Watch, Wait, and Wonder: An Infant-led Approach for Working with Infants and Their Parents

Watch, Wait, and Wonder: An Infant-led Approach for Working with Infants and Their

ParentsNancy J. Cohen

Hincks-Dellcrest Centre & University of Toronto

COLLABORATORS:

Mirek LojkasekElisabeth Muir

GOALS Discuss the underpinnings of Watch, Wait, and

Wonder in attachment theory Compare Watch, Wait, and Wonder to other

current interventions Describe Watch, Wait, and Wonder technique

and process Summarize research results on Watch, Wait,

and Wonder Consider applications of Watch, Wait, and

Wonder

On the surface, some infant problems may not appear to be relational. However, they often reflect the infant’s separation anxiety. The difficulties do not reside solely in mother or child but in the relationship.

SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION

Infant Symptoms Irritability and difficulty being soothed Excessive tantrums Sleeping problems Eating problems Clinginess

SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION

Parent Symptoms Depression Anxiety Risk for or allegations of abuse Complaints of not feeling bonded or

attached to infant

“A baby has none of the conventional attributes of a psychiatric patient. He can’t talk about his problem. He can’t form a therapeutic alliance. He has no capacity for insight. Such patients are usually labelled ‘not suitable for treatment’ in the language of psycho-therapy.”

CONDITIONS FOR SECURE ATTACHMENT

Accurate perception of infant cuesSensitive responsivity to infantDisplay of affectionAcceptance of infant’s behavior and

feelingsPhysical and psychological accessibility

when infant is distressed or when exploring

IMPLICATIONS OF ATTACHMENT SECURITY

Regulation of emotions and behaviorSense of selfCuriosity and explorationCognitive and language competenceCapacity to relate to othersCapacity to parent

Individual Differences in Infants Contribute to the Relationship

Infants have different personalities or temperaments from early on

These traits evoke different responses (e.g., some babies are soothed easily)

Some parents find it difficult to establish a “fit” with their infant.

The parents often have expectations of how their child should be. These expectations may be conscious or unconscious.

Even when the problem is attributed to something else (e.g., FAS; developmental exceptionality) a relationship focus can be of benefit.

SECURE BABIES

Explore freely and seek contact with the attachment figure as necessary.

INSECURE BABIES

AVOIDANT BABIESDo not show attachment needs in order to avoid rejection.

AMBIVALENTPreoccupied with the availability of an inconsistent caregiver and make repeated high intensity demands to ensure at least some elicit attention or are extremely clingy.

DISORGANIZED BABIES

Do not have an organized strategy that elicits care when distressed.

INTERNAL WORKING MODEL

Internal working models of self in relation to others are set down and unconsciously guide and filter attention and processing of experiences with regard to attachment. In this way, they impact on the course of future relationships.

An intervention consistent with attachment theory needs to meet a number of criteria:

Provides emotional and physical access to mother. Focuses directly on maternal sensitive responsiveness to the infant's behavior and emotional signals. Places the mother in a non-intrusive stance. Provides a space in which the infant can work through relational struggles through play and interaction with the mother. Provides a therapist who can function as a secure base for the dyad.

OTHER INTERVENTIONS: Support

Assist mothers to access community resources, such as housing, work, child care.

Counselling the mother or teaching social skills.

Therapist is resource.

OTHER INTERVENTIONS: Developmental Guidance

Provide information to the mother on infant abilities, developmental milestones and needs, and practical caretaking issues individually or in group format or informally during infant medical check-ups.

Therapist is resource.

OTHER INTERVENTIONS: Relational Guidance

Help mothers increase knowledge of and experience with infant in the context of spontaneous interactions.

Mothers helped to attend to their infants’ idiosyncratic cues.

Therapists provide feedback directly or by reviewing videotapes with the mother.

Therapist may also model parenting behavior.

OTHER INTERVENTIONS: Psychotherapy

With help of therapist, the mother gains access to repressed early experiences, re-experiences feelings associated with them, and achieves insight into the relational difficulties with her infant.

Infant included as a catalyst for change. Repetition of the mother’s past primary relationships

in her relationship with the therapist Therapist interprets and helps mother make links

between past and present. Therapist may guide mother to interact in a different

way.

In spite of our current knowledge that infants contribute to relationships, all of these therapies focus on the mother and assume that the work needs to be done with her before the infant can benefit. None of these therapies have as their goal that the infant should be able to use the time therapeutically himself.

Although it is the infant who is the greatest clinical concern, the actual focus of treatment is usually the mother. In our work, we have focused on how best to include the infant in infant-parent dyadic therapy directly through the infant’s activity.

“You be this way or else you will cease to exist in my eyes.”

The mother can only see certain behaviors. The dilemma for the infant is that if he is himself he loses his mother. If he loses his mother he loses himself. Ironically, if he keeps his mother he also loses himself. The outcome of this experience is separation anxiety.

HOW DO WE INCLUDE THE INFANT IN PSYCHOTHERAPY?

Allow the infant to explore and show his curiosity about the environment. through sensorimotor activity and play.

Use observation of the infant’s spontaneous gestures as a reflection of his innate potential.

Use a medium in which infants can seek and establish relatedness.

WATCH, WAIT, AND WONDER SESSIONS

Infant-led activityDiscussion

SUGGESTED LIST OF TOYS FOR WATCH, WAIT, AND WONDER

New born baby anatomically correct dolls with bottles and diapers an blankets

Stacking cups

Doll’s crib that is large enough for child to crawl into, or set up a space on the floor with a pillow and blanket defining a bed

Blocks

Bean chair Small cars including ambulanceTwo telephones Medical kit with stethoscopeMirror, (shatter-proof) Sets of vinyl family dolls (black

and whiteActivity board Set of tame and wild animals –

large solid varietySoft ball Bowls and mixing spoons

Stacking rings Train set

Policeman helmet or some other official hat Heavy duty blue vinyl (Pool manufacturers)

Undermatting polypropylene for padding

NOT ALL OF THESE TOYS ARE REQUIRED. IN FACT, WWW CAN BE DONE WITH VERY FEW TOYS IF NECESSARY

INSTRUCTIONS FOR WATCH, WAIT, AND WONDER

Get down on the floor with your baby. Follow your baby’s lead at all times. Do not initiate activities yourself. Be sure to respond when your baby initiates

but do not take over his activities in any way. Allow your baby freedom to explore;

whatever he wants to do is okay as long as it is safe.

Remember to Watch, Wait and Wonder.

DISCUSSION

What did you observe?

What was your infant’s experience?

What was the play about?

What were your thoughts and feelings?

RESEARCH OUTCOMES: KEY AREAS OF MEASUREMENT

Symptom reduction

Mother-infant relationship

Infant competence

Maternal distress and confidence

RESEARCH OUTCOMESPRE- TO POST-TREATMENT

Both treatment groups exhibited symptom reduction, improved quality of mother-infant interaction, and reduction in parenting stress.

Greater gains were made from the beginning to the end of treatment in the WWW group in attachment, infant cognition and emotion regulation, and maternal depression and parenting efficacy.

RESEARCH OUTCOMESPOST-TREATMENT TO FOLLOW-UP

Improvements that were observed at the end of treatment were maintained.

In some respects, further improvements were observed six months after treatment ended in reduced infant symptom severity, maternal intrusiveness, and dyadic reciprocity and parenting stress.

Changes emerged in WWW and PPT at a different pace. Dyads receiving PPT showed gains in infant cognitive development, attachment, and maternal depression at follow-up that had been observed in dyads receiving WWW at the end of treatment.

WHAT MIGHT ACCOUNT FOR DIFFERENTIAL TREATMENT EFFECTS - 1

Watch, Wait, and Wonder maximizes the requirements for forming a secure attachment relationship by providing psychological and physical accessibility to the mother and enhancing her capacity to respond to the infant reciprocally and without intrusion.

WHAT MIGHT ACCOUNT FOR DIFFERENTIAL TREATMENT EFFECTS - 2

In PPT, the primary focus is on the mother’s representations and the transference relationship. The latter focus may delay changes as the mother needs to work through earlier relationships before new insights can influence the relationship with her own infant.

CONCLUSION

All roads lead to Rome but taking some roads takes less time than others.