted, that the mother-child relationship had been established in the first year of life, a year which had been difficult for most of the women referred and characterised by feelings of failure. We were asked to be wary of thinking that it is difficult for everyone in the beginning with a new baby, and that the problems will go away as the child gets older. We were urged to act early where difficulties exist in Mother-infant relationships.

Dr. Berg Broden said that the period from pregnancy to when the child is one and a half years old is a time when there is flexibility in the nervous system. There is an openness, physically, mentally and emotionally. It is a good time to heal without wounds. The earlier one can work with the mother the better. For example, a mother of an infant who is having difficulty will say: “Help me with my baby”, ‘while a mother of a toddler will say: ‘Take him and fix him!” It seems that the psychotherapeutic intervention works best when the baby is aged 0-3 months. This is the maternally sensitive period. It is the wet, sloppy period of tears and goo!

In the past the only therapeutic intervention was in relation to the mother’s depression while now the emphasis is to work on lots of different levels. It is important to work with the imaginary baby in the mind of the mother which happens during pregnancy and is created by unconscious thoughts and feelings. During pregnancy the ‘pictures’ of the baby are slow to develop. During the seventh month, there is a peak in the clarity of mental pictures. The week of the birth the representation of the imagined child fades to allow for the arrival of the new baby.

The transition from imaginary to actual baby goes easily for most people. Where there is a difficult transition as in the case of a child with a physical or learning disability, we need to help the mother bring back the imagined/idealised baby and have time to mourn him/her and to say goodbye.

Another level is to work on the Early Maternal Functions of being a mother. These are: attending to physical need, being emotionally available, organised, focusing on the infant experiences, regulating the affect, regulating attention, regulating security. The whole idea of treatment is to create possibilities for the child to develop mutual identification of the mother and infant, helping the infant’s search for his/her own identity as a human being and the mother to identify as a mother. In order to support this mutual identification process, Dr. Berg Broden’s methods span from directly influ­encing the mother, the child or their interaction, to interventions aimed at building or strengthening a supportive context in which the identification takes place. This includes couple, family and extended family work. Inter­ventions are aimed at many levels.

Treatment Intervention

Stages of the treatment process include the following:

Referral
First Visit (with whole family)
Observation and assessment (without intervention)
Formulation of treatment goal and contract
Treatment
Evaluation and possible new goals
Termination phase
Follow up in six months

The treatment model follows two main avenues. The first is to effect direct contact by using channels of contact inherent in the child and the second is to stimulate and help the mother to internalise the child and see him/her as a unique person. This model is based on daily contacts which offer oppor­tunities to observe the interaction as it unfolds and enables the therapist to encourage the mother through difficult patches.

Direct Contact

The aim of direct contact is to create a strong bond between mother and child by encouraging the following:

Create mutual experiences
Broaden the repertoire of interactive activities
Initiate “meetings” between mother and infant
Focus on resources and possibilities. It is important to gratify and encour­age the mother.
Response to the baby’s signals. Help the mother to be aware to interpret signals e.g. if mother thinks child is tired every time he/she cries, there is a need to help her make the right response at the right time.

Internalising the Child

The aim of the treatment model is to help mother internalise her child. In disturbed mother-infant relationships the child is often not seen by the mother. If she has not internalised her child she will not respond to him/her in an authentic way. If the child is not seen as a unique person and not related to and confirmed, his/her physical development will be endangered.

How to do it

Separate out the real from imagined infant. The mother’s image of the “real” child can be distorted or incomplete which affects her way of interacting. By confronting the mother’s image of the child with the real child, it is possible to intervene directly and put her image to a reality test.

Acknowledging and disarming the mother’s projections. These are the notions we put on the baby e.g. a mother talking about a monster, not an infant. Be aware of the positive projections e.g. ‘This baby is fantastic, she knows exactly how I am feeling more than anybody else.”

Tell stories of everyday events. Mothers are encouraged to talk about the details of what the child did.

Activate and create a history. A sign of lack of bonding is that there is no history.

Explore child’s personality. Need to describe and point out special charac­teristics such as temperament and specific behavioural patterns.

Child’s Competencies. The therapist facilitates this process by calling attention to the infant’s ability e.g. capacity to imitate, sometimes a development assessment is used to illustrate the range of the child’s competence.

Ritual and Celebrations. Rituals arc important in order to recognise change in people’s lives. Encourage mothers to find out about old family traditions and create new ones. Celebration can be initiated as a way of focusing mother’s attention on the child’s development, aimed at recognising and affirming mother and child as well as their relationship.

Personal Reflections

Dr. Berg Broden’s presentation has given me concrete ideas about how to work with our own Mother and Baby group which, as members of the Early Intervention Team, we run for mothers and children aged 0-3 years, all of whom have a learning disability/mental handicap. I now feel more confident in my efforts to meet the infants face to face and give them the time to respond and interact. Traditionally in working with children with learning disability, much of the emphasis is on the stage of development from the child’s point of view, and assessing what needs to come next or be learned next. Dr. Broden highlighted the catalystic impact of the mother’s role in the development of the child. I found the diagnostic pointers interesting; for instance, the lack of movement in the child being linked to lack of joy in the home. Also the importance of not waiting for the child to grow out of the problem but empowering the mother early on.

A heartening conclusion was the strong message of hope. Dr. Berg Broden advocates a detailed intervention which enables a damaged mother-infant relationship to be repaired, and to allow mother and baby to feel confident and secure.

References

Berg Broden. M. (1989) Mother and Child in No Man’s Land: Therapeutic Interventions in Infancy. Almqvist & Wlksell, Stockholm.

Stern. D. (1985) The Interpersonal Work of the Infant. New York. Basic: Books,

(An excerpt of three chapters of this book is available in an English translation from Inger Nolan, Irish Inst. of Integrative Psychotherapy.)

(Mary Morrissey is Senior Clinical Psychologist with Cheeverstown House Ltd. Dublin which provides residential, day and community services for children and adults with a learning disability/mental handicap. She has completed her first year of psychotherapy training with the Irish Institute of Integrative Psychotherapy.)