The infant observation task as a tool in psychiatric practice

Method

The six month infant observation of a non-clinical mother–infant dyad is recommended in the psychotherapy advanced training for psychiatrists. Our supervision group consisted of three participants who each visited and observed a separate family once a week in the home of the infant, each observation lasting about an hour. Observations were compared in subsequent supervision sessions which occurred on a fortnightly basis.

As note-taking can interfere with paying close attention and prevent the observer from responding to the emotional demands of the mother, ⁴ it is recommended that writing up of each observational session be done as soon as possible following the session with literal and detailed descriptions of observed events as well as the observer’s internal responses. ³ This needs to be done with the awareness that the observer can enrich or distort the material ⁵ so it is important that the observer does not infer the feelings of the baby too quickly.

Case vignette

The following de-identified case vignette is a family who was observed by one of the members of the supervision group.

Lorna (age 35 years) and Amber (age 49 years) were a same-sex couple who had been together for a period of nine years. The pregnancy was by self-insemination, the donor being a male acquaintance. At the first meeting, when Lorna was 39 weeks pregnant, the couple had planned a homebirth. Their son, Richie, was born at term by emergency Caesarean section and spent his first 30 hours in an incubator at a neonatal intensive care unit. Lorna spent the first six months at home with Richie, establishing breastfeeding and routines.

Excerpt from an observation (baby age four weeks)

Richie was lying on a blanket on the floor, eyes wide open, legs kicking out, alert and looking around him. Amber was making constant eye contact, stroking his head, singing to him and speaking to him softly ‘My gorgeous little boy’. He gazed at her, making gurgling sounds, listening for her voice. Richie rubbed his eyes. Lorna scooped him up, held him in the crook of her arm and fed him from the breast, looking at him with a tender expression. He began to suck vigorously, his hand on the side of her breast, his eyes intent on her, his body relaxed and still. This was a perfect and powerful moment, the way she looked at him, fully engaged, and his contentment, being with her.

Discussion

There is a level of intimacy and openness in being an immediate and close observer of the creation of a bond between a mother and her infant; the joy experienced, a reflection of the mutual joy of mother and infant as they gaze at each other, the infant seeking its mother’s face; the sadness of the ‘misses’ in connection, as the infant seeks its mother’s face or response and does not receive it, her distraction at that moment; the pangs of loss of holding, as the infant is put down to sleep, away from mother’s arms; seeing and feeling the infant’s total bliss as it falls off the breast in contentment at the end of a feed.

When a baby is born, he or she is ‘in the position of an astronaut who has been shot out into outer space without a spacesuit’. ⁶ The observer occupies a unique position, external to a family with a new baby at a time of vulnerability and sensitivity. ¹ The baby’s primal dependence on its mother leads to a frantic search for ‘a light, a voice, a smell, or other sensual object’. ⁷ By paying attention to the infant’s search for its mother’s voice, eye contact and response, there is sustained focus on observing emotionally powerful psychic phenomena between the mother and infant. This provides stimulating reflection on the echo of this in all later relationships. ⁵

Richie’s experience in the case vignette is of an infant who experienced reliable and available care, the basis of a secure attachment. Attachment is how we learn rules of relationships (internal working models) and the aspects of self that are valued and evoke responses from others.^8,9 We viewed infant observation as an opportunity to make sense of the earliest relational experience and link these with experiences of working with children and adults in our clinical settings. ⁴ There is emphasis on having a sense of the baby in one’s mind in the consecutive observation of the mother–baby dyad, ⁷ in order to see how complex and intimate interactions ¹⁰ emerge and change as the relationship grows and develops. ⁴

The supervisor’s perspective

Supervision was a reminder of the range of ‘good enough’ mothering, ¹¹ the resilience of the human infant and the ways in which different dyads negotiate and express their relationship. As we learned more about the baby and the family circumstances over time, the evocative nature of the observation led participants to recall their own experiences of parenting, the temptation to make judgements about the mothering observed and the need to suspend judgement. ³ Also prominent was subtle pressure to become identified with one figure in the family, variably with the baby, mother, or other family member.

Difficulties and challenges

Finding a family can be a difficult process, with the need to forge networks of colleagues and the wider community in order to find a family willing to participate. There can be an unconscious matching between an observer’s own experiences in infancy and childhood and the families whom they select ¹ as they become part of the family’s ‘ordinary comings and goings and complexities’. ⁵

Observers need to be capable of tolerating situations where they feel they might like to intervene in a situation, for example, where a mother is dealing with the presence of a demanding toddler alongside a new baby. When the observer is confronted with difficulties, it is the task of the observer not to do anything.^3,5 The presence of an observer can be helpful to families, especially one careful to avoid undue involvement. Contributing to this might be the attention given to mother and baby as an empathetic presence and the containing function of observers. ³

Practical difficulties included how to manage the observation and the writing up of the observation amidst a busy clinical schedule. The participants discovered that documentation immediately after the observation optimised their recall and reflection. It was important to begin the observation and end it thoughtfully for the infant, mother, family and observer. Dilemmas included giving gifts to the family, how to place oneself in a household and how to receive hospitality, which presented a struggle for each observer to resolve in their unique situation.

The group explored the issue of the infant’s being overlooked, in some instances due to attention paid to dialogue with the mother or the distraction of other children present. This enabled reflection on the precursors to feelings such as guilt and anxiety that can stem from painful repetitions of grief and loss related to unmet attachment needs.^8,9 We were encouraged to pay more attention to the baby and less to the mother. In this regard, we learnt to tolerate and appreciate how mothers care for their babies and find their own solutions ⁴ to repairing the ‘misses’ and other small ruptures in their connection.

Relevance of the infant observation to psychiatric practice

The members of our group observed mothers with varying circumstances, including a mother who had suffered the loss of a child who died soon after birth. Such losses and stressors should make observers aware of the need to carefully observe the mother’s emotional state, its progression and the infant’s responses to these potential changes. This interaction can have significant impact on the infant’s development and the future happiness of both the mother and the infant.

Infant observation is unique from other learning experiences in the psychotherapy advanced training curriculum as it increases the observer’s understanding of an infant’s perspective, which may include non-verbal behaviour and play. The skills of infant observation may be extrapolated to wider clinical work, in observing the reactions, responses and behaviours that adults repeat in their relationships with others. As therapists, the need of the infant to develop secure relationships is replicated as we create emotional safety for individuals who may have had difficulty resolving rejection experienced in early childhood. The processing and triangulation of observers’ emotional responses during supervision lends itself to ‘a form of knowledge imbued with emotional depth’. ¹² This is the distinction between ‘learning about’ and ‘learning from experience’, the latter acknowledging the experiential impact on observers. ¹⁰

Perhaps the most potent lesson for our group was the sense of fine tuning of clinical sensitivity to what happens ‘in the room’ while attending to the process of observation. This has direct relevance to our attunement to patients in other clinical settings. Skills developed in an infant observation are akin to those of a safe-cracker. The safe-cracker sands the skin off the tips of his or her fingers with sandpaper in order to increase sensitivity to fine tactile changes. The infant observer opens his or her sensitivities to the finest of changes in the relationship between two people. It can help us to see how our own personal histories may shape how we see the outside world. It teaches us about our emotional reactions to others, our subjective bias, our countertransference, and when these processes lead us astray and when they serve us well in the attempt to understand others.

Conclusion

Infant observation is a unique study of the formation of the psyche and the process of personality formation in its earliest phase. ¹³ Consecutive observation of the mother–baby dyad constitutes a powerful method for vividly conceiving the infantile experience of our patients ⁴ and identifying patterns in their relationship, thereby understanding the influence of the first relationship that informs all future relationships.

Developing attunement to the nuances of relationships is relevant to psychiatrists working with a dynamic orientation, as the discipline of observation and the sensibilities learned in infant observation become an essential resource for therapeutic work in other clinical settings. We recommend infant observation to anyone interested in the formation and maintenance of relationships. We are grateful to our infants and their families for the privilege of observing them.