An Introduction
by Maree Foley (PhD) Editor-in-Chief, Perspectives in Infant Mental Health
Dr Patricia O’Rourke’s paper, “Working therapeutically with infants in the child protection system: Reflections”, provides readers with a glimpse into the inner world of the infant parent specialist; an inner world where the therapist purposefully creates a transitional space, for themselves with the infant and parent, and the many and often complex infant family relationships. This transitional space also holds the therapist’s team and supervision relationships. This personal and inter-subjective space is primarily relational, intentionally relational, and oriented towards the restoration, healing, and wellbeing of the infant in their family.
Holding in mind and the co-creation of a transitional space can be an effortless experience when the relationships held, are seasoned with lightness, joy, and relief when being helped in times of strife. Reciprocity and ease, line the boundaries of the relationship. However, Dr O’Rourke’s paper, eloquently outlines parent-infant/family relationships whose world includes engagement with child protection services and systems.
These families, who so many of us have met across the globe, arrive in this newly formed space with suffering and well-crafted self-protection mechanisms that are triggered by the nature of the help-seeking relationship. Unlike families where help-seeking and help-receiving engender relief and hope, for some families, help-seeking has been lined with trauma, aloneness, and further doses of trauma. The therapeutic relationship space and relationship we offer, can often engender fear, mistrust, and hopelessness.
This suffering, awakens the therapist into conscious welcoming, holding, and commitment to the new relationship. This is risky and courageous on the part of the therapist. There is no guarantee of shared joy, of collaboration, of working together to create a new pathway. In fact, these processes are outcomes, they arrive, if they do, much later in the relationship. It’s not the starting point. The process along the way is akin to a pilgrim’s tale.
Dr O’Rourke’s paper describes this process with such generosity to us as readers. Her paper gifts each reader with a view into the process. The narrative is richly raw, real, relatable. The process requires a herculean commitment to healing and restoration of the infant in their family.
Clinicians such as Dr O’Rourke and her team, along with similar services to the families with infants engaged with child protection services, are gold; gold for the infants and their families, and gold for the communities in which these services exist. While infants and their families as a population, remain present in terms of global and national commitments, these commitments can become fluid in terms of organizational practices. At best, the overarching organization, within which the service is situated, potentially provides a secure base within which therapists can brave these primary relationships and carve new pathways with longitudinal good outcomes for infants in and with their families, in their communities. However, this is not always the situation and anecdotally, is too frequently, not the situation.
Amidst excellent outcomes for parents and infants, the service, and the team, within which the work that Dr O’Rourke so eloquently shares, has recently been closed. It is unbearable to ponder and incredibly difficult for the staff and the families, present and future. As a Perspectives team, we invite you to join with us as we hold Patricia and the team in heart and mind as they navigate their way through this organisational decision.
Working therapeutically with infants in the child protection system: Reflections
Introduction
This paper attempts to describe my experience of working therapeutically with infants in the child protection system. It was presented at the national conference of the Australian Association of Infant Mental Health in Melbourne in 2017. My brief was to present a 30-minute session on therapy with harmed infants as part of a 90-minute plenary panel presentation. I remember having a sinking sensation even as I agreed to do it. I was thinking, thirty minutes on therapy with harmed babies! How could I possibly convey the dynamics, the requirements, and the complexities of the work, and to do so, in half an hour? How could I do justice to this work? Would I be able to convey the depth and extent of both the commitment required and the range of feelings awakened for everyone involved?
I wanted to take this audience along with me and give them a sense of what it feels like to work intensively with these babies and their families – what’s needed and what’s at stake. I decided to tell a story and show pictures.
This paper shifts that spoken story to a written paper. I have tried to maintain the integrity of the original paper while enabling it to be read without the images. I begin with the context within which the therapy sits.
Context: The Infant Therapeutic Reunification Service
The Infant Therapeutic Reunification Service (ITRS), is embedded physically and administratively in a major teaching hospital for women and children in Adelaide, South Australia. The service provides early assessment and therapy for infants under three and their parents where significant harm has occurred or is at high risk of occurring. The ITRS was set up in 2009 to address poor long term outcomes for these infants by providing them a therapeutic intervention and attempting to stop the revolving-door process whereby they moved repeatedly in and out of the out-of-home care system. It remains a very concerning situation. For example, in both the 2016 and 2017 financial years, over 3000 Unborn Care Concerns and High-Risk Infant reports were made in South Australia (Montgomerie et al., 2019). Moreover, it is known that 40% of infants younger than one year when first reported, are re-reported more than 5 times before age 5 (Montgomerie et al., 2018). The number of infants being reported to child protection is increasing annually (Pilkington et al., 2017).
The service takes referrals from Child Protection to assess parenting capacity and whether reunification is viable and in the best interests of the infant. Where indicated, we provide parent-infant therapy to reduce the impact of developmental and attachment trauma on infant and parent to facilitate positive relationships leading to a safer caring environment for the infant. Where reunification is not possible, we make timely long-term decisions that meet the infant’s developmental imperative and where necessary provide foster-parents with therapeutic support.
Our Clients
Infants always present to our service suffering from trauma and neglect, with attachment and/or developmental trauma demonstrably affecting their relational capacity.
Parents present with a range of issues that includes a history of childhood trauma and developmental trauma often including being under guardianship themselves as children. They usually have significant mental health issues including family violence and drug and alcohol issues, and some previous psychiatric diagnosis. Homelessness is also frequently an issue and there can also be ongoing forensic investigations. All these concerns impact on parenting capacity. Most parents present, deny any knowledge of maltreatment.
Note: All identifiable names have been changed with pseudonyms, unless otherwise agreed with the client.
Vignette 1: Lila
She seems to think that if she says it, it’s true. She’s sitting there telling me what a good mother she is, while she dabs at an oozing sore on her leg. A boil, she says. Her infant is here too, lying in her pram. Three and a half weeks old, dressed in a lary pink sundress with a matching hat. It’s cool in the room and her tiny arms are mottled.
The only thing that worries her, continues the mother, is that the Welfare might take her baby. Otherwise it’s a sure thing that the baby will, in due course, go on to university and have a great life, with both her parents. She digresses to explain how the father too, is being treated unfairly.
Nope, she says, there is no other way of thinking about it. He couldn’t have assaulted that other baby because it was already bruised prior to the accusation. She describes the injuries she’d seen in photos of that baby as if she was reading through a shopping list. And anyway, the mother was a bitch who had it in for him.
She backs up her view by stating he was never violent with her, he was totally there for her, throughout the whole pregnancy.
I’m no longer thinking; the feeling in the room is increasingly unbearable. The infant moves in her pram, her arms flail, her fingers find only empty space, her head turns away. The mother notices and gets off the couch. I think she’s hungry, she says, scoops her up like a kitten, and plugs the wobbling infant onto her breast. The infant stiffens, and struggles, and then sucks.
HW
Working therapeutically with maltreating families
It’s a fine line to walk – always holding the baby in mind while working empathically and authentically with a parent who has hurt their baby or allowed their baby to be hurt. It’s clear to me that my only chance to make a difference for the baby is to be able to really get alongside that parent, to see them, to let them see me, and together to see their baby, and to always keep that baby at the centre of any therapeutic endeavour.
In our service that can mean dyadic work with parent and baby, or working with the parent alone while holding the baby in mind, or working with the foster parent and the baby, or all three, sometimes consecutively and sometime simultaneously. It’s a moveable feast.
This work requires a team. A team is needed to provide therapeutic assessments, to make decisions, to provide therapy, to hold the system around the baby and to hold us, the workers.
It is a very specific population: parents who have harmed their babies and babies who have been harmed. Children don’t enter the child protection system on a whim. Assessment always highlights unacceptable levels of maltreatment and/or neglect. Our basic assumption is that every infant who enters the child protection system has also been psychologically harmed and this often ‘is not readily apparent’ (Donald & Jureidini, 2014). When this harm is unaddressed, that is, without therapeutic input, even if the baby is placed in a new context of good-enough foster or kinship care, their long term developmental outcomes will be impaired (McCrory, Gerin, & Viding, 2017; Shonkoff, 2012).
We know that there is no such thing as a baby – only a baby and someone (Winnicott, 1960). Yet the babies we work with have had no one. Very often their parents, as babies, had no one. There has been no mind to contain and hold them and help them make sense of their experience. This is an unavoidable fact about babies who enter and re-enter the child protection system – they all suffer this.
Another unavoidable fact is that working therapeutically with these babies and their broken parents is very disturbing for everyone involved. The baby’s vulnerability, the parent’s current distress and history of chronic trauma, disturbs those of us who are highly trained, experienced workers, and disturbs the child protection and non-government agency workers, who are usually less experienced, often overwhelmed, and under-resourced.
These factors are always present as we make decisions about the care of a baby – whether a parent is safe or can ever be safe to parent that baby. It’s a big responsibility to think about, and one that is difficult to hold in our minds.
Assessment: our client is always the baby
While this paper does not discuss assessment in detail, it is important to emphasise that the starting point is always a specialised assessment – of the baby, their parents, and their relationships.
This assessment needs to understand both the level of parenting capacity of the biological parents, and the relational capacity of the infant. We need to assess either or both biological parents, to understand how much they can think and feel about their baby, as someone separate from them, with their own experience and feelings. The one thing, above all else, that demonstrates protective capacity is a parent’s ability to take some responsibility for the predicament that their infant is in. The important word here is ‘some’.
Most parents when they first attend are overwhelmed and frightened. They no longer have their baby in their care, and they are full of excuses and rationalisations as to why this is so. Over the course of the initial assessment interviews, parents may express a moment of remorse or a moment of thoughtfulness that indicates there is some capacity to work therapeutically with that parent. These moments can flag the potential for protective capacity even though they are often quickly retracted, especially where violent partners have maintained contact, or the police are considering laying charges.
We decide which parent, if either, has some potential to change within the baby’s developmental timeframe. We want to understand how clearly this parent can see this baby and how they respond to their needs.
We are also thinking about the harm the baby or toddler has suffered and its effect on their relational functioning, how they signal their needs and respond to their parent. The baby has a lot to say about the relationship. The baby tells us where to focus our work and lets us know when we are making progress.
Vignette 2: Millie
In the waiting room the infant stands perfectly still, a wee slip of a girl with white blonde hair and big round eyes, looking into nowhere. She is almost transparent. In the playroom she hovers around her mother as if in a permanent limbo, waiting for something that may never sufficiently arise.
Her mother, drab and defeated, agonises over everything, every word tethered to crippling self-doubt. The mother looks down, at no-one, her face contorted. The infant goes to the empty dolls’ house and without a sound pushes her head deep into the upstairs room and stays there, unmoving.
Now, just today, eight months on, the infant tells a different story. She bounces in, smiling and chatting, with her pigtails up and out. She’s home now, with her mother, whose face I hardly recognize. When she looks at her daughter, she is beautiful, and her infant shines back.
The assessment phase is ongoing, over some time. We also need to hold in mind the baby’s current care needs. To limit the harm, we try to ensure that these current needs are met by more than just adequate care – they require the best care possible. Foster-parents need help to understand their baby’s experience and how this may be affecting their relational expression. They may for example, need help to understand why this baby is so quiet, so undemanding, so willing to sleep.
Holding and working therapeutically with the system
When we work with a family, we create a care team around that family containing the system and providing a space for reflection. We work therapeutically with the care team that includes the child protection workers, domestic violence service, drug and alcohol services, housing, childcare, and always an in-home reunification service, if we get to actual reunification. This care team is highly susceptible to the disturbed dynamics we’re trying to treat in the family. The critical effort required in child protection that isn’t direct parent-infant therapy, is this holding of and working therapeutically with the system.
For this reason, we allocate a systemic therapist for each family. Holding the system is a hidden and often unacknowledged therapeutic role. There is no mirror. When you work with a client, you both witness and get feedback from the changes you see in them, in the parent-infant relationship. There’s an acknowledgement of the roles of client and therapist. This in itself can be energising. What happens in therapy with a client can be very worrying at times, but the demands are clear.
However, the therapeutic role of holding the system doesn’t provide much immediate feedback. It can more easily remain unreflected on, when other work pressures mean time is short, or the service is short-staffed. The dynamics that require systemic work vary from family to family, and from care team to care team. It can feel like a straight case management role, until the process comes unstuck. Then we often discover that the parent-infant therapist, and the therapist holding the system, haven’t thought through the underlying dynamics together. Or we may realise that half the care team is operating like the harsh parent so familiar to our clients, and the other half is working from their own rescue fantasies. And we, the therapeutic service, are not immune.
In her seminal paper, Menzies-Lyth (1960), outlines how a social system uses defensive processes, in an attempt to contain anxiety. These defensive processes have been summarised by Jones (2015):
- Projection and denial
- Dehumanisation and depersonalisation
- Ritual task performance
- Splitting: Idealisation and denigration
- Detachment /withdrawal
It is always challenging to reflect on how these ways of coping with anxiety may be operating in us and in our clients and in the system, we are working in and with. In child protection work, it is critical that we acknowledge and manage these defences and the complex transference dynamics that often arise.
Denial: ever-present and pervasive
Think for a moment of the extent and level of denial in our present functioning as a global society and in our own cultural systems. We can only function as citizens by going along with the denial to some extent. Denial plays a major role in how we manage our everyday lives – how we navigate our social systems, how we’ve navigated our colonial and imperialist history in both my home country New Zealand, and here in Australia. Richard Flanagan (2017), the Australian Man Booker prize-winner, talking about denial said:
… Man survives by his ability to forget. We must forget so much in order to go on. Trauma is never just individual. It is passed down through families, into communities and then into generations. And they survive by forgetting…
This island here, [Tasmania] was a totalitarian gulag. The horror to its indigenous people is beyond belief. And nothing really happened for a century after that transportation… the island entered a long century of silence which it has only started emerging out of in the last 30 years…
Now bring to mind, how much denial operates in the family system of a harmed baby – how else could you hurt a baby?
Our parents always start by denying the abuse, or the extent of the abuse, or minimising the impact of the abuse, both for their child and for themselves as children.
Case study: Sharon and her children
Sharon is now a mother of four. When we started working with her and baby Joey, three years ago, she had no custody and little contact with her two older children, then aged nine and six. They lived with their alcoholic father.
When we first met her, Sharon was in a violent relationship with Max and had been for two and a half years. They had a three-month-old baby who was referred to us because of a cigarette burn behind his ear. Both parents denied harming the baby.
There were grave concerns regarding the level of violence and drug use. However, Sharon was assessed as having some reflective capacity.
We began an extended assessment, marked by all of the dynamics present in very violent relationships – lies, recriminations, desperate pleas and a sense that we are part of a system that is somehow, once again, failing this woman and her baby.
The child protection system around Sharon was uncontaining and indecisive. Workers and even offices constantly changed, and consequently, were easily deceived. After three months, they were considering Max to be the primary caregiver of the baby, in spite of his extensive history of violence. Our service offered an extended assessment of both parents and subsequently recommended working with mother and baby to try to extend the window of her reflective capacity.
As the months dragged on, it became increasingly clear that while Sharon was able to attend therapy and demonstrated small changes with Joey, she could not stop idealising this dangerous relationship, and kept returning to a scene marked by violence and drugs. Joey meanwhile was settled in a foster placement. He was doted on by a large extended family who had no time for Sharon – another obstacle to successful reunification.
It seemed hopeless, and then the system changed – the case was moved to a new office and a new child protection team. Their assessment, like ours, was that contact with Max was unhelpful at this time.
Then another bombshell – Sharon, after a weekend of drugs and bingeing with Max, was pregnant again to him, father of Joey, then 8 months old. Now we had two babies.
For three months, I worked intensively with this pregnant mother. She regularly attended therapy with me and met with both her domestic violence worker and her drug alcohol worker. She travelled for four hours on public transport to see her son at child protection offices. She denied any ongoing contact with Max. The care team began to feel hopeful.
Then, the child protection team began to worry that contact with Max, was maybe, occurring again. Sharon herself began to talk about wanting him at the birth of her new baby, because ‘every baby needs a father’, though she continued to deny having any contact with him. She denied this to me, to her domestic violence worker, and to her drug and alcohol counsellor.
Then a random drug screen returned positive for amphetamines, and (just before Christmas), the child protection team called an urgent case conference because they had proof that Sharon had been having contact with Max all year. More than once, she had even waited while Max attended therapy with a private psychologist, he had accessed to address anxiety and depression[1].
I said to her later that I just could not understand how she could front up each week and lie through her teeth to me. She shrugged and said she didn’t really lie, ‘just didn’t tell the whole truth’. Sharon went off the radar at this point. Everyone was concerned and then she showed up after three weeks at a local hospital, badly beaten, and again wanting to change her life.
Denial and the importance of ‘not knowing’
When I started writing this paper, I couldn’t describe the sense of betrayal and frustration I had felt, because I actually couldn’t remember it. My own self-preserving denial, learned very early in my family of origin, had kicked in. I couldn’t remember anything about challenging Sharon, how we got through that time, other than knowing that we did.
I re-read the notes. I read how she had stormed out and then returned apologising, but I still had no memory of it.
It wasn’t until I watched the video again that it flooded back. I had had to tell her on a blisteringly hot day, when she was eight months pregnant, had just caught two buses and walked half a kilometre to meet with me, that we would not be recommending Joey return to her care, and that she was not going to be able, in our opinion, to take her newborn baby home from hospital, as she could not keep the baby safe. She had not demonstrated she could keep herself safe.
She didn’t really take it in. We talked on about her losing a few battles but maybe not the war. I watched myself struggling to stay in relationship with her, trying to understand. And then I had to repeat it to her, repeat that I couldn’t recommend that she was safe to take her baby home. Tearful and angry, she stormed out.
Watching that tape, I felt again the sense of absolute hopelessness and inadequacy as a therapist, and as a person. It all flooded back.
However, like most of our parents, Sharon is made of stern stuff. She came back. I saw her weekly again up to the birth. Together we tried to understand her addiction to this relationship – both of us bewildered by it, as she related details of how he had hurt her, had held a gun to her head, had threatened that he’d always come back, quietly, when it was all over, and kill her.
And she would also talk about how Max still might change and she would remember longingly how he would tuck her up in bed; he ‘did that every night’. They might ‘even go fishing again…’
We would talk then about her loyalty to him, her ‘learned hopefulness’, her enduring belief that he could change. And we kept talking too, about how child protection services were going to take this newborn baby and were preparing long term Guardianship Orders until 18 years of age for Joey.
Sharon woke up… She was going to lose all of her children, for a relationship that she increasingly named as violent, hurtful, and hateful to her.
As therapists, we use denial. We use it from the moment we enter the room, to enable us to tolerate that parent, while holding that hurt baby in mind, as we are altogether in the room. Some level of denial allows us to slip in and out of empathising with, and understanding, a parent’s experience, while moment by moment, also holding in our minds the sufferings of the baby there in front of us. If we didn’t use some denial, we might leap out of our chairs and scream with rage, or begin to rock, crying soundlessly.
Working in the child protection system, it is crucial to recognise the role denial has in our work, and has had, in our own lives, in our own families, and in our own ways of coping.
The notion of ‘honesty’
Why did we place so much emphasis on Sharon being honest? Why do we think that any of our families would start from a position of honesty? That’s such a long journey for them when they start from a position of such mistrust.
Being authentic is dangerous for our clients. In an authority relationship, why would our clients trust that they can tell us what they know will make us disappointed and angry? Why would they trust until we’ve demonstrated for long enough a sense of caring, compassion, and thoughtfulness that we can manage the truth without retaliating? Until suddenly, as with Sharon, she takes the risk of being honest, and staying in relationship.
As therapists, we talk about the importance of creating trusting, honest relationships with clients. This is based on our belief in the different experience we are offering—the new, relational experience.[2] As professionals, we assume too readily that people will be truthful, and that therapy has to be honest. If we think about things from a self-preservation point of view, it makes more sense to ask why our clients would hold a moral position that values truth over survival.
Why would they change what they have had to do all their lives to survive? Where has honesty got them in the past? I remember one particularly angry parent, who often raged and sneered at me, especially at the beginning. She told me once how, as a child, she’d been playing in the backyard with her stepmother’s children. They were picking on her and throwing stones at her and making her cry when their mother called them in for dinner. When she told the truth about why she was crying and what the kids had been doing to her, her step-mother picked up some of the stones, put them on a dinner plate covered them with sauce and told her that that was dinner and she was to eat it.
So, it is a strange idea that we have, that these parents would tell us the truth, and that we can get disappointed and angry, when they don’t. The system can also get very punitive and harsh when untruths, lying, and deceitful acts come to light. The system is in danger then, of acting out the very dynamic we are trying to shift, the very dynamic these parents expect from those in authority—harsh repercussions.
The crucial role of supervision
Our approach is a team approach. Our assessment, therapy, systemic holding, and reflective practice includes the whole team. We know that all of the concerns that we attempt to address in therapy, we hold in our selves. While the team is an attempt to address this, we all feel the isolation of our clients – the babies who have had no one, the parents who have no one, no family, no support, only the services involved.
The level of vulnerability of our families can be intolerable – no safe housing, sometimes no home even where we can begin the reunification work.
A group supervision session: Ann presents Jenny
In the session, Ann presents Jenny – Jenny’s intense neediness. Ann presents her response to this: how she wants to cut Jenny off, be dismissive and rejecting of her. Then Ann speaks of her sense of disgust and horror at the level of gross emptiness she encounters in Jenny. Ann experiences it as a black hole that threatens to suck away her own vitality.
This taps into Ann’s own feelings as a child of always being experienced as never-endingly needy by an overwhelmed, unsupported, and stiff upper-lipped mother, who herself was contending with the loss of a baby and war trauma. On top of all of this, Ann has recently learned she has a chronic health condition, that both frightens her to think too much about, and saps her vital energy.
Ann realises she experiences Jenny as a refugee child; hands-to-face, pressed against the wire fence, clinging on, pleading.
To come to this realisation, Ann has to use her own self, to allow and feel those past experiences. She has had to allow that touching of experience-to-experience which is the necessary ingredient of being present with her whole self. She does this in spite of the multi-systemic pressure she is also feeling from a number of systems in her body – kinaesthetically, visually, audibly, proprioceptively – to switch off, change her focus, get angry, do anything, but stay present to herself.
This is what needs to happen, at a micro-level of our functioning, in order to create the meeting – that I/thou moment, there, in the intersubjective space. This will create a ‘change moment’ (Stern, 2004). And this is only one moment in a process that may occur, if you’re lucky, once in a 50-minute session, a session you have every week for months. But this is the power of connection, of truly meeting, of being willing to meet.
Sometimes I think therapy in the child protection space, is like those first responders seen on television who don’t turn and run away with everyone else from the chaos or burning buildings, but who run past those fleeing, on towards the smoke and fire.
And that’s how I feel too, in this group supervision session. I don’t want to see Ann there, hunched and suffering, looking like she’s been kicked, feeling like I’m holding her in there for more. I feel the intense pressure to let the pain of the encounter in the group slip sideways, to go along with another group member’s helpful suggestion of a ‘strategy’.
Instead, I need to push the pause button, help us all face and feel our colleague’s pain, our own pain and her client’s pain. It’s such a struggle to reject the little voice that tells me I could come up with some glib advice, or the other voice that tells me I could possibly look good – I could ‘manage it’ for us all.
And glowering below all of that are my own feelings of rejection and impotence. My rage wants to shout at them all to wake up, and think for themselves and to just work it out…
Discussion
Working with maltreating parents is inherently difficult. These parents who have had the least relationally themselves, have the most to lose – their baby. Their babies are babies who have had no one. Providing such a baby a ‘thinking heart’ (Alvarez, 2012) often feels intolerable. At the same time, containing their parent with a loving mind can be discombobulating to both parent and therapist as they are challenged to hold excruciating feelings.
The idea of maltreating parents needing to ‘be honest’ with therapists and case workers is fraught. While honesty is the cornerstone of a therapeutic relationship, it is fundamentally at odds with many of our maltreating parents’ well-worn ways of surviving. Epistemic trust only develops over time – both in infancy and in a therapeutic relationship. Neglected and maltreated babies often cannot wait. It is always an ongoing dilemma: how to build a therapeutic relationship at a pace a maltreating parent can tolerate while holding the baby’s developmental imperative front and foremost.
As therapists in this area we work to understand denial and all the ways it operates to sustain us and hold us back. While aspects of denial are illustrated in this paper, those other defensive processes delineated by Menzies-Lyth (1960) are always at play to a greater or lesser extent at some point throughout the therapeutic reunification journey. Going through the motions – ritual task performance – becomes the response of the overwhelmed and defeated clients and workers alike. Exhausted workers can dehumanise their clients, depersonalising their responses to parents who have depersonalised and dehumanised their babies, maltreating and neglecting them. Splitting is often used by our clients and when manifested in the dynamics of the case conference care team working with the family, can seriously derail everyone’s best efforts.
Increasingly, reflective supervision is understood as a necessary requirement that can mean success or failure in any therapeutic endeavour involving infants. Reflective supervision enables a therapist to ‘tolerate the intolerable’ by mentalising with them, their relational experience with their clients. However, the importance of providing a contained reflective space for a care team to express and reflect together on the dynamics affecting the system, the family, and the workers’ responses, is equally critical.
Working with infants in the child protections system is an attempt at intergenerational change – to interrupt the transmission of chronic, systemic intergenerational trauma. It requires a united response at all levels of a reflective system.
Postscript
Later as I’m leaving the hospital, I see a dad playing with two small sons in a sandpit: the boys’ little bodies, dressed against the cold in hoodies and track pants, leaning intently into the sand, heads together. It raises a sob in me…
I remember my own sons, the intensity of their preciousness to me, and the precariousness of our existence, and their solid little bodies solemnly examining the truths of their world in the sandpit.
I realise how vulnerable I’m feeling, how sad. The exhaustion and emptiness, following an ostensibly very successful supervision session, has left me ragged, open and mourning.
It is that familiar grief and loss that is the inevitable cost of living, of being fully alive.
[1] Max’s attempts to access psychological help for himself appeared to be more about maintaining some control over Sharon. He consistently lied to the private psychologist he met with who became aware of this only after he attended a case conference at the specific request of Child Protection Services. The complex dynamics of extremely violent relationships are well described in ‘Toxic Couples: The psychology of domestic violence’ (Motz, 2014).
[2] The parent-therapist relationship is the primary catalyst for change because within this relationship the parent begins to develop epistemic trust. Fonagy and Allison (2014) write that epistemic trust, a developmental task of infancy, enables social learning in a constantly changing social and cultural context, allowing individuals to benefit from their relational environment. The development of epistemic trust within the therapeutic relationship enables a parent to take in important information from others that previously was dismissed due to mistrust.
References:
Alvarez, A. (2012). The Thinking Heart: Three Levels of Psychoanalytic Therapy with Disturbed Children. UK: Routlege.
Australian Institute of Health and Welfare. (2009). A picture of Australia’s children 2009.
Australian Institute of Health and Welfare. (2009). Child protection Australia 2007-2008 (Child Welfare Series No.45). Canberra: AIHW.
Donald, T., & Jureidini, J. N. (2014). Parenting Capacity. Child Abuse Review, 13, 5-17.
Flannigan, R. (2017). Late Night Live (Radio program). In P. Adams (Host), Late Night Live. Melbourne: Radio National.
Fonagy, P., & Allison, E. (2014). The role of mentalising and epistemic trust in the therapeutic relationship. Psychotherapy, 51, 372-380.
Jones, A. (2015, February). Parents and babies: a way of understanding some perinatal emotional breakdowns. Paper presented at the Centre for Child Mental Health Conference, London, UK.
McCrory, E. J., Gerin, M. I., & Viding, E. (2017). Annual Research Review: Childhood maltreatment, latent vulnerability and the shift to preventative psychiatry – the contribution of functional brain imaging. Journal of Psychology and Psychiatry, 58 (4), 338-357.
Menzies Lyth, I. (1960). Social Systems as a defence against anxiety: An empirical Study of the nursing service of a general hospital. Human Relations, 13, 95-121.
Montgomerie A., Pilkington R., & Lynch J. (2019). Unborn Care Concerns in South Australia. Adelaide: BetterStart Child Health and Development Research Group, The University of Adelaide.
Montgomerie A., Pilkington R., Gialamas A., & Lynch J. (2018). Re-notification to child protection in South Australia. Adelaide: BetterStart Child Health and Development Research Group, The University of Adelaide.
Motz, A. (2014). Toxic couples: The psychology of domestic violence. London: Routledge, Taylor and Francis group.
Pilkington R., Grant J., Chittleborough C., Gialamas A., Montgomerie A., & Lynch J. (2017). Child Protection in South Australia. BetterStart Child Health and Development Research Group, School of Public Health, The University of Adelaide.
Shonkoff, J. P. (2012). Leveraging the biology of adversity to address the roots of disparities in health and development. Proceedings of the National Academy of Sciences of the United States of America, Oct 16;109(Suppl 2), 17302–17307.
Stern, D. N. (2004). The present moment in psychotherapy and everyday life. New York, NY: Norton.
Winnicott, D. W. (1960). The theory of the parent-infant relationship. In D.W. Winnicott (Ed.), The maturational processes and the facilitating environment (pp, 37-55). New York: International Universities Press.
Authors
Dr Patricia O’Rourke, Adelaide, Australia
Acknowledgement
This work is only possible with a team. Other members of the team were Jon Jureidini, Heather Warne, Sally Watson, Alison Knight, Kiara Price, Georgie Swift and Elsa Jureidini. Finally, thanks to Sharon for her generosity allowing her story to be told.
