Contents: Mindful Parenting: Enhancing Reflective Capacities of

Contents:

The Signal

Institute for Children, Youth & Families, Kellogg Center, Ste. 27, MSU, East Lansing, MI 48824 Tel: 517-432-3793 Fax: 517-432-3694

Vol. 11, No. 2 Newsletter of the World Association for Infant Mental Health April - June 2003

7 Literature Monitor

8 Antipodean Activities

15 Affiliate News

19 Conference Reports

26 President’s Perspective

27 By the Yarra River

By: Diane Reynolds, MFTInfant Mental Health Services CoordinatorThe Maple Counseling Center, BeverlyHills

IntroductionIntroductionIntroductionIntroductionIntroduction

At The Maple Counseling Center(TMCC), a large, non-profit,community mental health centerserving greater Los Angeles, we haveworked over the last two years todevelop a therapeutic parent-infantgroup design that utilizes observationas a starting point for enhancing thereflective capacities of group members.Known as “Mindful Parenting,” theseexperiential groups are part of a largerInfant Mental Health Service andTraining Program currently indevelopment at TMCC. The MindfulParenting groups, which began in Julyof 2001, are an experimental work-in-progress that evolved out of interest inthe clinical possibilities for interplaybetween contemporary psychoanalysis,infant observation, attachment theory

Mindful Parenting:Enhancing Reflective Capacities of Parents and

Infants in a Therapeutic Group

and research, infant and brain research,affect regulation theory, and relatedareas of study, as well as the non-clinical parent-infant group formatknown as RIE.

Starting from the assumption that 1) asecure attachment bond is thefoundation for adaptive infant mentalhealth (Schore, 2001); 2) that thesecurity of a child’s attachment isstrongly predicted by mother’s capacityto reflect on her child’s affectiveexperience (Slade, et al, 2001); and 3)that the core of prevention in earlychildhood should be the enhancementof mentalizing (Fonagy, 1998); theMindful Parenting groups aim first tocreate conditions that allow parents toexperience, cultivate, and practice the artof wonder—wonder about what goeson in one’s own affective mind-and-body experience as well as in that of theinfant.

With this paper, I will make explicit thedesign of Mindful Parenting and offerpreliminary thoughts on the utility ofthis therapeutic group in developingand supporting healthy parent-infantrelations. The interdisciplinaryunderpinnings of our group work,including the application of infantobservation and infant-ledpsychotherapies, will be followed byexposition of the structuralcomponents of Mindful Parenting.This will be complemented bydescriptions of unadorned momentsfrom our group experience, in an effortto make plain the ways that MindfulParenting seeks to restore, enhance, andsustain the most basic affective contacts

between parent and child, both verbaland nonverbal.

Reflective Capacity: AnReflective Capacity: AnReflective Capacity: AnReflective Capacity: AnReflective Capacity: AnInterdisciplinary LensInterdisciplinary LensInterdisciplinary LensInterdisciplinary LensInterdisciplinary Lens

What mediates the link between thequality of a parent’s earliest attachmentrelationships and the quality of aninfant’s attachment experience with thatparent? Main’s (1991) finding that achild’s security of attachment ispredicted by a mother’s ability toarticulate a coherent narrative about thequality of her own early relationshipshas led attachment research to finer andfiner examination of the underlyingmental mechanisms that might be ableto produce such narrative clarity.Fonagy (1996) found thatmentalization, or reflective functioning,the capacity to meaningfully reflect onstates of mind in self and other, iscorrelated with narrative coherence andadult attachment classification, and is astrong predictor of child attachmentsecurity. Current research showspromise that maternal reflectivefunctioning may serve as a mediatinglink between the mother’s prenatalattachment organization and theinfant’s attachment security in thesecond year of life (Slade, et al, 2001).

Psychoanalysis has long considered theimpact of the early relationalenvironment, the introjected experienceof that environment, and the power ofthese early experiences to shape lifeevents. Bion’s (1967) concepts ofmaternal reverie, alpha function, andcontainment, Klein’s (1946) projectiveidentification, and Winnicott’s (1956)

2 The Signal2 The Signal2 The Signal2 The Signal2 The Signal April - June 2003 April - June 2003 April - June 2003 April - June 2003 April - June 2003

Editorial Staff

Editor: Paul Barrows

Production Editor: Tina Houghton

Editorial Board:Susan BergerSalvador CeliaPeter de ChateauMauricio CortinaGraziella Fava-VizzielloEmily FenichelElizabeth Fivaz-DepeursingePeter FonagyCynthia Garcia-CollBernard GolseAntoine GuedeneyDavid LonieTuula TamminenMichael TroutElizabeth TutersHisako Watanabe

President’s Perspective: Peter de Chateau

From the Red Cedar: Hiram E. Fitzgerald

The Signal is a quarterly publica-tion of the World Association forInfant Mental Health. Addresscorrespondence to Paul Barrows [email protected]

All opinions expressed in TheSignal are those of the authors,not necessarily those ofWAIMH’s. Permission to reprintmaterials from The Signal isgranted, provided appropriatecitation of source is noted.Suggested format: The Signal,2001 Vol. 9, No. 3, WAIMH.

primary maternal preoccupation are allefforts to capture the same subtle,elusive, and mostly intuitive process bywhich one human being canmeaningfully grasp what is insideanother. More recently, concepts such asStern’s “ways of being with” (Stern,1985) and Lyons-Ruth’s “implicitrelational knowing” (Lyons-Ruth, 1998)have further illuminated the underlying,non-conscious relational processes thatmediate meaningful mother-infant andtherapeutic relationships.

Infant and brain research likewise exploreways in which two individual brain-bodysystems move together, producingsomething resonantly larger than thesum of their parts. Schore (2002) callsattention to the synchronic interplaybetween mother and infant, where arhythmic, affective dialogue unfolds, andwhere each matches the other’s temporaland affective patterns, recreating in theother their own inner psychobiologicalstates. Tronick’s ‘Dyadic Expansion ofConsciousness Hypothesis’ (Tronick et al1998) proposes mother and infant asindividually self-organizing systems,creating states of consciousness (or brainorganization) capable of expansion intomore coherent, complex states throughcollaboration with one another. Schoresuggests that the center of psychic life hasshifted from the verbal left to the highestlevels of nonverbal and non-consciousright hemispheric function, and he notesthat by incorporating interdisciplinarydata with psychoanalysis, the :talkingcure” expands into a more encompassing“communicating cure.”

Chandra: An InquisitiveChandra: An InquisitiveChandra: An InquisitiveChandra: An InquisitiveChandra: An InquisitiveCoo, AnsweredCoo, AnsweredCoo, AnsweredCoo, AnsweredCoo, Answered

Chandra, a seven month old baby girl,spontaneously engages the facilitator with asimple coo during her fifth group meeting.The facilitator responds in kind and aprolonged ‘conversation’ builds from looks andgurgles, with mother and group looking on.This gives way later to group reflection aboutthe nonverbal, nonlinear, musical nature ofplayful communications with infants, and thecycles of connection, failure and repair(Tronick, 1989) that define these early proto-conversations. Two meetings later, Chandraand her mother are the first to arrive for group.They settle quietly into the play area andChandra is placed on her back, facing hermother. In previous meetings, there has been asense of an as yet untapped connection betweenthe two—Chandra, a pleasant, cooperative

baby, is in fulltime daycare while her single,divorced mother works. In group, Chandragenerally seems content to gaze in long,sweeping movements at the silk canopy above,rarely interested in toys or motility and onlyoccasionally participating in more contactfulexperiences with mother—and even then, in anundeveloped way. There is a sense thatChandra’s easygoing temperament mightactually put her at risk by giving theimpression that all is right with her, always.She does not appear cut off at this point, butmight she eventually lose touch with or missopportunities altogether for more passionatecontact? In this seventh group meeting,Chandra directs an inquisitive coo in thedirection of her mother, and today, motheractively listens and responds in kind, withinterest greater than previously seen. Chandrathen purses her lips at mother, and motherpurses hers back. Chandra hums, then motherhums. Chandra hums again and mother repliesyet again. Ever so slowly, a delicate,improvisational melody of shared purrs, glances,smiles, hums, touches and coos unfolds.Minutes pass, with mother and infant fullyengaged in their intimate dance. For thoseobserving, the simple beauty of this moment isbreathtaking.

The Utility of ActiveThe Utility of ActiveThe Utility of ActiveThe Utility of ActiveThe Utility of ActiveObservation of Infants forObservation of Infants forObservation of Infants forObservation of Infants forObservation of Infants forParents and CliniciansParents and CliniciansParents and CliniciansParents and CliniciansParents and Clinicians

Infant observation as a training devicehas a rich history, including the EstherBick (1964) method of formalobservations of “normal” parent-infantdyads and families. Introduced at theTavistock Clinic in the 1940s, this non-intervening observation of infants hasbeen utilized at many clinical traininginstitutions as a tool for developing thetherapist’s intuitive equipment andcapacity for tolerating primitive anxieties(Hansen, 2002). In this method, anobserver meets with a family for weeklyone hour visits following the birth oftheir baby as a means of studying thedevelopment of the infant and mother-infant relations through the patterns ofbehavior that emerge and shift over time.Visits continue over a one to two yearperiod, with the observer making richlydetailed descriptive notes after eachmeeting. Visits are supplemented withweekly group seminars, where four to sixobservers gather with a more seasonedclinician-observer to reflect on theexperiences of both the observer and theobserved. While there is no intent tooffer clinical intervention in this method,it may provide an essentially unseen

World Association for Infant Mental HealthWorld Association for Infant Mental HealthWorld Association for Infant Mental HealthWorld Association for Infant Mental HealthWorld Association for Infant Mental Health The Signal 3 The Signal 3 The Signal 3 The Signal 3 The Signal 3

alpha function (Bion, 1967) for theparent-infant couple (McCaig, 2001,personal communication) through thereflective, containing activity of both thethinking observer as well as the largerseminar group.

Less formal versions of infantobservation—shorter, more active, orwithout group processing of theobservational experience - areincorporated into many childdevelopment curricula. Along theselines, the experiential, non-clinical parenttraining groups known as RIE, anacronym for Resources for InfantEducaters, utilize observation of infantsin promoting respectful interactionsbetween the caregiver and child.RIE was developed in 1978 by childdevelopment specialist Magda Gerber(Gerber, 1998) and colleague TomForrest, M.D. Working with smallgroups of ordinary parents and infants,Gerber created an experiential parenttraining format for learning respectfulparenting practices. The RIE philosophyplaces primary emphasis on unhurried,sensitive observation of infants. RIEsuggests that when a caregiver offers full,undivided attention to, respect for, andcommunication about the infant’sunique needs, especially during caregivingroutines, the groundwork is laid for theinfant’s trust in the caregiver. When thiscaregiver is patient and responsiveenough to allow time for the infant toactively participate in caregiving routinesas well as in their own discovery of theworld, this makes room for theemergence of an authentic self and asense of competence. RIE stressesnatural gross motor development (e.g.,allowing infants to reach motormilestones at their own pace, withoutinterference) and emphasizes therespectful use of narrativecommunications prior to interacting withthe infant (e.g., “I’m going to pick youup now,”) and patience in waiting for theinfant’s response before proceeding.RIE has a devoted following throughlocal and national groups facilitated byRIE associates and through applicationsin infant care centers and preschoolsettings.

In placing primary emphasis on theinfant’s inherent competence innavigating physical and socialdevelopment, RIE gives the infanttremendous room to maneuverdevelopment in their own particular way.

Though limited in exploration of theinternal worlds and affective exchanges ofparent and infant, RIE’s respectfulparenting principles, unhurriedobservation of infants, and experientialgroup format have untapped potential inclinical use. Likewise, Esther Bick’sobservational method - in particular, themindful attention to microscopic detailsof infant life and the unseen containingfunctions of infant observer and seminargroup - continues to find new clinicalapplications.

Infant-Led and Parent-Infant-Led and Parent-Infant-Led and Parent-Infant-Led and Parent-Infant-Led and Parent-Led TherapeuticLed TherapeuticLed TherapeuticLed TherapeuticLed TherapeuticFacilitationFacilitationFacilitationFacilitationFacilitation

In recent years, the use of infant-led workwith parent-infant dyads has grown.“Watch, Wait, and Wonder” (Cohen, etal, 1999), “Child-Centered Activity”(DeGangi, 2000), and “Floortime”(Greenspan, 1997) utilize similarobservational components where parentsfollow the infant’s lead. Duringobservation, the parent is on the floorwith the infant, observing the infant’sself-directed activity, and interactingprimarily at the infant’s initiative. Thismay be followed by a parent-centeredcomponent, where parent and therapistreflect on the observations, focusing ondevelopmental or relational themes inthe infant’s behavior, the parent’sstruggles in following the infant’s lead,or links to the parent’s early attachmentrelationships.

Other infant-led approaches are notablefor active therapeutic work betweentherapists and infant-as-subject(Thomson-Salo & Paul, 2001; Norman,2001). Emotional connections are madewith the infant through verbal and non-verbal means, e.g. gaze, touch, talk, orplay. The therapist commonly makesuse of his or her inner experience of theinfant as a link to the infant’s internalworld. While this work is primarilyinfant-centered, the therapist’s efforts tomake contact with the unknown in theinfant have a corresponding action onthe parent-infant attachment relation-ship, whether expressed overtly or not.

In contrast, psychodynamic infant-parentpsychotherapy (Lieberman, et al, 2000)pays clinical attention to the infant, butfocuses more on what transpires in theparent-infant couple. Subjectiveexperiences of parent and infant are heldmore equally, though work is often more

parent-centered. The mental representa-tions of the parent are a primary target ofmulti-modal intervention, accessed andmodified through links to the parent’searly and current relational experiences.Corrective attachment experiencesprovided by the therapeutic relationshipalso serve a primary role in this approach.

Only a few comparative studies examin-ing the effectiveness of infant-parentpsychotherapies have included infant-ledwork, but notably, these studies suggestthat infant-led interventions where theparent is the facilitator have considerableimpact on attachment status (“Watch,Wait, and Wonder;” Cohen, et al, 1999)and on inattention and irritability ininfants (“Child-Centered InfantPsychotherapy;” cited in DeGangi, 2000).The effectiveness of infant-led workwhere the therapist serves as facilitator isan area for further study.

Following the infant’s lead, by parent ortherapist, holds continuing promise as atool for intervention in the parent-infantrelationship. More importantly, whetherinfant or parent is in the therapeuticforeground, the remaining other’scontribution must be held in thebackground of the therapist’s mind. Toapprehend the full range and dimension-ality of the attachment relationship andto have maximum impact, each memberof the dyad must be held equally. Thismakes work with parents and infantstremendously challenging.

Creation of a GroupCreation of a GroupCreation of a GroupCreation of a GroupCreation of a GroupExperienceExperienceExperienceExperienceExperience

In juxtaposing interdisciplinary ideas, Ibegan to explore the creation of atherapeutic parent-infant group thatwould provide an experiential arenawhere parents and infants could play andlearn and simply be together in body-and-mindfulness. This group experiencewould create a kind of a potential analyticspace (Winnicott, 1951), where theemotional and spatial ebb and flow ofattachment and exploration could beattended to with equal regard, whereparticipants’ affective experiences couldbe mindfully reflected upon, and wherethe parent-infant couple could exploreand deepen how they know and feelabout each other and the world.Facilitators would serve to create andsupport the conditions that allow thisunfolding to occur and to offer bothparent and infant direct experience with areflective mind.


Onsite at TMCC over the past 20months, we have served 17 adults and 13children in two ongoing groups,composed of a culturally andeconomically diverse mix of primarilymothers with infants or toddlers, butoccasionally also including fathers,grandparents, and extended familymembers. With recent implementationof a school-based Mindful Parentinggroup offsite, we have also served fourteenage mothers, three fathers, and fourinfants in a time-limited groupexperience. As an alternative totraditional ‘mommy and me’ classes orsupport groups, Mindful Parentingprovides a setting that enriches parent-child relationships, offers opportunitiesfor motor development and socialcontact for infants, and occasions foradults to grow in parental competenceand self-awareness—all in a frameworkof observational and experientiallearning.

In onsite groups thus far, members havebeen primarily low to moderate risk,with some families intact, and othersdivorced. Some members have been stay-at-home mothers, with others workingfull or part-time, and also somestruggling with anxiety or depression.Among children, we have seen issues oflow weight gain, sensory integrationdifficulties, social anxiety, affectregulation problems, and aggression,alongside other developmental concerns.With our school-based group, we arenow also reaching a higher riskpopulation that includes un-wed teenmothers stressed with financial concerns,work, school, or little family support,and the demands of their premature orspecial needs infants. Regardless of thecircumstances, many parents, consciouslyor unconsciously, are grappling withtroubling psychic remnants from theirown early attachment relationships—pockets of unmentalized affectiveexperience—that make negotiatingstressors particularly challenging.A starting point in this group work isthe belief that there is profound bi-directional, relational and regulatoryutility in strengthening a parent’s capacityto come as close as possible to a child’ssubjective, affective experiences, and soour therapeutic work first of all attendsto enhancement of reflective capacity anddeep empathy—both verbally andnonverbally. This process is initiatedthrough the parent developing an activeobservational stance, through the

accumulated practice of directing quieted,patient, curious, receptive attention toboth child and self, and through learningto respect and follow the child’s lead incontact-seeking and exploratorybehaviors. The parent’s activity ofsimply slowing down enough to noticeserves as an empathic function. Thus,the infant’s ‘unadulterated’ capacity tosee, feel, venture into, experience, andeventually think about the textural,dimensional, or social properties of theirworld—hard/soft, close/far, in/out,fast/slow, etc.—is brought to theforeground of the parent’s mind forreflection. What are the properties ofthis chair, that ball, this child, thatmother? How might I make use ofthese objects? And, how does contactwith them make me feel? These samequestions may be applied to each newaffective moment.

Through each infant’s specificdevelopmental trajectory, parents havethe opportunity to wonder togetherabout how it is that we come to knowthe landscape of human experience—thephysical and psychic, temporal andspatial, sensory and emotional, subjectiveand co-constructed. The verbal andnonverbal facilitation of this interactiveflow of affective experience from parentto child to parent and back, ad infinitum,forms the basis of our preventiveintervention in Mindful Parenting.

Structural Components ofStructural Components ofStructural Components ofStructural Components ofStructural Components ofthe Group Experiencethe Group Experiencethe Group Experiencethe Group Experiencethe Group Experience

Mindful Parenting consists of weeklymeetings of one and a half hours each.With ongoing onsite groups, parentsmake an initial eight-week commitment,after which they may continue for as longas they find the experience useful forthem and their children. Offsite groupstend to be limited to pre-mobile babiesand may last as few as 12 weeks. Infantsare grouped developmentally, with rarelymore than four months difference in age,and no more than four to six infantswith parents per group. Alongside thelead facilitator, there are up to threeinterns or volunteer clinicians thatobserve and assist each group for thepurposes of clinical training andeducation. Groups may begin withinfant members as young as threemonths and continue through preschoolage, depending upon the needs of thegroup served.At our onsite location at TMCC, groups

take place in a 325 square foot gated areaof a larger conference room. Décor isspare and toys are minimal with theyoungest of infants, and increasinglychallenging as the children develop. Pre-mobile infants meet with their motherson a large blanket, and when settled andready, babies are placed on their backs,facing mothers and facilitators, whoform a circle on the floor around them.As infants grow older and begin to roll,crawl, sit, and cruise, the variety of toysand equipment increases, and theobserving circle gradually widens andforms a semi-circle of chairs at one end ofthe room, allowing greater space fortoddler exploration.

The play environment is aestheticallyengaging and developmentallychallenging, based upon the needs ofattending babies. A silk canopy spansthe center length of the room, protectinginfant eyes from overhead lights andproviding billows of pastel color forgazing. For the youngest, play materialsmay be as simple as a few woodenteethers and visually interesting clothnapkins propped as tents for study.Some are placed within reach of aninfant’s grasp and some invitingly justbeyond reach. As the babies’ interest,attention, and motor coordinationexpands, a varied assortment of simpletoys is gradually introduced, thoughtfullyplaced about the room alongside lowwooden platforms and step units toclimb and explore.

The toys chosen are intentionallyuncomplicated, have multiple uses andare mostly of natural materials. A toy’stextural features provide the infantopportunities for contact with andexpression of such experiences as hardand soft. The toys frequently take onemotional weight or serve as links tosignificant affective moments over time,or may be utilized as tools in makingsocial contacts. Simple cloth dolls andanimals; wooden teethers, blocks, andlacing beads; miniature wooden vehicles;balls made of felt, yarn, or rubber; wovenbaskets of all sizes and shapes; large andsmall pillows to rest or nurse on; text-free board books and wooden books;colorful silk or cotton scarves; and foundobjects such as gourd rattles or reflectivestainless steel bowls comprise themajority of play materials.The group time is organized around the


ebb and flow of observation, reflection,and live interaction. Following transi-tion into the play environment, there isa formal period of quiet observation,usually lasting 20 to 30 minutes. Withthe infants in the perceptual foreground,the group work is more infant-centered,and parents and facilitators may sit backquietly, following the infants’ lead withpatient curiosity about what may bepresented. Observations are usuallysilently noted, though facilitators mayassist in developing parents’ subtlerobservational skills by drawing specialattention to micro-events that occuramong the babies and adults. Withteen mothers, we modify the observa-tion period to include facilitatorsworking more intimately for a time witheach parent-infant couple. Offeringimmediate, live narration of micro-events assists the teens in growing theircapacity to reflect on the minutiae ofbaby’s experience. When parents areencouraged to slow down to the pace ofinfant life, they begin to notice finerdetails of their baby’s experience—andgradually tease apart their own as well asthe baby’s emotional responses.

Adam: Walking with hisAdam: Walking with hisAdam: Walking with hisAdam: Walking with hisAdam: Walking with hisEyesEyesEyesEyesEyes

In a group comprised of teen mothers,17-year-old Julie sits at the foot of herfour month old infant son, Adam.Adam pleasurably mouths a teether inexploration, then after some minutes,shifts with what may be the earlyregistration of hunger. Adam resorts tomore intent pressing of teether-and-fistinto mouth, followed by losing motorcontrol of the teether, then by moreurgent sucking on fists together witheyes now closed. He remains like thisfor some moments, all effort pressingfists into his mouth cavity, with eyesshut as if hunger and desire for thebreast has transported him there in hismind. Adam begins to whimper andthen fussing quickly mounts. Afacilitator queries, ‘What do you think ishappening?’ and mother responds, ‘Ithink he’s hungry,’ and gently butswiftly pulls baby to her breast, wherehe settles in at once for a feed.

Later, Julie gazes with wonder at Adam,lying on the floor now before her, sated,arms and legs in perpetual but irregularmotion, yet with eyes fixed on mother’sgaze. From our first meeting, Adamhas shown a preference for unusually

prolonged, uninterrupted gazing - intomother’s eyes and the eyes of receptivegroup members and facilitators - an eventdescribed by one facilitator as ‘walking withhis eyes.’ This opens a discussion of howdesire precedes action, how a pre-mobilebaby may ‘travel’ through senses orimagination or subtle motion to comeclose—long before gross motor achieve-ments direct him physically to his destina-tion. Several moments pass, then Juliequietly inquires, ‘Do babies havethoughts?’ The facilitator responds, ‘Whatdo you think?’After the initial observation period, thegroup as a whole then has an opportunityto reflect on what was seen. The facilitatorgenerally begins the reflecting period with aquestion such as “What are you noticingtoday?” or “What are your impressions?”or even “What are you feeling in thismoment?” at which point participants havethe opportunity to present what theynoticed both in the babies and inthemselves. Conversation will likelyinclude references to how a particularsequence of activity felt—either for theinfants involved or for the parents as activeparticipants or witnesses. At this point,the parents’ internal experiences move intothe perceptual foreground of the group,and the group work is, for a time, moreparent-centered. The infants’ activityremains further back but still alive in thegroup’s attention. A lively dialogue oftenoccurs as parents and facilitators comparenotes about what was seen and how it wasexperienced. Exploration of each groupmember’s unique point of view createsopportunities to consider subtle eventsfrom various perceptual and affectiveangles, providing moment-to-momentmicroanalysis of the group experience.

The flow of observation, reflection andinteractive experiencing continuesthroughout much of the balance of thegroup meeting, with parents and infantsalternately brought to the foreground formindful consideration. The group’s focusis akin to how a sensitive mother mightrespond to her large family: moving asneeded based on where the action is, withdifferent family members shifting in andout of the foreground, while still others aretracked in the background of her mind.The reflective group mind that emergescreates a container for primitive anxietiesassociated with encountering the unknownin self and other. A similar, albeit separate,layer of containment occurs when facilitatorand interns meet weekly outside group tofurther digest the experience in a reflective

supervision process, functioning notunlike an infant observation seminar.The possibility of multiple layers ofreflection and containment—fromparent to infant, facilitator to infant,parent to parent, facilitator to parent,and so on—make this interventionactive, alive, creative, and flexible to theparticular needs of each affectivemoment.

Finally, two structured activities areintroduced during the last half hourwith older toddlers. First, near thebeginning of the child’s second year (orwhen developmentally ready), thefacilitator will offer snack time to thetoddlers while parents relax andobserve. This structured time providesopportunities for parents to observe: 1)how patient waiting for children toenter new experiences on their ownallows for greater interest, autonomy,and cooperative interactions; 2) howfood may be offered in ways thatpromote positive, respectful interac-tions between caregiver and child; and3) how the use of comforting ritualsmay ease navigation of daily caregivingroutines. This also provides one of thefew opportunities in our relativelyexpectation-free group environment forchildren and parents to see andexperience the joys and challenges ofnavigating structure and turn-taking ina social event (e.g., washing hands,putting on bibs, sitting down, eatingwhile sitting, removing bibs, andwashing hands again).

Second, when developmentallyappropriate, an informal circle time isoffered just prior to closure of thegroup time. The parents andfacilitators form a circle and toddlers areinvited to join in for two or threerepeating short songs or finger plays orthey may continue independentactivities. Children often look forwardto this musical and rhythmic groupcontact and are intently engagedthroughout. Trevarthen (2000) notesthe close attention paid by infants tothe ordering of elements in simplemelody or poetry, and cites researchindicating how the musicality ofmother’s happy voice is important forsupporting mutually satisfyingcommunication with an infant. Aclosing song brings the group time toan end, and parents experience thepower of ritual and song as tools fortimes of transition. In sum, Mindful


Parenting is an effort to createopportunities for wholesome “ways ofbeing with” (Stern, 1995), and thinkingabout, parent and child and thecomplexity of experiences that the couplehas when engaged together andexploring apart.

Dana and Lee: MakingDana and Lee: MakingDana and Lee: MakingDana and Lee: MakingDana and Lee: MakingContact Through TakingContact Through TakingContact Through TakingContact Through TakingContact Through Takingand Givingand Givingand Givingand Givingand Giving

Dana, a 13-month-old toddler girl who hasbeen walking for less than a month, comes forher second meeting in a preexisting group. Shestays mostly near mother and father, venturingonly cautiously into the play area to tentativelyexplore some wooden teethers. She selects onecolorful teether that resembles a bracelet andtoddles somewhat shakily back toward theadults. Looking pleased with herself, Danacomes to a stop several feet from her parents,and peruses her prized wooden teether. At thispoint, Lee, a large 14-month-old toddler boy,suddenly approaches Dana. Lee, whosetremendous motor agility contributes to atornado-like physical presence, has spent hisgroup time today fearlessly bounding about theroom and becoming increasingly aroused. Lee’sfather, who at times engages Lee in roughphysical play, has on several occasions predictedwith rankled certainty that his son will be “abully.” Dana is gazing at her chosen teetherwhen, without hesitation, Lee plucks theteether out of her hands and walks in thefacilitator’s direction. Dana’s mouth begins toquiver, her body to tremble, then a cry burstsfrom her lips and she toddles hurriedly to hermother’s arms, where she collapses in tears. AsLee passes in front of the facilitator with awild look in his eye, she announces, “I’m goingto pull you close,” and in an unusual gesture,gently but firmly scoops him onto her lap—inan effort to physically slow him and to containhis high arousal. He settles there, stilled for amoment. Calmly and without expectation, thefacilitator says, “Dana had the bracelet…thenyou took the bracelet from Dana…now youhave the bracelet…and Dana is crying.” Leelooks at the wooden teether in his hands,pauses for a few moments, then rises, walksover to Dana, and extending his hand, offers itback to her. She looks up at him with astartled expression, then softens and after amoment, accepts the teether.Some three months later, on the day of his lastvisit to group, Lee, now 17 months old,searches intently early in the meeting througha large basket filled with many woodenteethers. Lee pulls out each teetherindividually, considers it, and then discardseach unwanted teether onto the floor. Thissequence continues through several teethers

until he finally comes upon the one thatresembles a bracelet. Lee stops his activity,pausing quietly, then immediately takes theteether over and presents it to Dana, whoaccepts his offering. Later that same meeting,while the group discusses the meaning of theexchange and links it to the empathic contactmade three months before, Dana spontaneouslygives Lee an affectionate embrace for the firsttime. At the end of group, after our finalgoodbyes to Lee, he gets up, walks over, andembraces Dana one last time.

ConclusionConclusionConclusionConclusionConclusion

While the effectiveness of MindfulParenting has yet to be measured,anecdotal evidence seems to point to apositive impact on the thinking, affectiverelationship between parent and child.Over the coming year, we will bemeasuring reflective functioning in pre-and post-intervention interviews, and wehope to offer preliminary findings whenavailable. Mindful Parenting representsthe effort by this clinician to evolve anovel, hybrid group that enhancesreflective capacities in parents and infants,promoting verbal and nonverbalcommunications. Utilizing elementsfrom various disciplines, these groupsstrive to positively impact the parent-infant attachment relationship throughallowing parents and infants to gainexperience with and benefit fromunhurried, focused, and bare attention tostates of mind and body in self andother. This is the art of loving wonder.

Note: I would like to thank the TMCCintern and volunteer co-facilitators,whose contributions allowed muchcollaborative learning to take place: AzieAfari, Sharon Eshaghpour, AlexandraGuzman, Wendy Haffner, Lee Herzog,Honey Pietruszka, Lori Schelske, andJody Turner.Portions of this paper were originallypresented at the James S. GrotsteinAnnual Conference:‘New Perspectives on Infant and ChildDevelopment: A Psychoanalytic View ofAttachment,’UCLA, June, 2002, and a fuller versionwill be published later this year in theJournal of Child Psychotherapy.

Diane Reynolds, MFTInfant Mental Health Services CoordinatorThe Maple Counseling Center9107 Wilshire Blvd., Lower LevelBeverly Hills, California 90210Email: [email protected]

References• Bick, E. (1964). ‘Notes on infant observationin psychoanalytic training.’ In Williams, M. H.(ed.) Collected Papers of Martha Harris andEsther Bick. Strath Tay: Clunie Press (1987).• Bion, W. R. (1967). Second Thoughts. NewJersey: Jason Aronson.• Cohen, N.J., Muir, E., Lojcasek, M., Muir, R.,Parker, C. J., Barwick, M., Brown, M. (1999).‘Watch, wait, and wonder: Testing theeffectiveness of a new approach to mother-infant psychotherapy.’ Infant Mental HealthJournal 20 (4): 429-451.• DeGangi, G. (2000) Pediatric Disorders ofRegulation in Affect and Behavior: ATherapist’s Guide to Assessment andTreatment. San Diego: Academic Press.• Fonagy, P. (1996) ‘The significance of thedevelopment of metacognitive control overmental representations in parenting and infantdevelopment.’ Journal of Clinical Psychoanaly-sis 5: 67-86.• Fonagy, P. (1998) ‘Prevention, the appropri-ate target of infant psychotherapy.’ InfantMental Health Journal 19 (3): 124-150.• Gerber, M. (1998) Dear Parent: Caring forInfants with Respect. Los Angeles: Resourcesfor Infant Educarers.• Greenspan, S. (1997) Developmentally-basedPsychotherapy. Connecticut: InternationalUniversities Press.• Hansen, Y. (2002) Does infant observationenhance the work of the clinician? Unpub-lished address, Symposium, ‘A View Into theBaby’s Beginnings: An Infant ObservationConference,’ Los Angeles, CA, May.• Klein, M. (1946) ‘Notes on some schizoidmechanisms.’ International Journal ofPsychoanalysis. 27: 99-110.• Lieberman, A., Silverman, R. & Pawl, J.(2000) ‘Infant-parent psychotherapy: Coreconcepts and current approaches.’ In Zeanah,C.H. (ed.) Handbook of Infant Mental Health,2nd ed. New York: Guilford Press.• Lyons-Ruth, K., Bruschweiler-Stern, N.,Harrison, A. M., Morgan, A. C., Nahum, J. P.,Sander, L., Stern, D. N., Tronick, E.Z. (1998)‘Implicit relational knowing: its role indevelopment and psychoanalytic treatment.’Infant Mental Health Journal 19 (3): 282-289.• Main, M. (1991) ‘Metacognitive knowledge,metacognitive monitoring, and singular(coherent) versus multiple (incoherent)models of attachment: Findings and directionsfor future research.’ In Parkes, C., Stevenson-Hinde, J. & Marris, P (eds.) Attachment Acrossthe Life Cycle. New York: Routledge.• McCaig, J. (2001) Personal communication.• Norman, J. (2001) ‘The psychoanalyst andthe baby: a new look at work with infants.’


International Journal of Psychoanalysis 82:83-100.• Schore, A. N. (2001) ‘The effects of asecure attachment relationship on right braindevelopment, affect regulation, and infantmental health.’ Infant Mental Health Journal22 (1): 7-66.• Schore (2002) ‘Advances inneuropsychoanalysis, attachment theory, andtrauma research: Implications for self-psychology.’ Psychoanalytic Inquiry 22 (3):433-484.• Slade, A., Grienenberger, J., Bernbach, E.,et al. (2001). Maternal reflective functioningand attachment: Considering thetransmission gap. Unpublished address,Biennial Meeting of the Society for Researchin Child Development, Symposium,‘Maternal Reflective Functioning in Relationto the Child: Attachment, Caregiving, andDisrupted Relationships,’ Minneapolis, MN,April.• Stern, D. N. (1985) The InterpersonalWorld of the Infant. New York: Basic Books.• Stern, D. N. (1995) The MotherhoodConstellation: A Unified View of Parent-Infant Psychotherapy. New York: BasicBooks.• Thomson-Salo, F. & Paul, C. (2001) ‘Someprinciples of infant-parent psychotherapy:Ann Morgan’s contribution.’ The Signal,World Association for Infant Mental Health,January-June, 14-19.• Trevarthen, C. (2001) ‘Intrinsic motives forcompanionship in understanding: Theirorigin, development and significance forinfant mental health.’ Infant Mental HealthJournal 22 (1): 95-131.• Tronick, E. Z. (1989) ‘Emotions andemotional communication in infants.’American Psychologist 44: 112-119.• Tronick, E. Z., Bruschweiler-Stern, N.,Harrison, A. M., Lyons-Ruth, K., Morgan, A.C., Nahum, J. P., Sander, L., Stern, D. N. (1998)‘Dyadically expanded states of consciousnessand the process of therapeutic change.’Infant Mental Health Journal 19 (3): 290-299.• Winnicott, D. W. (1951) ‘Transitionalobjects and transitional phenomena.’ InCollected Papers: Through Paediatrics toPsychoanalysis. New York: Basic Books,1958.• Winnicott, D. W. (1956) ‘Primary maternalpreoccupation.’ In Collected Papers:Through Paediatrics to Psychoanalysis. NewYork: Basic Books, 1958.

Some Other Papers onSome Other Papers onSome Other Papers onSome Other Papers onSome Other Papers onGroup WorkGroup WorkGroup WorkGroup WorkGroup Work

Mills, M. & Puckering, C. (1995)‘Bringing about change in parent-childrelationships.’ In Trowell, J. & Bower,M. (eds) The Emotional Needs ofYoung Children and their Families.London: Routledge.

Moradi, S. Robert (1997) ‘The father-infant toddler group.’ In Mark, BonnieS. & Incorvaia, James A. (eds)Handbook of Infant, Child andAdolescent Psychotherapy vol 2.Northvale NJ: Aronson.

Paul, C. & Thomson-Salo, F. (1997)‘Infant-led innovations in a mother-baby therapy group.’ Journal of ChildPsychotherapy, 23 (2): 219-244.

Woods, M. Z. (2000) ‘Preventive workin a toddler group and nursery.’ Journalof Child Psychotherapy, 26 (2): 209-233.

New BookNew BookNew BookNew BookNew Book

Pozzi, M.E. (2003) Psychic Hooks andBolts: Psychoanalytic Work withChildren Under Five and their Families.London: Karnac.

Soft cover / 217 pages / ISBN:1855759071 / £19.99 Euros 31.98

‘In this book it is made plain thatcomplex and powerful understandingcan take place in brief work. The baby’sdevelopment is carried forward, thefamily re-groups differently,understanding brings a change inbehavior.’ Lisa Miller, author of CloselyObserved Infants‘This book focuses on young children asold as five and the parents and siblingswho live with them. It wants to exploredeep, unconscious connections between

children and parents, especially in thosecases where symptomatic behavioursdevelop and turn a potentially pleasantand satisfying family life into hell.’ -MariaPozzi from the Introduction

ArticlesArticlesArticlesArticlesArticles

Anand, K.J. & Scalzo, F.M. (2000) ‘Canadverse neonatal experiences alter braindevelopment and subsequent behavior?’Biology of the Neonate, 77 (2): 69-82.

Cooper, P.J., Murray, L., Wilson, A. &Romaniuk, H. (2003) ‘Controlled trialof the short- and long-term effect ofpsychological treatment of post-partumdepression. 1. Impact on maternalmood.’ British Journal of Psychiatry182: 412-419.

Cooper, P.J., Murray, L., Wilson, A. &Romaniuk, H. (2003) ‘Controlled trialof the short- and long-term effect ofpsychological treatment of post-partumdepression. 2. Impact on themother‹child relationship and childoutcome.’ British Journal of Psychiatry182: 420-427

WebsitesWebsitesWebsitesWebsitesWebsites

The following website has been drawnto our attention:

www.tabs.org.nz

The hosts write: PTSD ANDCHILDBIRTH, a new website, fromTABS - Trauma And Birth Stress, NZ.We have had the pleasure and privilegeof presenting at two Marce Conferences,Sept 2001 and Sydney last year and noware working with Prof Cheryl Beck(Connecticut University) on a study ofmothers with PTSD after childbirth.Also includes material from JudyCrompton, Midwife and research fromthe UK.

LITERATUREMONITOR


By: Campbell Paul, Michele Meehan,Libby Ferguson, Susan Morse,Marell Lynch, Nicole Milburn, andFrances Thomson Salo

IntroductionIntroductionIntroductionIntroductionIntroductionA Toddler WithdrawnA Toddler WithdrawnA Toddler WithdrawnA Toddler WithdrawnA Toddler Withdrawn

Despite the apparent success of a livertransplant, 18-month-old Jacobappeared withdrawn, avoidant, wastedand he was refusing to eat. The medicaland nursing staff responsible for his carewere extremely concerned. There was nomedical cause for his persisting lassitudeand they referred him to the InfantMental Health Service at the RoyalChildren’s Hospital, Melbourne. In hisshort life, he had experienced a lot ofpain and had been near death manytimes as result of the complications ofhis congenital liver disease. It seemedtoo cruel to contemplate that a personcould inhabit so wretched a body and beso seemingly empty of soul as thisyoung boy.

However, clearly he was there, inhabitinghis body. There was a need for somelively interaction for him to come outand to meet his world again. Hismother was surprised that mental healthmight have something to offer her son.She had been immersed in so manymedical crises that she said it had nevercrossed her mind that he might be“depressed.” When staff from the InfantMental Health Team were able to engageJacob in a piece of playful behavior, hismother caught a glimpse of a child verydifferent to the one she had so farexperienced. She was startled byobserving a moment of lively play thatJacob demonstrated in a simple ballgame with Libby Ferguson and she wasthen able to pursue her own more livelyplay with him. After his mood hadimproved, she was able to say that it wasas if she earlier thought he had alreadydied; as if in her mind he had beenpsychologically dead.

Antipodean Activities:Aspects of the Infant Mental Health Program,

Royal Children’s Hospital, MelbourneHolding the child in therapy - holdinghim in our own minds and speakingdirectly with him- was of criticalimportance in his recovery. Our engaginghim even in a brief moment of enlivenedplay, when witnessed by his mother, ledto a transformation in the way sheexperienced him in her mind. She couldsee her son as alive and that there was apoint in hope for his survival. It couldalso be demonstrated that her pain, grief,and tragic sense of loss …that thesethings too, could be contained for hersake and for her son’s sake. Jacob wenton to thrive and now visits the hospitalfor infrequent reviews as a very healthyand talkative boy.

This is but one of several illustrations ofthe approach to clinical work with infantsand families that is at the foundation ofthe Infant Mental Health Programme atthe Royal Children’s Hospital inMelbourne. We believe that playfulengagement and psychotherapy directlywith the infant, in the context of workwith the family and the broader system,is critical for the best outcome for thechild.

In this series of four papers, we hope toillustrate something of the work ofinfant mental health in Melbourne. Wehope it will be an appetizer to the richertasting of the smorgasbord of infantmental health practiced in Australia. Welook forward to our overseas colleaguesjoining us in Melbourne for the 9thWorld Congress where there will be aseries of presentations by antipodeanclinicians and researchers. Even moreexciting for us will be to hear of the workof our colleagues overseas and to be ableto share ideas and extend our horizons.

Our Program in ContextOur Program in ContextOur Program in ContextOur Program in ContextOur Program in Context

There are a network of services inMelbourne, which address the mentalhealth needs of babies, toddlers and theirfamilies. There are several infant mentalhealth programs integrated into childand adolescent mental health services and

these occur both in the public and privatehealth setting. Australia has the unusualphenomenon of residential and homebased Early Parenting Centres. Thesehave developed out of a series ofhospital type settings for mothers andbabies who have had difficulties withfeeding, sleeping and other routines inthe early months of life. They are publicinstitutions accessible to all families, andthey have continued to develop andspecialize. Recently, a more specificexpertise has been built up to provideintensive assessment and assistance forthe most high-risk families who mightcome before children’s protective services.In Australia, there is also acomprehensive network of mother/babypsychiatric units and infant mental healthclinicians play an important role withinthese adult psychiatric units. In theprivate health system, there are alsoinpatient mother/infant units withmental health, nursing and child healthcomponents to their programs.Interconnecting with each of theseservices is a range of private infant mentalhealth practitioners drawn from thedisciplines of social work, psychiatry,psychology, nursing and others.All this sits upon the extensive bedrockof the maternal and child health nurse(who has different titles in differentStates). These highly trained nurses haveexpertise in working with mothers,infants and families and constitute auniversally available service with a veryhigh level of access. Some 98% offamilies with a newborn child havecontact with a maternal and child healthnurse. Increasingly, these maternal andchild health nurses have an additionaltraining in Australia’s university coursesin infant and parent mental health. Inher paper, ‘Enough is Enough,’ MicheleMeehan shows us how in brief workwith infants and their families the nursecan use insightful psychodynamicconcepts and effect rapid interactionalchange.

There remain nonetheless areas of unmetneeds for the families within our vast


creative and informed basis to a clinicalassessment, particularly for those infantsin greatest need. In their work withchildren who have been placed out ofhome in the context of serious protectiveconcerns, they demonstrate that buildingon interactional and psychodynamicunderstanding of the baby’s world canprovide real assistance to the infant’sbiological family and to those otherswho provide necessary care for himwhilst he is at risk.

Overall, we hope that this series of briefpapers will provide a keyhole perspectiveon the work of one infant mental healthprogram within one city in our vastcontinent. We believe that if we workfrom the perspective of the baby withinthe family and draw on multidisciplinaryteamwork and a broad range oftheoretical foundations, we are able toprovide something hopeful and usefulfor infants and their families.

The WAIMHThe WAIMHThe WAIMHThe WAIMHThe WAIMHCongress 2004Congress 2004Congress 2004Congress 2004Congress 2004

We look forward to sharing with youour interest and excitement about babiesand their minds when you come toMelbourne in January 2004. We alsolook forward to being able to share thesocial and physical excitements of ourcontinent. We hope you will be able tospend time at our beaches, galleries,concert halls, golf courses, sportingvenues or in the bush meeting some ofour unique fauna, as well as with ourwelcoming people. It may seem a longflight over the Pacific or Indian ocean,but it is a journey that Australians havemade many, many times and clearly it isvery possible. Accommodation isextremely comfortable and notexpensive. We believe that Melbourne isjustifiably described as one of the world’smost liveable cities and we trust that youwill be able to agree with us after youhave joined us here during our nextsummer.

Campbell PaulInfant Psychiatrist

ENOUGH IS ENOUGHENOUGH IS ENOUGHENOUGH IS ENOUGHENOUGH IS ENOUGHENOUGH IS ENOUGH

By Michele Meehan,Maternal and Child Health Nurse, RCH

Infant Mental Health Programme

As a Clinical Nurse Consultant inMaternal & Child Health, much of myday-to-day work is with infants with day-to-day problems. Sleeping, feeding,crying and behavior issues present in avariety of stories. Recently two cases hadbeen referred to me with similar storiesand an idea of ‘overindulging’ themseemed a way to help them shift.

Both babies were about 11-12 monthsand presented because of clingy anddemanding behavior. Both would cryeven as mum attempted to put them onthe floor. As a result they were carriedaround most of the time, which by 12months was well past acceptable to thefamily. Both were boys of marriedparents; Ben was a first child while Willhad an older sister of six years old.

‘Will’ was striking in his aversion tostrangers and his clinging to mother. Irecorded that I found him wary and slowto engage. He stayed on mum’s lap withhis dummy (he was sleepy but had notslept in the car on the way down, a 70-minute trip). Mum showed me that ifshe made a move to put him down hegrabbed hold of her - I told her to justwait while we talked for a bit. His sisterhad made herself at home with the foodand tea service and was busy preparinglunch for us. As we talked of howdraining this behavior was for her,especially with two children home on theschool holidays, he slid down and stoodat her knee. He sat down then pulled upon a chair I had near us and lay his headdown, then turned away as thoughhaving a nap. I approached him, talkedquietly, and stroked his back. He turnedhis head and looked at me. I then pickedup a soft toy and a cloth cube with a bellinside. He looked at the lamb and I saidit was sleepy too and laid it beside hishead. I very gently banged the cube onthe chair in a double rhythm. He smiledat the noise of the bell and I got morevigorous as he ‘woke’ up more. He letme pat his back in time to the bell andlaughed. As this went on for a fewminutes, I then picked him up and sathim between my knees as I knelt on thefloor with him facing mum, away fromme. He was looking around and I talkedabout what his sister was doing, and he

rural and outback places. Families willtravel long distances to access such help,but we are increasingly usingteleconferencing and the telephone toreach such families. Training for workersin remote sites is crucial. There is anexciting collaboration amongst manydisciplines to try to understand theworld of the baby andfamily and whatprofessionals, volunteers, and familiescan do to give the baby her best chance.

At the Royal Children’s Hospital MentalHealth Service, there is a long history ofclose collaboration between mentalhealth, pediatrics and nursing. There is astrong emphasis on us taking the baby’spoint of view; we try to respect thebaby’s perspective. In her paper, FrancesSalo tries to draw out some of thecomponents of “Respect.” The team atthe Children’s Hospital ismultidisciplinary and draws on develop-mental psychology and child health, aswell as psychodynamic theory. We havefound the works of Winnicott, Leboviciand Stern, and many others to be helpfulin our understanding of the baby andher family. We are lucky in Australia thatwe are a nation of travelers so that we areable to collaborate directly with colleaguesin all other continents. We see theforthcoming Congress as a way tofurther extend these professionalconnections.

We are also a land of migrants, but haveto come to terms with the traumasresulting from the Western occupationand dispossession of Australia from itsindigenous peoples. We have animproving relationship with Australia’soriginal inhabitants but the disruptionof families’ attachments caused bygenerations of dispossession ofAboriginal peoples has had a profoundimpact. Families may experience a crisisof confidence in parenting since manyhave lost contact with traditional babycare practices and supports.

Our work tries to reflect the multiculturalnature of this country and this may beseen in the paper by Libby Ferguson andSue Morse about the “Ooey GooeyGroup.” Being drawn from such adiverse range of peoples and cultures, wehope that we have the capacity to beimaginative and playful in our work aswell as our play. Marell Lynch andNicole Milburn in their paper about theStargate Early Intervention Programmehave found how important it is to have a


headed off to take her doll she had set atthe table. He was interested in the food,so I sat him at the table with her andthey remained playing there for the restof the session. His mother said hewould never do this and she had beensurprised that he let me approach him ashe had. It was obvious that he made noattempts to engage mum until he washappily playing and she respondedwarmly.

I told Mum that I thought the moredemanding Will became, the more shefelt pressured to ‘get rid of him’; so theharder he clung to her, and so on. Toexpect him to suddenly change was alarge request, especially as he felt that if heis upset this is where he needs to bebecause that is always what happens.While acknowledging that a main issuehere for mum was her postnataldepression (mentioned by the referringnurse) I felt she needed a real strategy tohelp make a change rather than addressany of her projections.

I suggested that, while it soundedhorrifying, what she could try is to NOTput him down as soon as he is settled.When he grizzles or cries, to pick himup, but sit or turn him to ‘take in theworld’ rather than cling to mum and‘see’ only mum as the solution: to sit asI had done and show him the worldwaiting for him and let him be the oneto say ‘I want to go.’ There was a similarstrategy she could try by taking him outin his pusher (where he was happy) andwhen he got home (when he wouldimmediately start crying) LEAVE himthere until he wanted to get out. In away you are saying “You can stay here aslong as you like” – his thinking may be“I can get as much of mum as I want, somaybe I’ll go off here for a while.” Hecan carry in his mind the memory ofgetting her whenever he needs.

A week later mum reported that she hadbeen able to do this, and that when hestarted grizzling she started by asking“what do you want?” instead of “what’sthe matter now?” and if she waited a fewminutes many times Will would go offto play with something. The pram walkswere very successful and she was gettingout more and feeling better. He lookedmuch more animated on arrival andgreeted me with a grin behind his hand.He pointed to the stove and pots anddemanded to get out of his pusher.

This idea of overindulging was alsosuccessful with ‘Ben’ whose mother saidhe was “an embarrassment” at playgroupor family outings, as he would ONLYstay in mum or dad’s arms facing thewall or away from everyone. In contrastto Will, Ben had no idea about playing.While he was sitting on the floor (againwith slow coaxing and pessimism frommum) I rolled a ball to him and helooked at it, then at me and did nothing.He made a similar response to any othertoy offered. It seemed his parentsthemselves played with the toys andshowed him what they did.

At no time in the session did the parentsattempt to play or talk with him andboth stayed on their chairs even though Iwas on the floor. I spent a fruitless hourtrying to get him involved with littlesuccess. I discussed that I felt he neededto feel comfortable to play and not justcling. Parents said they could do this athome, but what about the playgroupand they had a big family get-together onSunday! I talked about how Ben’sseparations were always at mother’sinstigation and he seemed to have norole in asking to leave, that just when hewas ‘settled’ mum tried to put himdown. Play group was the next day so Isuggested she keep him with her firmlyon her lap with an arm holding himtight while she talked about what thechildren were doing. If he lookedinterested in something to get it, andplay WITH him on her lap - only if HEwanted to get down should she let him.I faced the next week with sometrepidation, but as they came into theroom he scrambled out of dad’s arms,crawled over to the box, and broughtout some balls. Mum immediately gotonto the floor and sat there playing withhim or just watching as we talked. Hewas busy, interactive, laughing andhappy.

These two cases highlighted the dilemmaparents find when they are trying harderand harder to remove a ‘limpet’: themore they push the harder the babyclings.

Working directly with the infant canmake rapid shifts while the ongoingtherapy for mother and baby can stabilizethe relationship. As a nurse, parentscome seeking ‘intervention’ for theirbaby and are often not ready to addresstheir emotional issues or the relation-ship. Being able to bring in concepts of

the infant’s mind and possible thought/emotion processes, that the baby hasideas about what is happening and notjust being ‘difficult, clingy or stubborn’ isa good step to further exploration of therelationship being a duo and not just alist of ‘good mothers should.’ Mymembership in the Infant Mental Healthgroup reinforces the dual role nurses cantake in directly intervening with theinfant, then being able to address themother’s emotional issues at the sametime.

RESPECT: A MODEL OFRESPECT: A MODEL OFRESPECT: A MODEL OFRESPECT: A MODEL OFRESPECT: A MODEL OFINFANT-PARENTINFANT-PARENTINFANT-PARENTINFANT-PARENTINFANT-PARENTPSYCHOTHERAPY FROMPSYCHOTHERAPY FROMPSYCHOTHERAPY FROMPSYCHOTHERAPY FROMPSYCHOTHERAPY FROMTHE ROYALTHE ROYALTHE ROYALTHE ROYALTHE ROYALCHILDREN’S HOSPITAL,CHILDREN’S HOSPITAL,CHILDREN’S HOSPITAL,CHILDREN’S HOSPITAL,CHILDREN’S HOSPITAL,MELBOURNEMELBOURNEMELBOURNEMELBOURNEMELBOURNE

By Frances Thomson Salo

What I shall describe briefly are theguiding principles of the infant-parentpsychotherapy that has been practiced atthe Royal Children’s Hospital inMelbourne for about 20 years, and thiswill be described in more detail at the 9thWorld Congress of the WorldAssociation for Infant Mental Health tobe held in Melbourne in January 2004.This way of working has its historicalroots in the need to find ways to helpdistressed infants who have beenadmitted to the hospital in some kind ofmedical crisis, as well as their parents.Ann Morgan, a pediatrician, who heardWinnicott speak in meetings as a medicalstudent in the 1950s, set up the InfancyGroup in the Royal Children’s HospitalChild Psychiatry Department, in order tooffer infants and their families a fullerservice. The Group’s present co-ordinator is Associate ProfessorCampbell Paul. The theoretical roots forthis work can be traced to the work ofthe pioneers of infant mental health suchas Selma Fraiberg, and to Esther Bick’sinfant observation work.This in-patient model was then takeninto outpatient work by a number of theHospital infant mental health clinicianswho were working outside the Hospital,as well as consulting to other disciplinesin the community. It also underpins theteaching on the University of MelbourneGraduate Diploma /Masters in InfantMental Health. We have previously


described it as ‘direct work’ with theinfant (Thomson-Salo et al, 1999)although in retrospect this may not havebeen the best way to characterize workthat we see as in the tradition of infant-parent psychotherapy but honoring theplace of the infant in it. While much ofwhat we describe below may be part ofinfant-parent psychotherapy as practicedelsewhere, the mnemonic R.E.S.P.E.C.T.highlights our view of the need torespect the infant within the therapeuticprocess, even from a few weeks old.

The following elements are seen by theinfant mental health clinicians as crucial inbringing those ‘moments of change’ inthe therapeutic process, which have beenexplored by Daniel Stern and hiscolleagues in the Boston Process ofChange Study Group (Tronick et al,1998).

Relating withRelating withRelating withRelating withRelating withintentionality to theintentionality to theintentionality to theintentionality to theintentionality to theinfant and parentsinfant and parentsinfant and parentsinfant and parentsinfant and parentsThe clinician relates to the infant and hisparents, as James Herzog (1999)described it, ‘using their personality tofind the pain’, relating authentically as analive other. This way of working wasdescribed very evocatively by AnneAlvarez (1992) in ‘Live Company.’

The enigma of the child,The enigma of the child,The enigma of the child,The enigma of the child,The enigma of the child,his especial subjectivity, ishis especial subjectivity, ishis especial subjectivity, ishis especial subjectivity, ishis especial subjectivity, isrecognizedrecognizedrecognizedrecognizedrecognizedHere we are thinking of the specificity ofthe intervention for that particular childat that moment of time. Bill Blomfield, apsychoanalyst who also worked at theRoyal Children’s Hospital, is quoted assaying that, “you look at an infant withalready knowing eyes while knowingabsolutely nothing about the infant infront of you” (cited in Thomson-Salo &Paul, 2001). Often those intervening maydo so from a background of considerableexperience with infants and thereforeassume a knowingof the infant andmiss the unique-ness of the infantthey are with. Thebaby does notknow the clinicianeither, so connect-ing with him is atwo-way processallowing the infantto be active.

The infant as a subjectThe infant as a subjectThe infant as a subjectThe infant as a subjectThe infant as a subjectThe infant is regarded as a subject in hisown right, not to be objectified ormeasured. He therefore has an equalright with all other participants in thetherapeutic process to be attended tofully. With the infant present, the workis focused more on the infant-parentrelationship, rather than on the parent orthe infant.

The clinician brings theirThe clinician brings theirThe clinician brings theirThe clinician brings theirThe clinician brings theirplayfulness to the infantplayfulness to the infantplayfulness to the infantplayfulness to the infantplayfulness to the infantand her parentsand her parentsand her parentsand her parentsand her parentsHere our debt to Winnicott is obvious.Play is the infant’s language, and whenthe clinician relates to the infant with playthat is thoughtfully about her, the infanthas a sense of being ‘met’ and thisconveys hope to her.

The enjoyment of theThe enjoyment of theThe enjoyment of theThe enjoyment of theThe enjoyment of theinfant that the clinicianinfant that the clinicianinfant that the clinicianinfant that the clinicianinfant that the clinicianbringsbringsbringsbringsbringsTrevarthen (personal communication)highlighted the importance of theinfant’s wish above all else to beenthusiastically enjoyed by her parentsand significant others from birthonwards. This does not necessarilytranslate to an exuberance carried into theclinical encounter, but to an attunementto the infant’s affects, underpinned by aquiet enjoyment of what infants bring.The sense of pride for the infant, comingfrom successfully entraining the other, isa very powerful organizer in the first year.I think if the infant’s humor can bereached in a truthful way, this can alsooften kick-start some forward moves.

Creativity in theCreativity in theCreativity in theCreativity in theCreativity in theclinician’s work andclinician’s work andclinician’s work andclinician’s work andclinician’s work andintuitions, and theintuitions, and theintuitions, and theintuitions, and theintuitions, and theinfant’s answeringinfant’s answeringinfant’s answeringinfant’s answeringinfant’s answeringresponseresponseresponseresponseresponseI think when the clinician is most trulyhimself or herself the infant recognizesthe creativity in this. At times infant

mental health clinicians need to actcreatively on intuitions about the infant,to come up with new ways to ‘talk’ to her(as well as interpretively with the parents).A 13-month-old infant, who had beenseen with her mother by Brigid Jordanand Michele Meehan for feeding difficul-ties since she was 3-weeks old, wasbecoming resistant to giving up naso-gastric tube feeding. In a creative attemptto respect the little girl’s defenses buthelp her find her pleasure, Brigid Jordanmade an interpretation in play by taping atube to a doll’s face and offering the littlegirl the toy feeding bottle. The little girlinstantly understood that her need to bein control was respected and withpleasure she began to take somedevelopmental steps forward.

The clinician’s integrativeThe clinician’s integrativeThe clinician’s integrativeThe clinician’s integrativeThe clinician’s integrativethinkingthinkingthinkingthinkingthinkingThis is the kind of thinking that draws onpsychoanalytic concepts, such as the ideasthat Bion conveyed in his concept ofcontaining confusion and distress, andmaking sense out of it. It is also exemplifiedby Dilys Daws (1989) when she describeshow, when a story as an integrated narrativebegins to take shape in her mind, there canbe the possibility of it also taking shape inthe parents’ minds – and in that of theinfant.We think that these elements are present inevery therapeutic contact or process whensomething in the infant and his family joinswith what is offered by the clinician and amoment of change occurs. Being respectfulof the individuality of the infant takes timebut creates space for the infant to make hisown contribution to the therapeutic process.

References• Alvarez, A. (1992) Live Company.Psychoanalytic psychotherapy with autistic,borderline, deprived and abused children.London: Routledge.• Daws, D. (1989). Through the Night:Helping Parents and Sleepless Infants.

London: FreeAssociation Books.• Herzog, J. (1999)Child analytic casepresentation.InternationalPsychoanalyticalAssociation, Congress,Santiago.• Thomson-Salo, F. &Paul, C. (2001) ‘Someprinciples of infant-parent psychotherapy:Ann Morgan’s

R: Relating with intentionality to the infant and parentsE: The enigma of the child, her especial subjectivity, is recognisedS: The infant as a subjectP: Playfulness in the encounter with the infant and her parentsE: The enjoyment of the infant that the clinician bringsC: Creativity in the clinician’s work and intuitions, evoking the infant’s responseT: The clinician’s integrative thinking


contribution to infant mental health.’ TheSignal, 1-2.• Thomson-Salo, F., Paul, C., Morgan A.,Jones, S., Jordan, B., Meehan, M., Morse, S.& Walker, A. (1999). “Free to be playful”therapeutic work with infants’. InfantObservation Journal: The InternationalJournal of Infant Observation and itsApplications. 3: 47- 62.• Tronick, E., Bruschweiler-Stern, N.,Harrison, A. et al. (1998). ‘Dyadicallyexpanded states of consciousness and theprocess of therapeutic change’ InfantMental Health Journal. 19: 290-9.

OOEY GOOEY GROUP:OOEY GOOEY GROUP:OOEY GOOEY GROUP:OOEY GOOEY GROUP:OOEY GOOEY GROUP:A BEHAVIORALA BEHAVIORALA BEHAVIORALA BEHAVIORALA BEHAVIORALINTERACTIVE GROUPINTERACTIVE GROUPINTERACTIVE GROUPINTERACTIVE GROUPINTERACTIVE GROUPFOR YOUNG CHILDRENFOR YOUNG CHILDRENFOR YOUNG CHILDRENFOR YOUNG CHILDRENFOR YOUNG CHILDRENWITH FEEDINGWITH FEEDINGWITH FEEDINGWITH FEEDINGWITH FEEDINGPROBLEMS AND THEIRPROBLEMS AND THEIRPROBLEMS AND THEIRPROBLEMS AND THEIRPROBLEMS AND THEIRPARENTSPARENTSPARENTSPARENTSPARENTS

The Ooey Gooey Group is a group runwithin the Speech Pathology Departmentat the Royal Children’s Hospital, fortoddlers and young children with feedingproblems. Most of the children come tothe group with a history of complexmedical conditions and often are relianton tube feeding for most of theirnutritional needs. All of the childrenhave in common a reluctance to eat anappropriate amount or range of foods.Some have neurological difficulties andall have developed an unhelpful patternof behaviors around food and mealtime.This might mean gagging on particulartypes of food or refusal to let anything intheir mouth. They attend the group witha parent, usually their mother. The groupmeets weekly at lunchtime and comprisesa play session followed by a meal.

The name of the group, Ooey GooeyGroup, reflects its acceptance ofmessiness along with the developmentof comfortable familiarity with thesensory aspects of eating. Many of thesechildren have learned to associatediscomfort and unpleasantness witheating and drinking. Food intake hasbecome “medicalized”, measured andworried about. Neither parent nor childlooks forward to mealtime withpleasurable anticipation. Rather, theyanticipate struggle, anger,disappointment and a whole range ofemotions and behaviors not conduciveto pleasure and satiation of hunger.

Children attend the group at adevelopmental stage often vexed withfussy, changeable behavior. It is a timewhen they are still endeavoring toestablish a sense of autonomy andseparation from their primary attachmentfigure. Along with eating, the toddler istrying to become autonomous withtoileting, dressing, bath time etc. It isalso a time of curiosity and socialexploration. The group capitalizes onthis drive for independence and supportsthe parent in allowing their child to takerisks and extend boundaries. An aim isto replace panic and alarm with curiosityand playful exploration.

The group provides a place for thechildren to experience food and eating attheir own pace in an encouraging andoften entertaining environment. Thefood is usually provided by thetherapists and chosen to match thechild’s capabilities. It might be that thechild is afraid to chew and swallow solidfood because of a history of gagging orchoking. Some children will have poorlydeveloped oral motor skills and remainstuck at a level where they feel safe andpast which the parent is frightened to go.The group aims to replace anxiousanticipation with an expectation ofpleasure. The child and parent’s priorexperience has often contributed to aclassically conditioned link between foodand unpleasantness.

The group is led by two speechpathologists with experience in the fieldsof oral motor behavior, medicallycomplex children and infant mentalhealth. The therapists model eatingbehaviors, often playfully, and encouragethe child to follow. Explanations withthe parents happen at the time ratherthan following the event. Having funseems to enable the child to move onand to copy an adult in a safeenvironment. In this environment,parents also seem to feel able to trythings and offer comments knowingthey will be accepted. The group providesa place where risks can be taken. Thechildren and parents try new things andthe therapists risk looking inexpert andat times a bit silly. While the generalroutine of the group is set (i.e. movingfrom play to lunch to play), rather thanprescribing the individual steps, thetherapists enter into spontaneous anddynamic exchange, incorporating what

the children bring to the situation.Parents and children find themselves inpredicaments, they manage to survivethem and come to their own solutions,working out how to act together to learnfrom them.

Play experiences in the group are notspecifically based on eating and mealtime.The children might at times play withfeeding each other, the adults or dollsand teddies. They might also take upphysical challenges with balls and cars.They practice negotiating for possessionor dealing with dispossession of a toy.Parents join in the play or watch andreflect on the achievements of their ownor another’s child.Parents often watch what another parentand child are doing and recognize theirown situation. They develop an empathywith the other child and mother, andthrough that with their child. Theintensity of parental expectation for theirown child is reduced as they enjoyprogress within the whole group. Thechildren are also observant of each otherand other patterns of eating. Theyexperience the other children’s coughsand gags as well as their enjoyment andemerging competence. They imitate andidentify with the other children. Randomevents happen and are reacted to.Preliminary evaluation of the group hasbeen encouraging. Measures of feedingresistance, range of food consistenciesaccepted and total food intake are doneprior to and following attendance at thegroup. Preliminary results, on a smallnumber of children, suggest that feedingresistance is decreased and an increasedrange of food consistencies is accepted.What we observe early in the group isthat the children happily anticipatecoming to the table to eat and showpride in their developing ability tomanage food and mealtime. Theydevelop social relationships with theother children, the parents and thetherapists and within this safeenvironment feel more able to exploretheir environment and the messy,pleasurable environment of mealtime.

Libby Ferguson and Susan MorseSpeech Pathologists


UNDERSTANDING THEUNDERSTANDING THEUNDERSTANDING THEUNDERSTANDING THEUNDERSTANDING THEINFANT’S EXPERIENCEINFANT’S EXPERIENCEINFANT’S EXPERIENCEINFANT’S EXPERIENCEINFANT’S EXPERIENCEWITHOUT WORDS ORWITHOUT WORDS ORWITHOUT WORDS ORWITHOUT WORDS ORWITHOUT WORDS ORFAMILIAL HISTORY: AFAMILIAL HISTORY: AFAMILIAL HISTORY: AFAMILIAL HISTORY: AFAMILIAL HISTORY: ACASE STUDY FROM THECASE STUDY FROM THECASE STUDY FROM THECASE STUDY FROM THECASE STUDY FROM THESTARGATE EARLYSTARGATE EARLYSTARGATE EARLYSTARGATE EARLYSTARGATE EARLYINTERVENTIONINTERVENTIONINTERVENTIONINTERVENTIONINTERVENTIONPROGRAM FORPROGRAM FORPROGRAM FORPROGRAM FORPROGRAM FORCHILDREN AND YOUNGCHILDREN AND YOUNGCHILDREN AND YOUNGCHILDREN AND YOUNGCHILDREN AND YOUNGPEOPLE IN OUT-OF-PEOPLE IN OUT-OF-PEOPLE IN OUT-OF-PEOPLE IN OUT-OF-PEOPLE IN OUT-OF-HOME CARE.HOME CARE.HOME CARE.HOME CARE.HOME CARE.

By Marell Lynch & Nicole Milburn

The Stargate Early Intervention Programfor children and young people in out-of-home care is a pilot service modeldesigned by the Royal Children’sHospital Mental Health Service,Melbourne. The program provides acomprehensive therapeutic assessment toall infants, children and young peoplewhen they enter out-of-home care (fostercare, residential care and kinship care)through having been found to be at riskof significant harm by Child ProtectionServices (CPS), in a major metropolitanregion. The multidisciplinary therapeuticassessment aims to give parents, carersand workers within the system a clearunderstanding of the child’s behavior topromote a more attuned and empathicresponse to the child’s distress, bettermanagement of the child in care, andbetter planning for his or her future

The Stargate Program arose to addressthe barriers to accessing mental healthservices that had existed for children inout-of-home care. These barriers werepredominantly centerd on systemicissues whereby children’s placement inout-of-home care may not become clearand stable for some time. The result waschildren going into short-term or crisis-driven care while work was conductedwith their parents in hope ofreunification. The child remained in careand often needed to change to longer-term care when work with parents wasnot successful. Multiple placements oftenoccurred and children became increasinglystressed and distressed. Overburdenedfoster care and child protection systemsalso became increasingly stressed anddistressed.

The Stargate Program is based on theworks of the key attachment theoristsand recent findings from the traumaliterature (e.g. Schore, 2002; Fonagy,2001). Children seen by this program arebetween the ages of 0 and 17 years, with

30% under the age of three years. Resultsand discussion of the work with olderchildren and adolescents will be reportedelsewhere. As it pertains to infants, theprogram comprises a therapeuticassessment interview with the infant andhis or her carer and parent, a pediatricscreen and feedback to all stakeholders(parent, carer, foster care worker and CPScase manager). A comprehensive report isprovided for each infant that includesassessment findings, formulation andrecommendations. Referrals are made toongoing infant health, including mentalhealth, services if warranted.

One of the key roles built into theprogram is that of being an independentadvocate for the parent, the child and thefamily between the three systems: ChildProtection, Out-of-Home Care Agenciesand Mental Health Services. Prior toStargate, children in out-of-home carewere ‘parentless’ in the sense that they nolonger had someone to keep their needsin mind, communicate those needs andprovide continuity across environmentsin terms of Winnicott’s sense of ‘goingon being’ (1960). The case presentedbelow illustrates this position and theramifications for the infant.Working with infants who have enteredthe out-of-home care system presentsparticular challenges simply because theinfants at that point in time areparentless. Information that is generallyheld in parents’ minds is lost for manyinfants, or passed on to CPS in an ad hocway. As clinicians who were accustomedto the traditional mental health model oftaking a developmental and familyhistory from a parent, and hearing fromthe parent what they have noted thatwarrants the child’s attendance at theclinic, we have in the Stargate Programbeen forced to respond to the challengeof assessing the child with nodevelopmental or family history.Sometimes the only information Stargateclinicians have is the date of birth,mother’s name and the reason for goinginto care (e.g. ‘mother in psychiatricinpatient unit with psychosis,’ ‘infantwitnessed domestic violence and motheris uncontactable,’ ‘parents substanceabuse rendered them unable to care fortheir baby.’)

The challenge to the clinician’s methodsof understanding an infant case are aminor reflection of the challenge anddifficulties the infant faces in being caredfor by a stranger. The established

patterns of healthy communicationbetween mother and infant have beenwell documented (e.g. Trevarthen, 1984;Stern, 1985) and entry into out-of-homecare can be extremely disruptive to infantcommunication. However, as thefollowing case study illustrates, infantsare able to clearly communicate theirexperience without words and without aconsistent carer-translator.

Dee was a fourteen-month-old girl whocame to the Stargate Clinic with herpaternal grandmother, Angelina. Whenthe referral was received six days prior,we automatically assumed that thegrandmother would be able to providethe background history. When the childwas being registered with the service wediscovered that her grandmother spokeSpanish and that she had not beenaware of Dee’s existence until she wascontacted by Child Protection two weeksearlier and asked to provide interim carefor this infant. Shortly after the phonecall, on the same day, Dee was dulydelivered to her grandmother’s care injust the clothes she was wearing.

Dee was brought to the clinic byAngelina and her paternal aunt. She satquietly and watchfully in the pusherbeside her grandmother and initially didnot seek to engage with any toys, letalone people. Angelina described Dee’sfirst two nights with her and how shehad assumed that Dee would want tobe cradled and comforted to sleep.Therefore Angelina had placed Dee inbed with her. Dee would not settle andpulled away. On the third night, whenplaced directly into bed, she wentstraight to sleep. Angelina describedDee as a restless sleeper. Feeding hadalso been an issue as Dee becameextremely agitated and demandingaround food, and refused any help.Angelina found it difficult to pace herfeeding, as Dee would cram food intoher mouth. She would not allowherself to be held when drinking,preferring to be left alone to bottle feed.

Dee was described as initially makingfew demands on adults and beingsporadic in her engagement. Sheshowed little interest in explorative play.Angelina described an incident where apot plant had fallen and Dee, obviouslyfearful, had crawled away from theadults and it had been very difficult tosettle her. Angelina also noted that shehad to be careful as to how she touched


Dee because a slight movement or tapwould leave Dee startled as if she hadbeen hit. When Dee bumped or hurtherself, she did not cry or seek comfort.Dee was described as extremely engagingwith adult males when out and asattempting to gain their attention. Withadults in general, she showed nodiscrimination, and there was novariation in her response to separationsfrom her carers or other adults.

Angelina wondered whether Dee’sbehaviors were the result of an infancywhere she had witnessed manyfrightening events and had not beenreadily comforted and made to feel safe.She also wondered whether her“independence” was a result of being leftalone and having to grow up fast. Ofmost concern was Dee’s indiscriminatebehavior with adults

At the Stargate clinical meeting, wherecase discussion, formulation andrecommendations are made, theclinicians were struck by how Dee hadeffectively told her story and how shehad conveyed it through her relatingstyle, self-regulatory tasks and protectivebehaviors to her grandmother, who notonly knew nothing of her past, but didnot speak her language. Dee’s behaviormet all the criteria for PTSD andindiscriminate attachment disorder. Herpast experiences of witnessing domesticviolence, experiencing care takerspreoccupied and unresponsive due tosubstance abuse, and experiencing manycarers like a ‘pass the parcel,’ were evidentfrom her presentation. Dee’s experienceswere later confirmed in an interview withher mother.

One of the main underpinnings of theStargate Program is that therecommendations provided are targetedto ensure that all the people involvedwith the child are consistent in their care.With Dee, the recommendations werevery specific in order to target the wayDee interacted with the world. Forexample, recommendations included:· That it was important to monitorDee’s displays of indiscriminatebehaviour. There was a need for specificwork on developing Dee’s identificationof, and with, the key figures in her worldthrough the establishing ofindividualized rhythmical patterns ofrelating, sound/words usage, facial

gestures and touch. This could later bedeveloped using symbolic play ofmother infant interactions.· Monitoring for exaggerated startleresponse to sound and movement sothat intervention could occur early andDee be protected from further exposureto traumatic stimuli.· Promoting of modulation andsoothing activities/ games/ touch toassist Dee’s self-regulation.· Stimulative play on a one-one basis:peekaboo, rhythmical games, vestibularmovement, singing etc

It can be seen from the above that theStargate Program aims to providerecommendations for children that aretargeted at the manifestations of thespecific diagnoses of Post TraumaticStress Disorder (PTSD) and ReactiveAttachment Disorder. The diagnoses ofPTSD and attachment disorder are oftenperceived to be simplistic categories thatsay little about the lived experience of thepatient. What we seek to do at Stargate isto operationalize the concepts of traumaand disregulated attachment within thetheory base itself. Stargate attempts toenact Fonagy’s position that researchers(clinicians) should ‘concern themselveswith the mechanisms or psychicprocesses that may underlie suchbehavioural clusters’ (Fonagy, 2001:p.187).

References

• Fonagy, P. (2001) Attachment Theory andPsychoanalysis. New York: Other Press.• Schore, A. (2002) ‘Advances in

neuropsychoanalysis, attachment theory, and

trauma research: Implications for self-

psychology.’ Psychoanalytic Inquiry, 22: 433-

484.

• Stern, D. N. (1985) The interpersonal world

of the infant: A view from psychoanalysis and

developmental psychology. New York: Basic

Books.

• Trevarthen, C. (1984) ‘Emotions in infancy:

Regulators of contacts and relationships with

persons.’ In K. R. Scherer & P. Ekman (Eds.)

Approaches to Emotion. Hillsdale, NJ:

Lawrence Erlbaum.

• Winnicott, D. W. (1960) The Maturational

Processes and the Facilitating Environment.

New York: International Universities Press.

18th NationalTraining Institute

Zero to Three25th Anniversary

December 5-7, 2003(Pre-Institute December 4)

Join us in NewOrleans for the lateston research, policy,and practice in theinfant-family field.

Please visitwww.zerotothree.org

for registration in-formation


Affiliate NewsW A I M H

WAIMH Belgo-Luxembourgeoise

In May 1998, we became the Belgo-Luxembourgeoise Affiliate of theinternational WAIMH group. Dr.Annette Watillon was the first presidentof the group and we are still very pleasedto share her wonderful experience as aclinician working with the parent-infantrelationship. Since our foundation,the members of the board remainthe same. The current president isDr. C. Devriendt-Goldman. Fromthe beginning, Pr. D. Charlier-Mikolajczak has been responsiblefor international relationships.The initial group has generated alarger group open to other

professionals in the field ofinfancy: child psychiatrists,psychologists,pediatricians, gynecologists,nurses, etc. At this time, theBelgo-LuxembourgeoiseWAIMH has developed into agroup containing over 100members.

Future and Aims ofFuture and Aims ofFuture and Aims ofFuture and Aims ofFuture and Aims ofthe groupthe groupthe groupthe groupthe group

For the future, our aims and realizationswill be :• to continue the work inside the initialgroup.• to organize one-day meetings: The

Luxembourg

Belg ium

History of the groupHistory of the groupHistory of the groupHistory of the groupHistory of the group

At the beginning, three child psychiatristswent to the meetings of WAIMH-France. Six years ago, they decided tocreate a group of professionals (12people) in Brussels working in the fieldof infancy; these professionals weremostly child psychiatrists and psycholo-gists working in the infant mental healthdepartments of different Universities inthe French speaking part of Belgium.Two colleagues from Luxembourg werepleased to join the group. We thought itwas important to meet and share theexperience acquired from our clinicalpracticeand todiscuss ourtheoreticalpoints ofview. We haveplanned to meettwice a yearconcerning clinicalcases and articles.Previous meetings have helped usget to know more about each other’spractices. Some of the memberspresented a session at the WAIMHcongress in Tempere, Finland (1996) andin Montreal (2000). It became obviousthen that this group could apply foraffiliation with the internationalWAIMH.

first one was in 2001 : “A baby and hismultiple origins”; the second in 2002:“First signs of autism” and in March2003: “Sufferings of caregivers.”• to constitute groups with the aim ofdeveloping local networks relating to theperinatal period (the desire for children,

pregnancy and age zeroto three.) At the presenttime, we initiate smallgroups in differentplaces around one of ourmembers, whostimulates thoughtsabout different themes.There is, for example, agroup aroundpsychological issues inneonatal care (Dr. M.P.

Durieux, Dr. C. Devriendt-Goldman).Other members have proposed at ourWAIMH meetings the formation of twofurther groups: one around “Training inrecognizing the first signs of autism”(Dr. A.Wintgens) and the second :“Signs and treatment of post-partumdepression and psychosis” (Pr. D.Charlier-Mikolajczak.)• to develop clinical research projects.• to maintain tight relations with theFrench, European and the InternationalWAIMH as referent groups.

By: Prof. Dominique Charlier-Mikolajczak


Report by Bernard GOLSE (Fr) and RobinBALBERNIE (UK)

The second meeting of the Europeanaffiliated WAIMH groups was organizedin Paris, on the 25th and 26th January2003, by Bernard GOLSE (France), SamTYANO (Israel) and MassimoAMMANITI (Italy.) The first one wasalso held in Paris, in January 2000.Between these two meetings, fordifferent reasons, it proved difficult togather representatives from all thegroups even though this was tried inIsrael, Lisbon, Pisa and Amsterdam.

This time all the groups wererepresented, invited for two days in Parisby the French-speaking group, thanks totheir ability to call upon a number ofgenerous sponsors (EuropeanAeronautic Defence and Space Company,Société Française du Radiotéléphone andthe Fondation BETTENCOURT-SCHUELLER).

Here is the list of participants:Dominique CHARLIER and AnnetteWATILLON for the Belgian andLuxembourg group, Robin and CeliaBALBERNIE for the English group(AIMH-UK), Tuula TAMMINEN andMerja-Maaria TURUNEN for theFinnish group, Fernanda PEDRINAfrom Switzerland, Marguerite DUNITZ-SCHEER and Peter SCHEER fromAustria for the German-speaking group(GAIMH), Sotiris MANOLOPOULOSand Meropi MICHALELI for theHellenic group, Miri KEREN and SamTYANO for the Isareli group, MassimoAMMANITI and Filippo MURATORI

for the Italian group named « AISMI »,Grazziella FAVA-VIZZIELLO, LenioRIZZO and Francesca SIMION for theItalian group named « GIOSUEgroup », Hanne MUNCK fromDenmark and Pia RISHOLM-MOTHANDER from Sweden for theNordic group (NFSU) and, finally,different members of the French-speaking group including BertrandCRAMER from Switzerland, BernardGOLSE, Antoine GUEDENEY andValérie DESJARDINS from France.

The meeting took place at the Necker-Enfants Malades hospital where BernardGOLSE is working, and was attended byPeter de CHATEAU (Sweden), thePresident of WAIMH.

Saturday morningSaturday morningSaturday morningSaturday morningSaturday morningsessionsessionsessionsessionsession

Bernard Golse opened by emphasisingthe practical difficulties involved ingetting this meeting organized on aregular basis. There was a move towardsmaking the European Group moreintegrated. He talked about a wish todevelop joint projects, with an emphasison research. He reminded us that threeyears ago there had been talk oforganizing a European Group initiativeat EEC level with regards to infancy.

Then, Peter de CHATEAU explained tous that WAIMH has to consider threedifferent levels: international, regionaland then national, and how theseinteract. The WAIMH board has beentrying to get rid of one of these levels -preferably the regional one – as they feltit made the administration too topheavy. But they found that this did not

work. There was some thought thatthere was a difference between Europeand America in the overall approach toWAIMH. In the debate it was notedhow in Europe ‘clinical discussion’ isconsidered to be very important; and thiswas seen as perhaps favoring a slightlydifferent emphasis from the moreresearch-oriented, quantitative approachemanating from America.

The Melbourne Conference in 2004 wasdiscussed, while recognizing that manypotential delegates from Europe mightnot attend because of the distanceinvolved. We learned that the bid forParis to host the 2006 Congress seems tobe the favored one. As soon as thislocation is officially confirmed, planningwill begin on how to give it a more“European” slant. Members are invitedto begin considering presentations now!

Bernard Golse went on to discuss theimportance of the links that theEuropean Group have with WAIMH,and (as was emphasized by everybodyelse throughout the meeting) went on tospeak of the discrepancy in numbersbetween the National Affiliates and theCentral Organization. A theme thatthreaded itself through the two days was:should more people be encouraged tojoin WAIMH, and how could this bebrought about? In response, Peter deChateau pointed out that there are fiveexisting resources to encourage increasedmembership. These are: (1) TheInternational Journal (2) The Signal (3)The Video Library (although theAmerican system is not universallycompatible with other countries) (4) TheMembership Directory (5) The WorldCongress that members can access at areduced fee.

Meeting of the European AffiliatedWAIMH Groups, Paris

January, 25-26, 2003


It was thought that there was too big adistance in the relationship between theWAIMH Board and the members. Thiswas one reason for trying to bring theAffiliates more onto the Board, as well aslooking at other ways by which theirinfluence could be increased. As a meansof facilitating communication within theorganization, Antoine GUEDENEYsuggested that The Signal could developinto a world-wide “Zero to Three” withdifferent language editions.

After that, each group gave apresentation of its functioning andactivities. This was a rich and full session,and it is difficult to give a resume herethat would do justice to the different andextremely stimulating content and issuesthat were covered. One especiallyinteresting initiative was the course ininfant mental health set up by theFinnish group as part of theircommitment to supporting healthvisitors in Finland. They have trainedover 2,500 health visitors, and thisincludes all of those practicing inTampere and Helsinki. This training isrecogniced by the fact that it merits ahigher salary. It consists of eight daysspread over several months plusongoing supervision for two years. Thedelegate from Finland spoke of how theyhad tried to “make differences interestingrather than threatening.” They have beengiving much thought to how they mightpromote infant mental health at alllevels.

To close this session, TuulaTAMMINEN, the President elect ofWAIMH, underlined the three maingoals of WAIMH : a scientific goal, aneducational goal and a charitable one. Shedid this in the light of the different levelsof the infants’ development, and drew aparallel between the ways to improveboth the infant’s development andWAIMH’s functioning. Everybodynoticed the importance accorded byTuula TAMMINEN to the scientific goalof the association, especially the necessityfor continuing the commitment to reflectupon infant psychopathology and howthis might be addressed.

Saturday afternoonSaturday afternoonSaturday afternoonSaturday afternoonSaturday afternoonsessionsessionsessionsessionsession

The Israeli group presented the newcomputerized chart for infants andtoddlers that they have created for IMHwork. This records all relevant details ofassessment and treatment, and can evenprint out a closing letter that leaves outall the negative bits! It is called thePRINCE system and will soon beavailable for purchase. It perhaps has thepotential to abolish paper files and, moreimportantly, provides a means ofstandardizing and organizinginformation to provide a basis for inter-country research.

There was then a presentation from Italythat included a video of clinical work.The work focused on a little boy namedWilliam, two years old, who waspresenting as isolated and obsessive. Inkindergarten he was shy and timid. Allphysical examinations were normal. Hismother saw him as having regressed,especially in terms of social competence.This had been going on for the previoustwo months; and the first session wasvideotaped when William was just abouttwo. His father had epilepsy, and hismother was thirty years old and wasborn in Russia. She had a previous child,born ten years before, who had died attwo weeks from pneumonia, and thischild had a different father. It was anormal pregnancy and the initialdevelopment was on track, with Williamdeveloping language up until abouttwenty months. It was then that hisdevelopment seemed to halt and he lostthe language skills he had alreadydeveloped.We were struck by the group impulse topathologize the child in the subsequentdiscussion, which was in danger of beingdominated by a determination to givehim a psychiatric label. Not everyone washappy with this, and the importance ofthe story was slightly lost. Some talkedabout how he might be showing someautistic features, and there appeared to bea risk that the audience was assumingthat the problem resided within thechild, perhaps unconsciously almost

colluding with the mother. The qualityof the ongoing relationship with themother or father was not really seen ascentral, nor were the other pressures onthe family given any consideration.

As far as we could gather the clinicalintervention consisted of someindividual work with the child, althoughnot on a regular basis, and a few sessionswith mother. However, a second videoclip when the child was nearly two yearsolder showed that he had regainednormal development, and with thetherapist he was showing curiosity,playfulness and normal language. In theinterim (and again family stresses werenot considered) the mother had divorcedand was looking far less strained.

At the end of the afternoon, thereseemed to be agreement that we hadreached a general sense of a Europeantradition that was more clinically, or casebased, and that this should be seen as astrength that could be developed. Thisled to a long (and sometimes heated!)discussion about the two mainbackgrounds to WAIMH, research andclinical work. The main feeling of themeeting was that more case exampleswere needed in the literature, with agreater emphasis on in-depth clinicalwork. It was thought that every otherCongress could be more on the theme ofclinical work; or that each Congressshould include a training element.Someone also suggested that after such aCongress, a selection of the trainingpresentations could be sponsored toenable them to be taken around to thedifferent Affiliates, benefiting a widerportion of the membership. Methods ofpromoting non-English clinical papers inthe Journal was also discussed.

Sunday morning sessionSunday morning sessionSunday morning sessionSunday morning sessionSunday morning session

On Sunday morning, Bernard Golse andhis group explained their project on thesemantic and behavioral precursors ofspeech. This is a piece of research just atits beginning, and he was presenting it atthis stage, while they were setting it up,in order to gain some immediate


feedback from the audience. He was alsolooking for some wider Europeancooperation from any other researchgroups that might have similar interests.What he received were some ideas and alot of others’ past projects.

This research project was based on theidea that the first communicationbetween baby and caregiver is throughthe medium of gesture and the prosodyof the adult’s speech. They pointed outthat it is the non-verbal aspect of adultspeech that provides the channel ofcommunication, and they called this“analogic” communication while alsostressing its importance for conveyingfeelings and emotions. This wascontrasted with the “digital,” moreprecise, content of speech that mainlytransmits concepts, thoughts and ideas.They were thinking along the lines ofhow there is a developmental changeoverof emphasis here, and this is part of thenormal process of inter-subjectivity, sothat digital communication eventuallybecomes predominant. However, theystressed how analogic communicationcontinues in all the non-verbal channelsthroughout life (e.g. tone, gesture, gaze,music, etc..)

The research project was looking at howarm and hand movements for the babycan be a sign that inter-subjectivity hasbeen achieved. True communicationimplies that the baby and other aredifferentiated, there is a sense of inter-subjectivity, and signals can beexchanged. This sets up what they called“a loop of communication,” which is aform of closed sequence. They alsopointed out how, as an adult, it isalmost impossible to speak withoutmoving one’s hands. They introducedthe concept of motor representations,seen to have the function of filling thetransitional space between parents andtheir infant. From this, they postulatethat the roots of communicationproblems might be found in the armand leg movements of the first andsecond years of life. If they can analyzethese as they plan to, then it mighteventually lead to a way of diagnosingfuture problems in communication fromthese early movements.

They are trying to answer the question“where does the baby look when theadult speaks to him?” They felt there wasa natural evolution of the baby’smovements of arms and hands whenthe adult speaks, and also when the adultstops speaking. They want to investigatelinks between the baby’s gaze andrepresentation, and the prosody of theparent’s speech. They will begin bystudying the trajectories of the baby’shands and arms and linking this to thebaby’s direction of gaze. This will involvefilming from different angles with digitalcameras, co-ordinating these and thenanalyzing the data with the aid of adedicated computer program they aredeveloping. The whole project beganfrom the observation of how the babyresponds to music. They are looking forconcordances between movement,parent’s speech and eye contact. Themethodology will involve conductingmultiple analyses simultaneously (e.g.hand movement and gaze) on the wayjoint attention is being focused on thespace between baby and parent, and howeach is filling it. They were keen to gatherup any ideas that other researchers orclinicians might have on this (contactBernard Golse at the following emailaddress [email protected].)

The second part of the session wasdevoted to the business meeting, whichopened (again) with a discussion aboutmembership fees and how WAIMH isfinanced. People stressed how a widermembership might mean reduced fees,so how could this be made attractive?

Nominations of new members of theWAIMH board are due shortly, andPeter de Chateau invited proposals fromEurope. As part of the discussion peoplespoke about the risk of a potential splitwith the United States on the horizon,and how this could be avoided. He alsoreiterated the idea of using the WAIMHhome page and The Signal todisseminate more information; but sincethis is currently limited to full members,it will not affect Affiliates. The generalidea seemed to be that WAIMH shouldtake on more of a role in integrating thedifferent Affiliates, especially since the

importance of infant mental health isbest promoted at local level. This is onereason, all delegates stressed, why anover-centralized system will not work. Itwas felt that the different continentsshould each have a representative on theBoard or Executive Committee.However, it was also acknowledged thata Board with too many members simplydoes not work. There was a balance to bestruck between costs and creating a groupthat can work effectively.

Bernard Golse proposed setting up aEuropean Group as a separate entity. Itwas generally agreed that this would be agood idea and would provide a forumfor an exchange of knowledge and ideas.It was discussed whether or not thiscould lead to a single European Groupmeeting with a representative from eachcountry, but it was recognized that thiswould first need to be discussed at a locallevel. There are practical issues here, suchas how is this to be financed. People alsobrought up the need to bear in mindhow many countries are now joiningEurope, and certainly infant mentalhealth needs to be promoted there aswell.

Each country’s Affiliate needs to generatea mandate to proceed with this idea,moving towards setting up some formof European network. Somebodysuggested that there may be EEC fundsthat could be accessed, but practicaldetails were a bit vague. Several countriessaid that they did not feel it wasappropriate for them to appoint thePresident of their group to such ameeting, as this post changed so rapidlythat there would be no continuity withinthe European Group, and thus nogroup would ever actually form.

Bernard Golse wanted the EuropeanAffiliates to start thinking about theplace of the European Groups inplanning the Congress in Paris for 2006.The meeting ended with this idea, onethat will have to be developed whenParis is officially confirmed as the site forthe 2006 Congress.


The Tavistock Clinic AnnualInfancy Study Day: What is aHealthy Baby?

A Multi-disciplinary Perspective

London, Friday 8 November 2002

This day brought together speakersfrom different countries and differentprofessional bases, all working withparents and infants in a variety ofsettings. The audience shared thisdiversity as well, and the list ofparticipants revealed people had travelledfrom around the country to attend.

The day began with Mary Sue Moore(Consultant Clinical Psychologist,Colorado, U.S.A.) asking “HealthyBabies and Parents: Are They ConflictFree or Skilled at Repair?” She posed thequestions: What is ordinary, healthyfunctioning? How can repair andrecovery occur? Does healthy equalhappy? She stated that there is no suchthing as trouble-free infancy orparenthood, nor can they can be free ofconflict. She saw struggling in a healthyway to become a parent as leading toresilience and feelings of internal stabilityin the infant. She spoke about thedevelopment of attunement and affectregulation in healthy babies and howevents which cause anxiety in the infantor toddler may cause regression, whencertain newly-acquired skills may be lost.The context, i.e. the disruptedenvironment, causes the changedbehavior, which in itself need not beviewed as unhealthy.

Conference ReportsA major part of the remit of The Signal is to keep WAIMH members abreast of recent developments in the field. It is hoped that this newsection of The Signal, together with the “Literature Monitor,” will be helpful to readers in this respect by updating them on the latestconference presentations from across the globe and the most current literature of note. The success of both these sections, however, will verymuch depend on members’ contributions, so please email me with details of any interesting articles/books/videos that you come across andwrite-ups of any conferences you may have attended. Send to: [email protected] Thanks.

All three of the following reports originallyappeared in the AIMH (UK) Newsletter andare reproduced with the Editor’s kindpermission.

Mary Sue Moore based her thinking onattachment theory, on developments inneuroscience and on evidence fromresearch. With the brain achieving 80%of its development in the first two yearsof life, the right hemisphere intact, andfunctional, at birth, and the lefthemisphere fully functional by fourmonths, the infant is highly receptive toenvironmental influences. The processof attachment develops through theinfant’s experiences with others and alsoby observing how others interact (whichshe termed procedural memories.) Suchlearning is stored and its memorytriggered by later experiences. Thus shegave an example of how the experienceof witnessing domestic violence ininfancy could lead to being bullied atschool. The experience would haveinitially triggered a freeze-response, as theinfant is unable to flee or change thesituation; the further experience in schoolmight subsequently trigger a similarresponse.

Mary Sue Moore spoke about the effectof high arousal on neonates: their self-regulation becomes disorganized andthey may turn away or shut their eyes toavoid over-arousal. She showed adiagram, which was new and innovative,describing the correlations she had foundbetween high and low flexibility/inflexibility and high and low vigilance,combining to form the various states ofattachment. This new work will bepublished shortly and we can lookforward to studying her analysis andschema more closely and in more detail.

The second presentation was a filmmade and presented by Effie Lignos(Child Psychotherapist, Athens, Greece)of three singletons and a pair of twins.

She produced it for teaching purposes.The babies were observed in the usualway, weekly, for two years. Each babywas filmed over a brief period to show acertain stage of development, withintheir family settings: with fathers,siblings, an au pair and a grandmotherpresent. We saw a baby being bathed,both parents in attendance; a baby at thebreast and trying to get to sleep,appearing to try to brush away hermother’s stroking hand; an older babywhose sister “loved” her so much,almost smothering her with her jealousy,and affecting the mother’s ability todevelop a direct relationship with thebaby; and twin boys of whose differentneeds mother was well aware, yet we sawhow giving her attention to oneappeared to make her feel she wasdepriving the other and so neither gother undivided attention.

The richness of the film’s contentshowed, among other things, ways inwhich babies develop security, thecapacity to be alone, to tolerateseparation, parents’ abilities to identifywith their babies, babies’ abilities to bothexpress their wishes in a variety of waysas well as to protest against unwantedexperiences. We saw parental reverie inaction in the way they talked to theirbabies about their thoughts. Fatherswere shown as involved, joining themothers in caring for their babies (andeliciting their own maternal aspects) anda grandmother was shown in her helpfulrole. The twins showed us that each oneexperiences mother being in relation tothe other, which related to what MarySue Moore had said regarding proceduralmemories (i.e. learning from observationof others interacting.) We were able tosee how observations of infants can lead


to noticing how infants react, how eachin his or her own way has his or herown alive response. The use of videocan show these things to students, and,in use with parents, highlight what ishard to notice or when it can seem thatnothing is happening. The vignetteswere able to show us moments atdifferent levels of complexity, so thatparental failure could be noticed by theway in which the infants struggled withit, but also survived.

The discussion gave rise to some veryinteresting considerations of culturalfactors involved in assessing what oneis observing, and to the danger ofapplying too harshly some conceptionsthat can easily become misconceptionsor even stereotypes.

Small group discussions followed toallow participants to think about thetopic of the day. One important aspectof the discussion in my group reflectedwhat was becoming a common themefor the day; that is, both the strugglewith difficulties and the struggle tobecome an individual were seen ashealthy aspects of developing the abilityto manage conflict (i.e. conflict in theinner world.)

Annette Mendelsohn, ChildPsychotherapist, and Betty Hutchon,Paediatric Occupational Therapist(London, U.K.) presented work withparents in a neonatal care unit of ahospital. Their interest is in movingaway from a deficit model andpromoting psychological health. Theypresented their use of Brazelton’sNeonatal Behavioral Assessment Scale,explained its use and showed a video ofthis work. The emphasis was to showthe potential for development withvulnerable, hospitalized infants such asthose born prematurely withcomplications, and to help parentsrecognize that potential.

Annette Mendelsohn spoke about thecontribution of a psychoanalyticallyinformed child psychotherapist in theneonatal unit with the focus of

attention on thinking about theuniqueness of the infant, and on seeinghow the infant’s behavior describes his orher state of mind. This method is rootedin the subjectivity of the observer’semotional experience and her receptivity tothe emotional content ofcommunications. This subjectivity ofexperience is akin to countertransference inpsychotherapy. We heard that thematernal capacity for reverie (empathywith, and thoughtfulness about, theinfant’s emotional experience, as describedby Bion) can remain frozen when aninfant is born prematurely. Also, themother’s (and father’s) receptive/interactive capacity for repair and recoverycan be absent.

During pregnancy, representations of thebaby develop in the mother’s mind andpeak at seven months gestation,subsequently diminishing. In thedescription of “Thomas,” born at 30weeks, we heard that he was not the babythe mother expected to have. At 30 weeksreality came as a blow and mother froze(she perceived Thomas as rejecting her.)Traumatized by the actual baby, thismother was prevented from havingmeaningful, and therefore empathic,contact with him. Annette Mendelsohn’sintervention helped her to think of him assomeone who needed her to help him,thereby bringing her into contact with amaternal part of herself that had been lostin the traumatic experience of the birthand the reality, which she could not face.

When Betty Hutchon assessed Thomas,initially mother was unenthusiastic and onthe video one could see her turning away,not wanting to be involved. At the fourthmeeting she was shown an excerpt of thevideo and things began to improve. Afollow-up after discharge showed Thomasand mother’s relationship progressingwell. Mother’s angry rejection, as a resultof her disappointment, had been heardand contained. It is interesting to thinkabout an infantile part of herself havingbeen too highly aroused by the reality shefaced, i.e. not the baby she had fantasizedshe would have, and self-regulating byturning away, in the way that Mary Sue

Moore had described earlier. Mother washelped to turn back toward Thomas, tosee him as he was and to see herselfneeded by him.

The day brought us into the realm ofearly infancy, with its delicate and intricateweb of influences on development.With the emphasis on healthydevelopment, this was a differentperspective from the more commonfocus on pathology at such events. Thevicissitudes of early development areunpredictable but we were led intothinking about resilience and howbeneficial experiences can promotehealthy development despite them.

Gabriella KleinChild and Adolescent Psychotherapist

EXPLORINGEXPLORINGEXPLORINGEXPLORINGEXPLORINGRECIPROCITY: ARECIPROCITY: ARECIPROCITY: ARECIPROCITY: ARECIPROCITY: ACORNERSTONE OF THECORNERSTONE OF THECORNERSTONE OF THECORNERSTONE OF THECORNERSTONE OF THESOLIHULL APPROACHSOLIHULL APPROACHSOLIHULL APPROACHSOLIHULL APPROACHSOLIHULL APPROACH

The 4th Annual Solihull Conference

21st October 2002

This conference was led by Dr Mary-SueMoore and Janet Dean, visitors from theUnited States, already known to manypresent because of their extensiveexpertise in the field of infant mentalhealth. In their presentation theydeveloped ideas about the enduringconsequences of early trauma and neglectand examples of the kind ofmultidisciplinary/cross agency workingnecessary to provide effectiveinterventions with infants and theirparents. Janet and Mary-Sue’s focus forthe conference was ‘reciprocity’ which wasrichly exemplified in their mutuallyaffectionate and respectful relationship,which provided many of the day’s mostenjoyable moments.

Mary-Sue Moore and Janet Dean bothwork in Boulder, Colorado: Mary-Sue asa Research Psychologist and ChildPsychotherapist, and Janet Dean asClinical Director of the Community


Infant Program. This is a home-visitingpreventive-intervention service forinfants at high risk and their parents,staffed by infant mental health special-ists, nurses and para-professionals. Mary-Sue Moore is also a visiting teacher at theTavistock Clinic in London.

Reciprocity is a cornerstone of theSolihull Approach. As some readers maybe aware, the Approach is a psychothera-peutic and behavioral intervention basedon theories of containment, reciprocityand behavior management. It is devisedfor all care professionals working withyoung children and focuses on children’ssleeping, feeding, toileting and behav-ioral difficulties as a way of thinkingabout mind/body relationships. It hasbeen shown to enhance health-visitingpractice by enabling more effectiveworking and leading to improved jobsatisfaction (Douglas & Ginty, 2001).Work is currently in progress to developa similar resource to support the work ofschool nurses, and in the future formidwives, social workers, Sure Startprojects and others involved with infantand child mental health services.

Reciprocity is concerned withattunement, and is contingent upon themutual regulation of affect betweenmother and baby. Building upon ideasfrom Stern (1985) and Murray andCooper (1997), the Solihull Approachdescribes how from the moment ofbirth, the baby and its primary caretaker,usually the mother, have effects on eachother:

“The baby communicates with his mother withevery means at his disposal, through crying,shrieking, stretching, flexing, cooing,grimacing, gurgling, smiling, looking and soon. It is of enormous significance to the babythat he can influence the mother’s response tohim, rather than being a passive object to whomthings are done, as he then has the experienceof being in an active, dynamic relationship.”

Early in the day Janet Dean emphasizedthat the motivation to be reciprocal inour relationships is a prerequisite if ourinteractions with others are to be

meaningful. She highlighted howreciprocity is concerned with the ability tosustain pleasurable, rhythmic interactionswith another, and also importantly, to beable to regain this rhythm whensynchronicity is temporarily lost. Thiswas reminiscent of the work of AllanSchore (1994) who argues that thecapacity of a mother (or primary carer) tore-engage her infant, shortly after anemotional connection has been broken,is key to promoting secure attachmentsand resilience to emotional distressthroughout our lives.

Janet Dean suggested that whenassessing infants, a critical questionrelates to the child’s ability to self-soothe,and to develop an internal process ofself-regulation. This ability has impor-tant implications for impulse control,mood, and self-esteem not only forgrowing infants but also for us aspractitioners. Janet argued that asworkers, we need to prioritize makingspace, through reflective or clinicalsupervision, to put ourselves back intosynchrony; to face the emotional impactof our work and to address our owninsecurities – our life-long struggles withhelplessness, being overwhelmed andautonomy.

Mary-Sue spoke of how ‘holding amemory with another individual is madeup of micro physical and affect cues’which provide crucial information aboutthe other person. For healthy full-terminfants the capacity to read others’ cuesand to produce cues for others isneurologically hard-wired into our brainsand is in play from birth. The infantinitially needs a soothing adult toregulate arousal levels for him, andthrough experience an understanding ofself-soothing and sensory-down-regulation is built up. This process isvery finely tuned across the first monthsof life, so that if there is no helpful adultintervention, the ability to regulate one’sown breathing and be in a calm,regulated state, will be thwarted. Babiescannot do this for themselves, and if it isnot processed for them as infants theywill be less able to do it for themselves in

later life. The close link with Bion’s(1959) concept of maternal containmentof infantile anxiety and distress so thebaby can experience it in a more manage-able way was evident in the materialpresented by Mary-Sue and Janet Dean.However, this basic tenet of Britishpsychoanalytic thinking has apparentlynot had the same impact across theAtlantic.

Reciprocity, or contingent responsive-ness, can go awry when there are non-contingent responses made to an infant’scues i.e. parental actions are not respon-sive to the child but responsive to needsof the adult. For example, an infant maybe feeling overwhelmed by face to facecontact and turns away but the parentexperiences this as rejection and looms,becoming overly intrusive and leavingthe child feeling powerless either to avoidinteraction or to regulate their emotionalstate. In such a way, reciprocity may be‘de-railed’ in early infant-parent dyadsand consequently in families as a whole.Experiences that are accompanied withstrong emotions build up fasterpathways in the brain and the responsesevoked up to two years of age willtherefore become ‘hard-wired’ into thebrain and show itself as the infant’s‘attitude towards and expectations of’others.

Equally, although babies are wired fromthe beginning to respond to seekemotional contact with others, theresponsiveness of individual babies canvary. The impact of disability, prematurebirth, drugs in utero, and the geneticcontribution, can all influence the child’slevel of ability to read and give out cues.The ‘goodness of fit’ between the parentand child, and their adaptability to eachother’s style of relating, is critical for apositive attachment relationship.

Mary-Sue provided a new and interestingframework that we are unable toreproduce here as she has recentlysubmitted it for publication in a journal.The diagram represented her thinkingabout the link between patterns ofregulation and attachment. The various


insecure attachment categories:‘avoidant,’ ‘ambivalent,’ and ‘trauma-tized’ were positioned in an ascendingscale of how far they reflected a greater orlesser focus on either ‘self’ or ‘other.’This relates to the child/parent dyad’scapacity for movement back and forthbetween awareness of self and awarenessof others. The bottom axis referred tothe scale of vigilance towards incomingsensory data. It is worth noting thatthese axes shifted from low – high – lowrather than increasing in a straightfor-ward linear way. Mary Sue also wished toemphasize that ‘an attachment labelcannot be applied to just one person, itis always a dyad you are describing whendiscussing infants and parents’ (personalcommunication).

Children with a secure attachment have asense of expectation and are able topredict that their caregiver will recognizeand meet their different cues for feeding,stimulation, sleep etc. They do not needto be especially vigilant of their environ-ment or parental mood and can be openin the expression of their own cues aswell as their awareness of those of others(low vigilance/high capacity to movebetween an awareness of self and other.)This group will develop mutual affectregulation whereby both mother andinfant each have an impact on theregulation of the emotional state of theother; the process is two-way and,therefore, positively reciprocal in nature.

Those dyads that fall within an avoidantor anxious attachment category are thosethat are preoccupied with their ownemotional state (high vigilance/lowawareness of other) understandablyfinding difficulty with empathy and/orare resistant to interpersonal contact. Theorigins of such a state of mind may bebiological, genetic or environmental. Thisgroup can also include those on theautistic spectrum, or who have requiredintrusive medical intervention but mayalso reflect those who suffered emotionalor physical neglect, including neglectfrom maternal mental illness or depres-sion.

A key feature of attachment is the abilityto predict what will happen in our earlyrelationships; if we cannot do this webecome highly anxious. When we havemultiple unpredictable experiences, it canlead to rigid defences against futureemotional contact and, unfortunately,may block even potentially positiveinteractions. Mary-Sue stressed thatindividuals with such rigid defences donot evolve them arbitrarily; they will havedeveloped them innocently as a way ofstabilizing their world in the face ofuncertainty. This should alert us to theunderlying reasons when we come acrosssome of the same features in our workwith parents and other adults.

The dyads in the top right hand section(high vigilance/high awareness of ‘other’at the expense of self) included thoseinfants who have highly unpredictableand traumatic early experiences at thehands of their parents, which mayinclude physical abuse. They are hypervigilant and are only secure when able tomonitor closely the emotional state ofthe primary carer. They block self-expression having learnt that assertingtheir own needs may have negativeconsequences and avoid interaction whenthey sense the parent is in a negativestate.

A child who experiences trauma does notusually have a sense of its own agency inthe world. He becomes passive or freezesas a last-ditch survival mechanism. Mary-Sue argues that this early freeze response,as a way of getting through painfulexperience, is associated with dissociationin later life.

It was interesting to hear Janet Deandescribe how, over the past decade, sheand her colleagues have begun to assessfor dissociation with their adult clients.She suggests being alert to the kind oflanguage that reflects dissociation, suchas: ‘I’m out of it,’ ‘not in the room,’‘zoned out.’ Some clients cannot be inthe room long with a worker or attendand take in information and process it.She emphasizes that our presence as

workers inevitably creates ambivalencebecause it demands a relationship withour clients. We should not underesti-mate how anxiety-provoking our contactcan be for parents as it re-arouses oldfears of rejection. She also stressed theneed for us, as workers, to identify ourown anxiety and levels of arousal, whichmay trigger our own dissociation from adifficult situation. These are the mo-ments when we go somewhere else inour mind rather than remainingemotionally available and present in theroom to attend and listen to clients.Janet’s style, directly observable on video,is one of patience and ‘wondering with’parents, not approaching issuesconfrontationally or head-on, allowing arelationship to develop where possiblebut taking definitive action where shedeems necessary. It was a privilege to beable to watch her at work.

The gap in professional understandingof and response to child protectionissues, often apparent between healthservices and social services, was givensome thought during the day. Janetshared some of the dilemmas her ownservice had in the beginning and howdifficult it can be to persuade socialservice colleagues that certain infants areat risk from emotional and/or physicaltrauma without physical evidence linkedto a perpetrator. Again, the freezeframing of the micro moments of facialexpressions of a mother with her child,captured on video, but almost unidenti-fiable in real time, provided strongevidence for the power of this medium.

Janet argued that health professionalscould have a key role in helping socialworkers identify some of the aspects thatpoint to problematic interactionsbetween parents and their infants. Weneed to be alert to parental capacity forempathy, whether they respondcontingently to their infant’s cues, thelevel of dissociation in parents and howthis impacts on ourselves as workers.How parents talk about their baby canoffer insight into what the infantrepresents for them in their inner world,i.e. is the child a threat in some way? Or


how a parent physically handles a childmay offer further clues, i.e. is there a realemotional connection when bathing ordressing the child? The value of under-standing the micro-nuances of reciprocalinteraction and also when it is absent wasapparent. Where there are observabletriggers for risky behavior from a parenttoward their child, whilst very worrying,this may mean treatment might be morepossible. Janet’s position, which madeclear sense, is that the situation is moredangerous for both the mother andinfant when triggers are not observableand originate outside the dyad.

Many thoughts and images haveremained firmly in mind since the day inOctober. However, one central theme inJanet Dean’s work with parents andinfants at risk has held particular sway.Janet emphasized the necessity ofoffering validation of the expressedfeelings or experiences of the adult,especially those thoughts elicited frominquiries about whether they wanted toraise their children in a similar way totheir own upbringing. Often theseresponses reflect the mental representa-tion of the baby in the parent’s mind. Byvalidation, Janet means not collusion orsimple reassurance, but some positiveacknowledgement that you have takenthe parent’s words seriously, at the sametime attempting to avoid evoking furtheranxiety or resistance.

Diana Fallowes and Clare HadleyChild Psychotherapists

References

• Douglas, H. and Ginty, M. (2001) TheSolihull Approach : changes in HealthVisiting practice. Community Practitioner74, 6: p222 – 224• Stern, D.N. (1985) The InterpersonalWorld of the Infant. New York. BasicBooks• Murray, L. and Cooper, P.J. (1997)Post-partum Depression and ChildDevelopment. New York. GuilfordPress• Schore, A. (1994) Affect Regulationand the Origin of the Self : the Neurobi-

ology of Emotional Development.Hillsdale, N.J. : Lawrence Erlbaum• Bion, W. (1959) Second Thoughts.Heinemann. pp 103-104

Mental Health in InfantsMental Health in InfantsMental Health in InfantsMental Health in InfantsMental Health in Infantsand Parents: A Studyand Parents: A Studyand Parents: A Studyand Parents: A Studyand Parents: A StudyAfternoonAfternoonAfternoonAfternoonAfternoon

St Clements Hospital, Mile End.East London and the City Mental HealthTrust

The Mental Health in Infants andParents study afternoon was jointlyorganized by the Child and Adolescent,Adult Mental Health and AdultPsychotherapy Department in TowerHamlets. It followed the successful daythat was held in September 2001, whichlooked at the psychodynamics ofparenting infants and young children(Dawson, 2001). This year two speakerswere invited, who were able to help us toconsider the trans-generational effects ofchildhood experiences upon mentalhealth and well-being. Dr Neil Morgan,Locum Consultant Psychiatrist in AdultPsychotherapy, and Dr Cathy Urwin,Consultant Child Psychotherapist, bothof whom work in Tower Hamlets,chaired the afternoon.

Dr Neil Morgan began by remarkingupon an apparent growing convergencein thinking by different approaches toadult psychotherapy in accounting foradult distress as being influenced bychildhood experiences. More specifically,he referred to models that focus uponthe interpersonal experience between thechild and their care-givers, conceived asschema development within thecognitive tradition, and the process ofbuilding up an internal representation ofthe child’s outer world in thepsychodynamic tradition. Referring toBowlby, he suggested that anappreciation of inter-generationaltransmission could help us asprofessionals work towards inoculatingagainst mental ill health in the way thatgeneral medicine has been able todevelop inoculations against physical illhealth.

Dr Urwin introduced the speakers. Shebegan by commenting on the impactthat a new baby can have upon thefamily, suggesting that it is a time ofconsiderable turbulence. She alsoreminded us that the processes involvedaffect both the parent and the child.

The first speaker, Paul Barrows, (LeadClinician for Child and AdolescentMental Health Services in south Bristol,Course Organizer of the MA in InfantMental Health, and Chair of TheAssociation for Infant Mental HealthUK) asked us to consider a vital, butoften neglected, issue withinmultidisciplinary teams, which is: whoshould be seeing a particular family, andwhy? He linked this to a consideration ofhow the role of fathers has often beenneglected in the formulation of cases,particularly within the psychodynamictradition. This was illustrated by a casestudy, involving an 18-month-old boywhose parents were considerablydistressed by his chronic night waking.He commented on how affectionate theparents were towards the child and, aftera relatively short time, he was able toformulate the case as being an exampleof how the strategies employed byparents to soothe their children at nightcan prevent the children from developingautonomous self-soothing strategies,which results in disrupted sleep for thewhole family. The result, as many of uswill know, is a child who demands thepresence of his parents intermittentlythroughout the night whenever hehappens to wake.

He was aware that this family hadreceived generous portions ofmultidisciplinary time already, none ofwhich seemed to have had much impact.In keeping with his normal approach, heinvited the whole family to attend. Ingaining a greater appreciation of thefather’s understanding of the problem,there was significant progress. It becameclear that it was the father who was leastable to tolerate his son’s crying. Healways attended to him when he woke,regardless of advice that he had beengiven by professionals. An investigation


of the intergenerational family historyrevealed that the boy had come torepresent for his father his paternalgrandmother, who had died shortlybefore the baby was born. Unresolvedgrief and personal guilt had contributedto a belief by the father that beingallowed to cry would damage the boy.The ‘ghost’ of the paternal grandmother,in this case, had come to ‘haunt’ thenursery of the child in the present.Discussions around this theme led tothe family – particularly the father -returning home with a remarkable newsense of freedom. This enabled them toempower the child to develop his ownresources for self-soothing at night. Thiscase showed how important theinformation of the father’s history hadproved in its resolution.

Paul Barrows suggested that theimplications of this case hinted at howthe neglect of the role of fathers in thedevelopment and maintenance ofchildhood difficulties within thepsychodynamic tradition has been amarked and missed opportunity, andstated that this imbalance should beredressed. Rather than merely existingwithin a dyadic relationship at birth,infants are actually exposed to a complexmatrix of social relationships, each ofwhich has an impact upon theirdevelopment, mental health and well-being. At the heart of this is the parentalcouple. How does the child envisage therelationship between these twoimportant significant others? How doesthe child allow it’s parents to cometogether, identify with this, and go on todevelop their own mental map ofparenthood? The parental relationship,whether it is healthy and adaptive or not,exists as a vital early model of socialrelatedness.

The second case study presented by PaulBarrows, continued the ‘ghost in thenursery’ theme (Fraiberg, Adelson &Shapiro, 1975), demonstrating how theparents’ own experiences of childhood(in this case violence on the mother’sside, and humiliation on the father’s)influenced the way they perceived their

child’s behavior (in this case their twoyear old son’s violent temper tantrums.)Their different childhood experiencesgave them very different perspectives onhow to respond to their son, and herepresented different things to both ofthem. As this case developed it becameapparent that the parents’ ownmemories of childhood were beingprojected onto the child in the present,and that the father’s ghosts were just asinfluential as the mother’s. Again, toneglect the impact of the father, and hisown personal history would have beenan important oversight.

In his concluding remarks, Paul Barrowsdrew two implications. The first was thatas professionals we should be aware ofhow tempting it might be to step intoan absent father’s shoes and replace him,rather than working hard to find outexactly what his influence is upon thefamily. Secondly, we were reminded ofhow an understanding of the wayrelationships are observed andinternalized as representations of theworld can in itself be used therapeutically.The modelling of self-reflection as ahealthy and adaptive way of thinkingabout childhood problems can be auseful tool for families to take away withthem both during and after therapeuticcontact.

The second speaker, Dr Alia Parvin, aClinical Psychologist in the communityteam in Tower Hamlets presented herresearch thesis, which exploredBangladeshi mothers’ explanations ofpostnatal distress.

She began with a consideration of whycultural variation is important,particularly when thinking about thesubjective experience of distress. Morespecifically, in preparing for her study,she noticed that there was a lack ofresearch into how other culturesunderstand postnatal distress, or anyconsideration of how these ideas mightmap onto Western notions of postnataldepression as a diagnosis. Her startingpoint was the apparent lack ofpostnatally depressed non-English

speaking Bangladeshi mothers in TowerHamlets. She was interested in findingout why this was. Did postnatal distressnot occur in this population, or was itthat they simply remained undetected?

Alia Parvin’s research has thrown somevery interesting light upon the differentways that this phenomenon is thoughtabout. She completed a qualitative study,interviewing non-English speakingBangladeshi mothers referred for PND,and GPs with a specific interest in thecondition. More specifically, she wasinterested in finding out how theaccounts of these two groups of peoplecompared/contrasted to one another inrelation to their understanding andconceptualization of maternal distress.

In relation to childbirth, the mothersseemed to draw upon a culturaldiscourse that described the experience interms of pain, illness and the importanceof having plenty of time to recover fromthe trauma of having had a baby. Thisconceptualization of childbirth extendedto the way they understood postnatalpsychological distress – that it was causeddirectly by the trauma of the birth. Thiswas placed within two explanatoryframeworks:

1. Religious/Spiritual Framework:This discourse presents postnataldistress as being the result of anindividual having to endure a trial set byAllah, to test her faith (Fara).Alternatively, it may be the result of the‘weak and vulnerable’ body being moresusceptible to possession and spiritualexploitation (the Bai.)

2. Embodied Framework:This discourse states that the mind isaffected by the weakness of the body,and this is seen as an inevitable andunderstandable result of the ‘physicaltrauma’ of birth.Alia Parvin suggests that one function ofthese frameworks is to distance thephenomenon from individualresponsibility, and any resulting stigmaassociated with being unable to cope.Psychological distress is located as either


having been inserted spiritually, orcaused by and expressed through thephysical phenomenon of pain. Shestressed that the ‘embodied’ concept isless like western notions of‘somatisation’ and more like the conceptof ‘reactive depression.’

This group of mothers seemed to havevery different expectations of whattreatment was available to them, andoften did not know that a diagnosis ofPND had been given, what it meant, oreven how they were being treated for it.They often referred to their medication as‘vitamins,’ or asked for vitamins insteadto help them. They saw psychologicaldistress as a result of physical trauma,and did not consider that ‘depression’could be why they felt unmotivated,tired, and lethargic. The idea ofdepression filled many of them with fearbecause they saw it to be a dangerousand terminal condition (this is incontrast to UK white mothers withPND who are often relieved to receivethe diagnosis.) The mothers also hadvery different ideas about whatconstitutes a successful recovery –agreeing that to be better meant beingmore able to function physically, notnecessarily feeling less psychologicaldistress. They often attributed recoveryitself as being the result of changes insocial context (i.e., the baby became lessdifficult as it got older) or the result ofprayer to Allah.

Alia Parvin’s account was illustrated withsome fascinating excerpts from theinterview transcripts. She placed theresearch within a discussion thatemphasized how wide the mismatch wasbetween the understandings andmeanings held by GPs and those held bythe Bangladeshi women, specificallyaround what is meant by ‘recovery.’ Shealso stressed the importance of socialcontext in understanding distress,particularly an appreciation of the extentand quality of the family support thatmight be available to a mother who hasjust given birth. Finally, we were asked tothink about whether enough is beingdone to clarify the expectations and

understandings held by our clients whenthey seek our support, and also whetherenough is being done to consider howpatients from ethnic minoritycommunities might understand andthink about the diagnoses and treatmentstrategies that are often taken for grantedby health care professionals.

The two presentations were followed bya plenary session, consisting of thespeakers, the two chairs and Allie Nolan(Sure start Coordinator in TowerHamlets), Rosemary Loshak(Coordinator of services for childrenwhose parents have mental healthproblems, a brand new Tower Hamletsinitiative) and Dr Eleni Pilazidou (AdultPsychiatrist with an interest in affectivedisorders and intergenerationaltransmission.)

The plenary session began with adiscussion about the themes generatedby Alia Parvin’s talk, specifically inrelation to whether second- and third-generation Bangladeshi mothers havesimilar understandings of PND to non-English speaking mothers.Consideration was given to whether theincreasingly stretched resources of theNHS contribute to an increasinglynegative social context of childbirth forthis group of women, and it wassuggested that this might contribute to ahigher incidence of postnatal depressionin this community than is acceptable.

Attention was then given to PaulBarrows’ statement about the neglect ofthe role of fathers in approaches to childmental health. It was agreed that whilstthe psychodynamic model may haveneglected this important aspect, othermodels such as Systemic Family Therapy,had not. Distinctions were drawnbetween models that base theirunderstanding of child mental healthupon the internal representations thatthe infant is developing during itsformative experiences, and those that donot. Cathy Urwin commented that thisunderstanding allows us to considerhow the infant can trigger the ‘infantile’experiences of the parents, making them

think and behave in certain ways. DrJulian Stern, Consultant Psychotherapist,also reminded us that some of theearliest work in the psychodynamictradition did not neglect the role offathers, and he cited Freud’s ‘Little Hans’case as an example.

In summing up, Neil Morgan invited usto think about whether Tower Hamletsis doing enough to address the needs ofwhole family systems within the contextof inter-generational transmission.Comments from the floor includedquestioning whether enough is done toavoid increasing the numbers of childrenwho are taken out of their families and‘looked after’ by the local authority. Itwas noted that the new initiatives, suchas the Looked After Children Team, andthe new team being coordinated byRosemary Loshak are both addressingthese issues directly. Julian Stern alsoreminded us that specialist teams alsoserve to mask more profound defenceswithin services, which ring-fence theiradmission criteria in order to avoidworking inter-generationally. Allie Nolannoted that initiatives such as Sure Startpromote preventative, community-based, non-pathologising approaches tomental health care of the whole familyand it was agreed that this would seemto be a clear step in the right direction.

Dr Jonathan WellsClinical Psychologist

References• Fraiberg, S, Adelson, E & Shapiro, V.(1975). Ghosts in the Nursery: apsychoanalytic approach to the problemsof impaired infant-mother relationships.Journal of the American Academy ofChild Psychiatry, 14 (3), 387-422.

• Dawson.L (2001). The Psychodynamicsof of parenting infants and youngchildren – A study day. AIMH (UK)Newsletter. Vol 2 Issue 4, pp 8-10.


PPPPPresident’sresident’sresident’sresident’sresident’sPPPPPerspectiveerspectiveerspectiveerspectiveerspectivePeter de Chateau

In our bylaws the purposes of WAIMHare laid down in the following openingstatement: “The Association has beenorganized to operate exclusively forscientific, charitable, and educationalpurposes”, followed by a more detaileddescription. As we are now approachingour 25th anniversary and soon will becelebrating this happy occasion itperhaps is appropriate to discuss someof the issues connected with thesepurposes.I will address a few of theissues currently of great importance forour organization’s development and thechoices to be made for our futuredirection and growth. In particular it isuseful and necessary to especially lookinto organizational matters: globalrepresentation within WAIMH at alllevels,voting procedures for differentcommittees and task-forces, theorganization of our congresses andfinally our cooperation with otherinternational organisations and otherbodies in our field.

During the last years there has been alively discussion on the internal,organizational structure of WAIMH.The bylaws with their amendments, thebusiness meetings and the meetings ofthe board of executives have been thevehicles for decisions influencing thechanges in organization andmembership representation. Especiallythe position and the role of the affiliateshave been the subject of changes. (seealso Brigid Jordan’s, Bernard Golse’sand my own contributions in earlierissues of the Signal.) The result of whichhas been a new and more influentialplatform for the affiliates, a neworganization and place for theircooperation and their contributions tothe Executive Committee and the Signalas well as a more distinct input in theprogram of our world congresses and in

the Journal. It is also wonderful to seethe growing number of affiliates and weshould work hard to achieve that thispositive trend is continued and newmembers and new affiliates, especially inregions with underrepresentation, canfind their way to join the globalization ofWAIMH.

Voting procedures are characterised by alow degree of participation in ourassociation. This seems also to be thecase in many associations comparable toours. However as we only haveindividual members, unlike many otherinternational organizations with countrymembers, and are a multidisciplenaryorganization not much can be expectedto be changed in this respect. As ourmembers unfortunately only in 10% usetheir democratic rights in differentelection procedures over time,we here doacknowledge a rather substantialproblem. I therefore strongly would liketo ask the membership to vote wheneverinvited to by WAIMH, to attendbusiness meetings during ourcongresses, to actively participate indiscussions and decisions within theirown affiliate, and also to react and towrite to members of the ExecutiveCommittee and other officials. As we arepreparing the agendas for manyExecutive Committee Meetings,meetings with the Local OrganizingCommittee, the Program Committee,and the business meeting in Melbournewe would like to ask the members to letus know their proposals, ideas, andwishes so membership participation anddemocracy can increase.

Athough we are in the midst ofpreparations for Melbourne, we alsohave to look at the 10th World Congressto be held in Paris in 2006. Themembership most certainly has a great

opportunity to influence what willhappen and what it will be like there andthen, organizing an international andmultidisciplinary meeting with a low-budget has obviously over the years since1980 become a more difficult,complicated, and financial risk.Pharmaceutical industries and othercommercial and also public institutionsare not very eager to sponsor meetingson very young infants’ and children’smental health, since not much moneycan be made by doing so. Also our ownattitude has over time been not tobecome dependent on commercialinterests influencing perhaps theprogram and other activities of ourcongresses.In order to keep ourassociation financially sound andindependent our income is from themembership fees,the Infant MentalHealth Journal and our worldcongresses. This last activity is by far themost dominant in terms of generatingfunds and therefore absolutely of vitalimportance. In order to ensure a highquality of congress presentations thework of the different ProgramCommittees has been much appreciatedby our members. Different wishes andexpectations do however live in ourmembership due to its international andmultidiciplinary composition.Here againour members do have a marvellousopportunity to make their wishes andexpectations come true: make your voiceheard at different opportunities and donot hesitate to contact our officers at alocal or central level. Also ideas on howto improve and guarantee our financialhealth and future will be especiallyappreciated by us all.

Last but not least much work has to bedone in terms of international exposureof our knowledge and ideas.Cooperation with other internationalassociations in our field is an ongoingprocess that has resulted in informalmeetings with representatives of thoseorganizations, the presentation of officialsymposia at each others congresses andcollaborative actions and points af view

Continued on page 28


By Hiram Fitgerald,By Hiram Fitgerald,By Hiram Fitgerald,By Hiram Fitgerald,By Hiram Fitgerald,Executive Director WAIMHExecutive Director WAIMHExecutive Director WAIMHExecutive Director WAIMHExecutive Director WAIMH

In just a few months, WAIMH will bedeeply involved with its 9th WorldCongress in Melbourne, Australia. Theprogram committee has crafted anexciting program that promises to keepall participants actively centered on infantmental health issues delivered by way ofpre-congress institutes, clinical teach ins,plenary speakers, symposia, workshops,poster sessions, poster workshop, andvideo sessions, conversation hours, andmentor luncheons. Plenary speakers areJames McHale, Joy D. Osofsky andCindy Lederman, Antoine Guedeney,Alicia Lieberman, Kaija Puura, and Peterde Chateau. Program activities providevivid evidence that the field of infantmental health is both vigorous anddiverse. And when the intellectual feastdraws to an end, there are countlessopportunities for all family members torelax and refuel.

Yarra ValleyGo north east to visit HealesvilleSanctuary and view koalas, kangaroos,wombats, platypus, dingoes, emus, andTasmanian Devils. Enjoy on-sitetastings at 38 wineries, stay at any one of71 hotels, and enjoy the valley’s manyparks, crafts and antique shops.

Macedon RangesGo northwest to the Great DividingRange, to take in one the most beautiful

wine regions in Australia, featuringchardonna, semilion, pinot noir, shiraz,and cabernet wines.

Werribee ParkInterested in tranquil beauty, visit one ofVictoria’s largest private residences, withover 4,500 roses forming a center piece ofone of Victoria’s finest gardens.

Phillip IslandGo 90 minutes southeast and visit withKoalas from treetop boardwalks at theKoala Conservation Centre, get close toseals at the Seal Rocks Sea Life Centre atNobbies, and in the evening join thePenguin Parade and watch little Penguinscross the beach on their way to theirburrows in the sand dunes.

Great Ocean RoadBeginning at Torquay, enjoy 300kilometers of spectacular coastline, and atPort Campbell National Park view theTwelve Apostles and the Loch Ardshipwreck.

Murry RiverGo 50 kilometers east and ride theMurray River Paddlesteamer whileviewing majestic river red gums,Cockatoos, and Galahs. Train buffs canhop on the Puffing Billy steam train for a13 kilometer ride from Belgrave toEmerald Lake through the beautifulBlue Dandenong Ranges National Park.

In MelbourneVisit the Queen Victoria Market, acentury (1878) old center of trade andcommerce that spans 7 hectars and hosts

fabulous foods and wines as well asclothing, fabrics, flowers, jewelery,handicrafts, and artefacts. Findaboriginal art at the Aboriginal Gallery ofDreamings, walk through theextraordinary Royal Botanic Gardens,established by Charles La Trobe in 1945,or try the Fitzroy Gardens and CaptainCook’s Cottage. Children will especiallybe awed by the Melbourne Acquarium.Melbourne was founded on a sitehistorically occupied by AboriginalKoorie tribes. The Yarra river, namedfrom the Aboriginal words “YarraYarra” (running water), is a focal pointfor much of Melbourne’s cultural life.

Combining the clinical and scientificprogram with Australia’s unique historywill make this World Congress one totruly remember. Located in the SouthPacific, Australia is equally accessible fromnearly any part of the world. Melbourne’s2000 restaurants and 70 differentnational cuisines provide justification forits reputation as Australia’s culinarycapital, just as its glorious parks justify itas the garden capital. January is summerwith average temperatures ranging from26C (79F) to 14C (54F), and with morehours of sunshine than many othercountries in the world. Congressattendees will need to have a validpassport and a visa.

All members of the WAIMH Board ofDirectors, the Scientific ProgramCommittee, and the Local ArrangementsCommittee look forward to greeting youin Melbourne and working with you aswe collectively examine “The Baby’s Placein the World.”

By the Yarra RiverBy the Yarra RiverBy the Yarra RiverBy the Yarra RiverBy the Yarra RiverMELBOURNE 2004!MELBOURNE 2004!MELBOURNE 2004!MELBOURNE 2004!MELBOURNE 2004!


WORLD ASSOCIATIONFOR INFANT MENTAL HEALTHUniversity Outreach & EngagementKellogg Center, Garden LevelMichigan State UniversityEast Lansing, MI 48824-1022

Tel: (517) 432-3793Fax: (517) [email protected]

NON-PROFIT ORG.U.S. POSTAGE PAIDEAST LANSING, MIPERMIT 21

www.waimh.orgwww.waimh.orgwww.waimh.orgwww.waimh.orgwww.waimh.org

in situations of mutual interest. Stillmuch work has to be done to improvethese possibilities in which themembership can be very helpful. Thisholds true also for collaboration at aglobal level. Our knowledge ofimproving mental health conditionsfor infants, young children, and theirfamilies is unique. Oue voice ishowever very seldom heard at aworldwide level. WAIMH shouldmake a priority of changing this stateof affairs and see to it that channels canbe found to diffuse our solidknowledge to a high level ofinternational organizations in order topromote our view on the conditionsunder which many of the youngest andtheir families live worldwide today.In closing, I would once again like toask you all kindly to react to my ideas,which you are very welcome to do atWAIMH’s central office or directly tome at [email protected].

President’s Perspective Continued

REGISTRATION:For your convenience, program information together with on-line registration andaccommodation forms are posted on the Congress website http://waimh.org/Information_2004.htm

HOTEL: http://waimh.org/Information_2004.htmOn-line accommodation bookings will not be accepted without an accompanying credit card payment.Payment of fees must accompany all registration forms, and confirmation will not be forwardeduntil receipt of payment.

WAIMH MEMBERSHIP:Please visit our website at http://waimh.org/Information_2004.htm

TOURS:To make a booking please go to:http://waimh.org/Information_2004.htm

WAIMH 9th World CongressJanuary 14-17, 2004

Melbourne, Australia

Contents: Mindful Parenting: Enhancing Reflective Capacities of

Documents