Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary developmental science can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Monday, May 18, 2015

How Does Infant Mental Health Inform Psychoanalysis?


Distancing from interpretation, when the analyst explains back to the patient the meaning of her words as he understands them, was a common theme at three recent psychoanalytic presentations. At one, a leading psychoanalyst explained how rather than interpret a patient's words, he seeks "clarification." A second spoke of how he too steers away from interpretation, aiming instead to "get out of the way" and let the patient come to his own understanding, to,  echoing the words of D.W. Winnicott, become himself.  A third similarly tried to distance him from this classical analytic concept, describing instead an attention to the "field of characters" that inhabit the patients thoughts. 

As I sat in the audience of these lectures, I found myself trying to retro-fit what I had learned in the past few years of immersion in infant mental health -or what I prefer to describe as the developmental science of early childhood- to the classical psychoanalytic theory I was exposed to as a scholar with the Berkshire Psychoanalytic Institute. 

When a recent talk I gave about my infant mental health informed treatment of a 2-year-old boy prompted a psychoanalyst colleague to ask, "what about the unconscious?" it all came together in a kind of "aha" moment. 

Psychoanalysis, originally called the "talking cure" is sometimes described as an effort to make the unconscious conscious. The idea that we have feelings that are out of awareness but yet influence our current relationships and behavior is so integral to our understanding of ourselves that it is hard to imagine that we did not always think this way. Yet the "unconscious" was in fact Freud's revolutionary discovery. 

In infancy and early childhood we have the original experience of connecting feelings with thoughts and words.  The analytic relationship thus in a sense seeks to recreate that original experience.  That is not to say that the analyst is the "better parent." Rather, by offering similar kind of holding environment, the analyst helps the patient to discover, or re-discover, that capacity. We can become calm, creative, flexible and develop healthy relationships- or as Freud said "to work and to love" -when we are able to think about and give words to our feelings. 

The mother (or primary caregiver) originally fulfills this function by containing the infant's experience, not only with words but also with her body, her voice, her presence.  In toddlerhood the actual words take on more significance. As a mother labels her child’s feelings with words, the child develops the capacity to think about and give words to feelings.

However, when the mother is not able to hold the child in this way, feelings remain unconnected to thoughts or words. They remain unlabeled and confused. Or one could say, they remain unconscious.

There are many reasons why a mother has trouble with this holding, containing, meaning-making function. She may be depressed. She may have experienced loss- as in infertility and pregnancy loss- and/or in her own childhood.  A baby may be particularly dysregulated, making this containing function particularly challenging. As a mother feels inadequate to the task, she may then slide in to depression, especially in the context of the severe sleep deprivation that accompanies a dysregulated baby.

When I treat a parent-child pair, I have the opportunity to support- in real time- this capacity to give words and thoughts to feelings, make meaning of experience, or, as I describe in my first book, to hold a child in mind. The transformative effects, for both parent and child, are often dramatic. 

In order to support a mother’s efforts to think about her baby’s mind, it is not necessary to analyze her, a process that may be helpful but can take a long time. As soon as a mother feels recognized and understood, she begins to be more present with her baby.  The baby becomes better regulated, in turn improving a mother's sense of self-esteem and decreasing feelings of shame. These changes, in turn, positively affect the mother’s ability to hold her baby in mind, further facilitating the baby's capacity for emotional regulation and development of a healthy sense of self. This process is described by Ed Tronick as the mutual regulation model.

Without this kind of holding, this kind of giving voice to feelings, a young child will have only a bodily awareness of stress without being able to connect thoughts and words to the experience. When there are no words connected to feelings, the experience continues to exert influence, living both in the unconscious mind and in the body. As such it maintains a grip on an individual's behavior and relationships. 

The analytic process then, in making the unconscious conscious, in a sense recreates this early experience of being held, recognized and understood in such a way as to connect feelings with thoughts and words. Rather than being hijacked by these feelings that are out of awareness, an analytic patient develops the ability to pause, to think about a feeling rather than unconsciously act it out.  

As I listen to these senior analysts wrestle with the question of how to capture the therapeutic effects of the psychoanalytic process, I see how the discipline infant mental health, where the work is done in real time with infants and parents, adds an important dimension to this exploration.




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