Introduction
by Astrid Berg (South Africa)
I am grateful to my four colleagues from different parts of the world, for sharing with us their personal responses to what reflective practice means to them at this point in time.
Whether these come from the context of the sagging couch and the sickly sweet smell of spoiled milk, or mothers struggling with mental illness and impoverished backgrounds, or the therapist sitting with patients hearing war sirens and being frightened for the lives.
What holds the therapist, the mental health counsellor together to enable her to be there for the families, for the infants, in need of holding? What is evident in all of these precious individual accounts? It is the collective notion that we are all human, equally human, and that which evokes despair, anxiety and terror feels the same for all of us. It is our thinking capacity, our ability to reflect, and for brief moments stand outside of ourselves, to suspend judgement and reach a deeper understanding, as is so beautifully depicted in one of our contributions. Only then can we see the other, only then are we able to truly be there and have a mind that is open to take in the other.
I hope that these cameos of personal experience will encourage others in the WAIMH family to share their feelings and thoughts about this important topic.
Holding the fragmented mind in mind
by Juané Voges (South Africa)
A young mother tentatively puts her infant down on the playmat, watching him look at the adults seated around him and then picking up a green block, before turning to her. Mom observes as older women share their struggles with depression, poverty and absent fathers, seeming to relax somewhat before also sharing her own difficulties of caring for her firstborn, while recovering from a psychotic episode and trying to complete school. As the group members encourage and gently guide her, it becomes clear that she feels held within this small community. Through the months that followed, the young mother became able to share her joys and challenges within the group and she seemed to develop a greater sensitivity to her son’s bids for engagement.
Working with mothers struggling with various forms of mental illness and distress most of whom come from an impoverished background, I find myself holding sometimes contradictory feelings of hopelessness, uncertainty, confusion, optimism, wonder and joy. Within a weekly mother-infant mentalising group, I aim to create an experience of safety within which group members can reflect on their own and each other’s experiences of mental illness and parenting of young infants. However, the most impactful moments often derive from observing and wondering together about their infants interacting at the centre of the group circle.
Reflective practice became a guiding influence in my clinical work when I had the opportunity to collaborate with the late Nancy Suchman on a pilot project focussed on implementing a mentalising intervention with mothers of young infants who suffered from a severe mental illness. Since then, I have found myself returning to one guiding concept time and again – a parent needs a felt experience of being reflected upon, understood and mentalised, in order to provide that experience for her infant or young child.
Parents with mental illness often struggle to make sense of their own thoughts, feelings and experiences – even more so during the journey of pregnancy and early parenthood. Within this context, the mind of an infant may seem especially indecipherable and daunting! I have found that a mentalising group for mothers with mental illness creates a useful framework for encouraging reflective practice between group members and within mother-infant dyads. Mothers in the group can put words to their own feelings and experiences and these can be reflected upon. This experience helps them to feel mentalised, which enables them to reflect more actively on their infants’ internal worlds.
Clinicians and patients in war: Some personal reflections
by Miri Keren (Israel)
In situations of war, the clinician is herself/himself exposed to survival threats. My personal experience as a clinician for almost 12 months now, makes me wonder about the impact of a shared, life-threatening environment on the essence of psychotherapy and its impact on the therapist-patient relationship.
For instance, how to keep a therapeutic reflective stance when, in the midst of a Trauma-Focused Child Parent Psychotherapy session, the noise of the siren cuts the air, and the team together with parents and children have to rush to the shelter together? What can the situation of being-afraid-together bring to the therapeutic relationship? A sense of humanity, facing a shared fate? Could we see it as an ultimate Attachment-Theory-based Interpersonal Psychotherapy setting, especially if we, the clinicians, are able not to be overwhelmed with fear and can put words on the unusual situation?!
Also, being together in extreme existential situations often breaks the standard setting rules. For instance, those families who have fled the war zones find it difficult to come to the clinic. Flexibility and creativity become essential tools: we go to them, wherever they are, and we bring with us our toy kits (including trauma-related toys).
To my mind, the major risk is for clinicians in wartimes is to lose our containing and reflective capacities, to adopt a dichotomous good/bad standpoint… reflecting those of the traumatised parents and the wider political environment. Being a helper is a way to cope. But what does it mean to help, when we have no control over mass processes, politicians, distorted media information, demagogy and demonization? I think that the clinician’s role is not only to help parents and infants mentalize and put words to their traumatic experiences, but also and may be even more, to convey a basic trust in humanity, in spite of the surrounding inhumane acts, and to hold hope and trust.
Musings on Reflective Practice
by Deborah Weatherston (United States)
One of the greatest gifts given to me has been the opportunity to work reflectively with families referred because their babies or toddlers were not thriving, or their parental caregiving capacities placed them at grave risk, as well as the regularly scheduled meetings with a supervisor who invited reflection about my work and myself. What follows are my musings about reflective practice.
The crisis of poverty surrounded me in my work as an infant mental health (IMH) home visitor. The frail baby’s cry, the silent toddler’s raspy cough, the young mother’s hopeless stare, the fog of cigarette smoke, the sagging couch where they sleep, the chilly room, the sicky sweet smell of spoiled milk…this is what I witnessed on many home visits to very young children and their families who were underserved, marginalized, and undervalued. After shedding my own feelings of despair and vulnerability in response to the overwhelming circumstances of their lives, and opening myself to be present to each parent-infant pair, I would ask myself: What does this baby need? This toddler? This mother? This father? I would hold my emotions close to my heart until I could bring them to my reflective supervisor.
Trained in Selma Fraiberg’s IMH home visiting model, I would return weekly, building my trust with families and they with me, to consider their immediate needs, connect them with health care, food banks, advocate for housing. Within the context of our relationship, those who felt invisible became visible. Listening to their stories, many of trauma, grief, hopelessness, and loss, helped them to feel heard. Sitting with parent and child together, I held the space for their reflections about the loss of other babies, removal of toddlers for months to foster care, past histories of drug use, abuse, maternal neglect, domestic abuse, and community violence. I listened carefully, offered guidance as appropriate, and tried to respond with empathy, without judgment, to what they shared that made caregiving so difficult. I tried to support their capacities – a baby’s smile, a toddler’s first words, a parent’s efforts to play. As my relationship with each developed, the veil of depression, pain, or anger shifted enough so that mothers or fathers might hold their babies and respond with warmth to the cries, the hunger, the silence or the upset of very young children in their care. There were things I could not change – persistent poverty, marginalization, discrimination. But I could offer a relationship that impacted their relationships with their children.
What I witnessed and the feelings aroused were often intense. In order to practice reflectively, from a relationship perspective, I needed a supervisor to help me navigate the felt experiences of IMH home visits with babies and families, week after week. The IMH supervisory relationship, founded on mutual trust, provided me with a holding space, an invitation to reflect, to feel held and heard, to be gently guided, to share the burdens, the hopes, and the pains. Supervision became a place for me to think about the impact of relationship centered practice with babies and families whose lives had been altered by trauma, grief, as well as the distress of persistent marginalization, discrimination, and poverty. Thoughts and feelings about my work opened possibility for more deeply personal reflections about other babies, other mothers, my experiences as a parent, relationships, past and present, as well as biases that I held. Such relationship centered supervision strengthened my belief that reflection could restore parental capacity to nurture and reduce the risks of relationship failure between parent and child. Reflective supervision also led me on a personal journey to become more introspective, self-aware. A two-fold, extraordinary gift.
Reflective Moments
by Hisako Watanabe (Japan)
Reflective practice is an indispensable part of our clinical encounter, immediately linking to primum non nocere (First do no harm) a credo of the Hippocratic Oath and also of infant mental health.
There are moments after a particularly difficult session with a client when I find myself struggling to recall or understand all that transpired. In such moments, I work to still myself, close my eyes, and stay silent in the darkness for a moment until I find my way back to being grounded. It feels as if having travelled to a different world or having returned to the surface from a deep dive under water, exploring together with my client. In this afterglow of the tangible moments of encounter with a client, I am deeply immersed, body, mind and soul, in a lingering reflection until meanings of what transpired are fully realized.
As we face an increasing number of complex cases of traumatized children in this era of global crises, we need to widen and deepen our capacity for reflection and to pay greater attention to our gut feelings, nonverbal somatosensory clues of affection and caution. To this end, poet Keats’s concept of ‘negative capability’ is useful. During his short life between 1795 and 1821, he was a young medical doctor who had to experience utter helplessness, witnessing multiple losses, including his family. Keats coined the term, negative capability to urge us to suspend judgement in order to reach a fuller understanding. It is a capacity to bend flexibly when encountering something unexpectedly hard to overcome. Negative here implies the ability to resist explaining away what we do not yet understand. Inspired by Shakespeare’s work full of misconceptions, Keats suggests that we take time to look at matters from multiple perspectives to gain new insights.
Reflective practice takes us back to the basics of life and the enigma of encounters and relationships.
Authors
Berg, Astrid, WAIMH President,
Psychiatrist, Child & Adolescent Psychiatrist, Jungian Analyst,
Emerita A/Professor at the University of Cape Town,
A/Professor Extraordinary at the Stellenbosch University,
South Africa
Voges, Juané, Clinical Psychology, PhD,
Department of Psychiatry, Tygerberg Hospital,
Stellenbosch University,
South Africa
Keren, Miri, M.D., WAIMH Honorary President,
Child and Adolescent Psychiatrist,
Associate Clinical Professor, Bar Ilan University Azrieli Medical School,
Israel
Weatherston, Deborah, PhD,
Infant Mental Health Home Visitor, Supervisor & Consultant,
Michigan, United States
Watanabe, Hisako, M.D., Ph. D.,
Life Development Center, Watanabe Clinic,
Japan
