WATCH, WAIT, AND WONDER:WATCH, WAIT, AND WONDER:An Infant-Led Intervention for Treating An Infant-Led Intervention for Treating Troubled Parent-infant RelationshipsTroubled Parent-infant Relationships

Nancy J. CohenNancy J. Cohen

Hincks-Dellcrest Centre & University of TorontoHincks-Dellcrest Centre & University of Toronto

Swedish National Association for ChildSwedish National Association for Child and Maternal Health Care Psychologistsand Maternal Health Care Psychologists

National Conference - KalmarNational Conference - KalmarSeptember 24, 2009September 24, 2009

COLLABORATORS:

Elisabeth Muir

Mirek Lojkasek

OBJECTIVESOBJECTIVES

Describe Watch, Wait and WonderDescribe Watch, Wait and Wonder

Discuss the theoretical underpinnings of Discuss the theoretical underpinnings of Watch, Wait, and WonderWatch, Wait, and Wonder

Explain and illustrate Watch, Wait, and Explain and illustrate Watch, Wait, and

Wonder technique and processWonder technique and process

SYMPTOMS THAT BRING INFANTS SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION: TO CLINICAL ATTENTION:

INFANT SYMPTOMSINFANT SYMPTOMS

Irritability and difficulty being Irritability and difficulty being soothedsoothed

Excessive tantrumsExcessive tantrums Sleeping problemsSleeping problems Eating problemsEating problems ClinginessClinginess

SYMPTOMS THAT BRING INFANTS TO SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION:CLINICAL ATTENTION:PARENT SYMPTOMSPARENT SYMPTOMS

DepressionDepression AnxietyAnxiety Complaints of not feeling bonded or attached Complaints of not feeling bonded or attached

to infantto infant Difficulty playing with and enjoying childDifficulty playing with and enjoying child Not understanding what child wants or needsNot understanding what child wants or needs Self endangermentSelf endangerment Risk for or allegations of abuseRisk for or allegations of abuse

THEORETICAL UNDERPINNINGS OF

WATCH, WAIT AND WONDER

IMPORTANCE OF ATTACHMENT IMPORTANCE OF ATTACHMENT

Attachment theory helps to Attachment theory helps to understand how individuals:understand how individuals:

manage (regulate) emotionsmanage (regulate) emotions think and behave in relationshipsthink and behave in relationships organize inner experiencesorganize inner experiences manage separation & individuationmanage separation & individuation

CONDITIONS FOR SECURE CONDITIONS FOR SECURE ATTACHMENTATTACHMENT

Accurate perception of infant cues Accurate perception of infant cues Sensitive and appropriate response to infant Sensitive and appropriate response to infant

cuescues Acceptance of infant’s behaviour and feelingsAcceptance of infant’s behaviour and feelings Physical and psychological accessibility Physical and psychological accessibility

when infant is in distress or when exploringwhen infant is in distress or when exploring Responses to infant that are consistent and Responses to infant that are consistent and

predictablepredictable Display of affection and pleasureDisplay of affection and pleasure

““GOOD ENOUGH” MOTHERGOOD ENOUGH” MOTHER

Mothers cannot always be sensitively Mothers cannot always be sensitively responsiveresponsive

Misattunements can be adaptive because this Misattunements can be adaptive because this helps infants to learn to differentiate helps infants to learn to differentiate themselves from their mothers & presents themselves from their mothers & presents opportunities for repairopportunities for repair

The critical aspect is a balance toward The critical aspect is a balance toward sensitivity, responsiveness, and accurate sensitivity, responsiveness, and accurate reflectivity over misattunementreflectivity over misattunement

IMPLICATIONS OF IMPLICATIONS OF

ATTACHMENT SECURITYATTACHMENT SECURITY Engaging and relatingEngaging and relating CuriosityCuriosity Initiative and explorationInitiative and exploration Emotion and behaviour regulationEmotion and behaviour regulation Reflective capacityReflective capacity Resilience and coping skillsResilience and coping skills Trust, intimacy and affectionTrust, intimacy and affection Capacity to relate to othersCapacity to relate to others Cognitive and language competenceCognitive and language competence Capacity to parentCapacity to parent

Through repeated interactions, infants form Through repeated interactions, infants form attachment representations or internal working attachment representations or internal working models of self in relation to others. These include models of self in relation to others. These include perceptions, thoughts, feelings, beliefs and perceptions, thoughts, feelings, beliefs and assumptionsassumptions

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

INNER WORKING MODEL OF

ATTACHMENT RELATIONSHIPS

HOLDINGHOLDING

Meet the infant’s spontaneous gesture Meet the infant’s spontaneous gesture with a reciprocal gesture with a reciprocal gesture

Mother’s nonintrusive presence; being Mother’s nonintrusive presence; being present without making demands.present without making demands.

(Winnicott)(Winnicott)

““GOING ON BEING”GOING ON BEING”

These maternal functions These maternal functions meet the infant’s need for meet the infant’s need for “going on being” without “going on being” without impingements where the impingements where the infant can experience his infant can experience his true selftrue self

CONTAININGCONTAINING

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

(Bion)(Bion)

REFLECTIVE FUNCTIONREFLECTIVE FUNCTION

Ability to envision mental states in self and Ability to envision mental states in self and others in a particular moment and to others in a particular moment and to understand one’s own experience and that understand one’s own experience and that of others in terms of mental processes---of others in terms of mental processes---desires, feelings, beliefs, intentionsdesires, feelings, beliefs, intentions

Hypotheses used to understand why we or Hypotheses used to understand why we or another might have thought or have done a another might have thought or have done a particular thingparticular thing

FAILURE TO KEEP THE CHILD’S FAILURE TO KEEP THE CHILD’S MIND IN MIND MIND IN MIND

Failures in reflective function Failures in reflective function include misattribution, distortions, include misattribution, distortions, projectionsprojections

Child takes on mother’s affect and Child takes on mother’s affect and own internal experience is own internal experience is

distorted in an effort to adaptdistorted in an effort to adapt

REFLECTIVE FUNCTIONREFLECTIVE FUNCTIONAND ATTACHMENTAND ATTACHMENT

A secure attachment relationship is one where A secure attachment relationship is one where the infant’s signals are accurately interpreted the infant’s signals are accurately interpreted by the mother, giving them meaning in terms by the mother, giving them meaning in terms of the mother’s response to the infant.of the mother’s response to the infant.

When a mother has a history of a secure When a mother has a history of a secure attachment relationship she can observe her attachment relationship she can observe her infant, explore her own mind and think about infant, explore her own mind and think about the mental state of her baby.the mental state of her baby.

GHOSTS IN THE NURSERYGHOSTS IN THE NURSERY (Fraiberg, Adelson & Shapiro)(Fraiberg, Adelson & Shapiro)

““Unresolved mourning related to early Unresolved mourning related to early privation restricts the mother’s own privation restricts the mother’s own development, autonomy, and relationships. development, autonomy, and relationships. These mothers can be overwhelmed by an These mothers can be overwhelmed by an activation of disavowed feelings activation of disavowed feelings associated with those early experiences. associated with those early experiences. These “ghosts” influence the mother’s These “ghosts” influence the mother’s relationship with her own infant affecting, relationship with her own infant affecting, in turn, the infant’s attachment security.”in turn, the infant’s attachment security.”

GHOSTS IN THE NURSERY: GHOSTS IN THE NURSERY: KEEPING THE CHILD’S MIND IN MINDKEEPING THE CHILD’S MIND IN MIND

Current views would add that the ghosts Current views would add that the ghosts render the mother unable to keep her render the mother unable to keep her child’s mind in mind, that is, to think child’s mind in mind, that is, to think about the mental state of the baby.about the mental state of the baby.

These deficits lead to repeated failures These deficits lead to repeated failures to grasp the child's own effort to to grasp the child's own effort to establish himself as an intentional being establish himself as an intentional being in his own right.in his own right.

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

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

He/she only loves me if I am who He/she only loves me if I am who he/she wants me to be. If I don’t go he/she wants me to be. If I don’t go along with it, he/she is angry and cold along with it, he/she is angry and cold toward me and I begin to feel as if toward me and I begin to feel as if he/she will leave me. That scares me he/she will leave me. That scares me because I need him/her. But if I am because I need him/her. But if I am always going along with what he/she always going along with what he/she wants me to be, I lose sense of who I wants me to be, I lose sense of who I am. And that is terrible too.am. And that is terrible too.

UNDERSTANDING PROBLEMS UNDERSTANDING PROBLEMS IN INFANCYIN INFANCY

Many problems in infancy can be Many problems in infancy can be understood as emerging when a stifling understood as emerging when a stifling compromise occurs in the relational compromise occurs in the relational connection between mother and infantconnection between mother and infant

Infant symptoms represent a way of Infant symptoms represent a way of simultaneously coping with and simultaneously coping with and protesting protesting against a relational and against a relational and developmental developmental dilemma related to dilemma related to attachment and attachment and autonomyautonomy

RELATIONAL PERSPECTIVERELATIONAL PERSPECTIVE

Whether the problem resides Whether the problem resides more or less in the mother or more or less in the mother or the infant, it is how they the infant, it is how they negotiate their needs and fit negotiate their needs and fit with each other that with each other that determine whether a problem determine whether a problem will developwill develop..

GOALS OF WATCH, WAIT, & WONDERGOALS OF WATCH, WAIT, & WONDER

Increase appropriate maternal sensitivity and Increase appropriate maternal sensitivity and attunement to her child and their relationshipattunement to her child and their relationship Increase maternal responsiveness and reduce Increase maternal responsiveness and reduce intrusivenessintrusiveness Increase positive affect and pleasure within the Increase positive affect and pleasure within the relationshiprelationship Increase the chance for a secure attachmentIncrease the chance for a secure attachment Increase child competence observed through Increase child competence observed through improved quality and complexity of playimproved quality and complexity of play Increase child self efficacy and development of a Increase child self efficacy and development of a potential self and self-esteempotential self and self-esteem Possibly generalize positive effects within the family Possibly generalize positive effects within the family and in relation to the outside world (e.g., peer relations)and in relation to the outside world (e.g., peer relations)

HOW DO WE INCLUDE THE INFANT HOW DO WE INCLUDE THE INFANT IN PSYCHOTHERAPY?IN PSYCHOTHERAPY?

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

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

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

THERAPIST IN WATCH, WAIT, THERAPIST IN WATCH, WAIT, AND WONDERAND WONDER

Creates a space for the Watch, Wait, and Creates a space for the Watch, Wait, and Wonder process to take placeWonder process to take place

Models curiosity. Watches, Waits, and Models curiosity. Watches, Waits, and Wonders about the mother and infantWonders about the mother and infant

Accepts and endures whatever happens Accepts and endures whatever happens (holding and containing). Models openness(holding and containing). Models openness

Reflects on own feelings and uses these Reflects on own feelings and uses these reflections as a guide to talking with the reflections as a guide to talking with the mother about her observations and her mother about her observations and her experience of herself and her infantexperience of herself and her infant

ASSSESSMENT

Establishing therapeutic allianceEstablishing therapeutic alliance Gathering relevant information Gathering relevant information

on concernson concerns Obtaining developmental and Obtaining developmental and

family history family history Parent attachment historyParent attachment history Quality of parent relationshipQuality of parent relationship Attempted solutionsAttempted solutions

GOALS OF ASSESSMENT FOR GOALS OF ASSESSMENT FOR

WATCH, WAIT, & WONDERWATCH, WAIT, & WONDER

Family meetingFamily meeting Free play and WWW playFree play and WWW play Developmental assessmentDevelopmental assessment FormulatingFormulating ContractingContracting

COMPONENTS OF ASSESSMENT FOR COMPONENTS OF ASSESSMENT FOR

WATCH, WAIT, & WONDERWATCH, WAIT, & WONDER

FREE PLAY AND WWW PLAYFREE PLAY AND WWW PLAY

Free play – play with infant much as Free play – play with infant much as would play at homewould play at home WWW play – instruction not to initiate WWW play – instruction not to initiate but to follow infant’s lead. Consider:but to follow infant’s lead. Consider:

Parent’s capacity to allow infant to initiateParent’s capacity to allow infant to initiate Note activities parent finds most difficult to Note activities parent finds most difficult to

toleratetolerate Ask parent to make and reflect on observationsAsk parent to make and reflect on observations Ask about how this kind of play feelsAsk about how this kind of play feels

FORMULATIONFORMULATION Take into account how presenting problems relate Take into account how presenting problems relate to:to:

infant’s development infant’s development parent personality/mental health parent personality/mental health parent history parent history strengths and weaknessesstrengths and weaknesses

Parents’ understanding of the problemParents’ understanding of the problem Pay attention to what feelings were stirred upPay attention to what feelings were stirred up Use parents’ language and metaphor to link Use parents’ language and metaphor to link problem problem with recommendation of WWWwith recommendation of WWW Explain how intervention and the problem relate to Explain how intervention and the problem relate to each othereach other

CONTRACTINGCONTRACTING

Initially arrange for a minimum of 6-8 Initially arrange for a minimum of 6-8 sessionssessions

Emphasize that therapist does not give Emphasize that therapist does not give adviceadvice

Reiterate the importance of play and activity Reiterate the importance of play and activity (exploration, curiosity); the idea of play and (exploration, curiosity); the idea of play and infant activity as forms of communicationinfant activity as forms of communication

Rationale often has to be repeated Rationale often has to be repeated Sometimes it helps to write out reason for Sometimes it helps to write out reason for this approach with particular dyadthis approach with particular dyad

POSSIBLE CONTRAINDICATIONSPOSSIBLE CONTRAINDICATIONS

FOR WWWFOR WWW Infant younger than 4 monthsInfant younger than 4 months Preoccupation which prevents the mother Preoccupation which prevents the mother

from following her infant’s lead and from following her infant’s lead and becoming absorbed in play/activitybecoming absorbed in play/activity

Poor spousal support Poor spousal support Mother is very depressedMother is very depressed Reflective capacityReflective capacity Mother wants and insists on something elseMother wants and insists on something else Limited intellectual capacity of motherLimited intellectual capacity of mother

WATCH, WAIT, WATCH, WAIT, AND WONDER SESSIONSAND WONDER SESSIONS

Infant-led activityInfant-led activity

DiscussionDiscussion

INFANT-LED ACTIVITYINFANT-LED ACTIVITY

A relational connection cannot be A relational connection cannot be directly taught in that it is emotional directly taught in that it is emotional and experiential. The Watch, Wait, and experiential. The Watch, Wait, and Wonder process is not the same and Wonder process is not the same as teaching parenting skills. It is not a as teaching parenting skills. It is not a process that informs parents about process that informs parents about ways to parent. Rather, parents are ways to parent. Rather, parents are told that they and their infants will told that they and their infants will need to find their own way of relating need to find their own way of relating with each other.with each other.

PROCESS OF WATCH, WAIT, & WONDERPROCESS OF WATCH, WAIT, & WONDER

Offers the mother and infant a safe uninterrupted play Offers the mother and infant a safe uninterrupted play spacespace

Releases the mother from pressure of her unresolved Releases the mother from pressure of her unresolved relational issues which can intrude upon and distort her relational issues which can intrude upon and distort her relationship with her infants relationship with her infants

Gives mother permission to become the observer of her Gives mother permission to become the observer of her infant and respond to her infant’s cues infant and respond to her infant’s cues

Gives the mother the space to think about, rather than Gives the mother the space to think about, rather than do to or for, her infantdo to or for, her infant

Allows infant to experience himself through Allows infant to experience himself through manipulating toys in the presence of an attentive manipulating toys in the presence of an attentive observing motherobserving mother

Allows mother to experience herself with her infantAllows mother to experience herself with her infant Provides an arena where the mother is sometimes Provides an arena where the mother is sometimes

stimulated to talk about her conflictual past relationshipstimulated to talk about her conflictual past relationship

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

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

Bean chairBean chair Two telephonesTwo telephones Mirror (shatter proof)Mirror (shatter proof) Activity boardActivity board SoftballSoftball Policeman helmet or some otherPoliceman helmet or some other official hatofficial hat Undermatting for paddingUndermatting for padding

WATCH, WAIT, AND WONDERWATCH, WAIT, AND WONDERSUGGESTED LIST OF TOYSSUGGESTED LIST OF TOYS

Stacking cupsStacking cups BlocksBlocks Small cars including Small cars including

ambulanceambulance Medical kit with stethoscopeMedical kit with stethoscope Sets of vinyl family dolls Sets of vinyl family dolls

(black & white(black & white Set of tame and wild animals - Set of tame and wild animals -

large solid varietylarge solid variety Bowls and mixing spoonsBowls and mixing spoons Train setTrain set Heavy duty blue vinyl (Pool Heavy duty blue vinyl (Pool

manufacturers)manufacturers)

None of these toys are required. In Fact, WWW can be done with very few toys if necessary

INSTRUCTIONS FOR INSTRUCTIONS FOR WATCH, WAIT, AND WONDERWATCH, WAIT, AND WONDER

Get down on the floor with your childGet down on the floor with your child Follow your child’s lead; let him take the Follow your child’s lead; let him take the

initiativeinitiative Do not initiate activities yourselfDo not initiate activities yourself Be sure to respond when your child initiates Be sure to respond when your child initiates

but do not take over his activities in any waybut do not take over his activities in any way Allow your child freedom to explore; whatever Allow your child freedom to explore; whatever

he wants to do is okay as long as it is safehe wants to do is okay as long as it is safe If unsure what to do, remember to Watch, If unsure what to do, remember to Watch,

Wait and WonderWait and Wonder

DISCUSSION

DISCUSSIONDISCUSSION

What did you observe?What did you observe?

What was your infant’s experience? What was your infant’s experience?

What was the play about?What was the play about?

What were your thoughts and What were your thoughts and feelings?feelings?

FUNCTION OF DISCUSSIONFUNCTION OF DISCUSSION

To deal with the mother’s anxiety To deal with the mother’s anxiety evoked by WWWevoked by WWW

To help mother be a better To help mother be a better observerobserver

To stimulate thinking about the To stimulate thinking about the child’s inner world (reflective child’s inner world (reflective capacity)capacity)

DIFFICULTIES THAT ARISE DIFFICULTIES THAT ARISE IN SESSION (1)IN SESSION (1)

After initially observing, the mother After initially observing, the mother becomes intrusive or detachedbecomes intrusive or detached

Mother becomes busy, bored or Mother becomes busy, bored or sleepysleepy

Mother says she does not like to playMother says she does not like to play Mother wants to change WWWMother wants to change WWW Mother is uncomfortable with the Mother is uncomfortable with the

therapist sitting in a chair and therapist sitting in a chair and observingobserving

DIFFICULTIES THAT ARISE IN DIFFICULTIES THAT ARISE IN SESSION (2)SESSION (2)

Mother is impatient regarding solutions of Mother is impatient regarding solutions of problems/wanting adviceproblems/wanting advice

Mother wants to focus on events outside Mother wants to focus on events outside the sessionthe session

Mother has difficulty making observations Mother has difficulty making observations in the Discussion in the Discussion

Infant falls asleep, wants to escape the Infant falls asleep, wants to escape the room, or otherwise acts outroom, or otherwise acts out

DIFFICULTIES THAT ARISE IN SESSION (3)DIFFICULTIES THAT ARISE IN SESSION (3)

Difficulties typically arise in sessions when Difficulties typically arise in sessions when strong feelings are stirred up in the mother strong feelings are stirred up in the mother

Often accompanied by the mother saying Often accompanied by the mother saying she does not know how to interpret child’s she does not know how to interpret child’s play and that she wants the therapist’s play and that she wants the therapist’s interpretations interpretations

Important to let mother know that children Important to let mother know that children stimulate feelings and that this is one of stimulate feelings and that this is one of the ways children communicate. Therefore the ways children communicate. Therefore it is important for the mother to talk about it is important for the mother to talk about the feelings stirred up in her.the feelings stirred up in her.

TRANSFERENCE AND TRANSFERENCE AND COUNTER-TRANSFERENCECOUNTER-TRANSFERENCE

Transference Discomfort being observedDiscomfort being observed Wanting specific adviceWanting specific advice Feeling contained (mother and infant)Feeling contained (mother and infant) Feeling acknowledged/acceptedFeeling acknowledged/accepted Mother wanting mothering. Keeping the infant Mother wanting mothering. Keeping the infant as as

the focus is problematicthe focus is problematicCountertransference Tension re conflict and dangerTension re conflict and danger Feeling criticized, not doing anything for dyadFeeling criticized, not doing anything for dyad Wanting to focus on mother rather than dyadWanting to focus on mother rather than dyad Feeling of being in loveFeeling of being in love

KNOWING WHEN TO KNOWING WHEN TO TERMINATE TREATMENTTERMINATE TREATMENT

Reduction or disappearance of Reduction or disappearance of presenting problemspresenting problems

Shift in interactional patternShift in interactional pattern Increased comfort in Increased comfort in

relationshiprelationship

Infant signals readiness to stopInfant signals readiness to stop