Watch, Wait, and Wonder

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Watch, Wait, and Wonder An Infant-led Approach
for Working with Infants and Their
Parents Nancy J. Cohen
Hincks-Dellcrest Centre University of Toronto
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COLLABORATORS Mirek Lojkasek Elisabeth Muir
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GOALS

• Discuss the underpinnings of Watch, Wait, and
  Wonder in attachment theory
• Compare Watch, Wait, and Wonder to other current
  interventions
• Describe Watch, Wait, and Wonder technique and
  process
• Summarize research results on Watch, Wait, and
  Wonder
• Consider applications of Watch, Wait, and Wonder

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On the surface, some infant problems may not
appear to be relational. However, they often
reflect the infants separation anxiety. The
difficulties do not reside solely in mother or
child but in the relationship.
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SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION

• Infant Symptoms
• Irritability and difficulty being soothed
• Excessive tantrums
• Sleeping problems
• Eating problems
• Clinginess

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SYMPTOMS THAT BRING INFANTS TO CLINICAL ATTENTION

• Parent Symptoms
• Depression
• Anxiety
• Risk for or allegations of abuse
• Complaints of not feeling bonded or attached to
  infant

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A baby has none of the conventional attributes
of a psychiatric patient. He cant talk about
his problem. He cant form a therapeutic
alliance. He has no capacity for insight. Such
patients are usually labelled not suitable for
treatment in the language of psycho- therapy.
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CONDITIONS FOR SECURE ATTACHMENT

• Accurate perception of infant cues
• Sensitive responsivity to infant
• Display of affection
• Acceptance of infants behavior and feelings
• Physical and psychological accessibility when
  infant is distressed or when exploring

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IMPLICATIONS OF ATTACHMENT SECURITY

• Regulation of emotions and behavior
• Sense of self
• Curiosity and exploration
• Cognitive and language competence
• Capacity to relate to others
• Capacity to parent

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Individual Differences in Infants Contribute to
the Relationship

• Infants have different personalities or
  temperaments from early on
• These traits evoke different responses (e.g.,
  some babies are soothed easily)
• Some parents find it difficult to establish a
  fit with their infant.
• The parents often have expectations of how their
  child should be. These expectations may be
  conscious or unconscious.

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• Even when the problem is attributed to something
  else (e.g., FAS developmental exceptionality) a
  relationship focus can be of benefit.

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• SECURE BABIES
• Explore freely and seek contact with the
  attachment figure as necessary.

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• INSECURE BABIES
• AVOIDANT BABIES
• Do not show attachment needs in order to avoid
  rejection.
• AMBIVALENT
• Preoccupied with the availability of an
  inconsistent caregiver and make repeated high
  intensity demands to ensure at least some elicit
  attention or are extremely clingy.

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• DISORGANIZED BABIES
• Do not have an organized strategy that elicits
  care when distressed.

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• INTERNAL WORKING MODEL
• Internal working models of self in relation to
  others are set down and unconsciously guide and
  filter attention and processing of experiences
  with regard to attachment. In this way, they
  impact on the course of future relationships.

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• An intervention consistent with attachment theory
  needs to meet a number of criteria
• Provides emotional and physical access to
  mother.
• Focuses directly on maternal sensitive
  responsiveness to the infant's behavior
  and emotional signals.
• Places the mother in a non-intrusive stance.
• Provides a space in which the infant can work
  through relational struggles through play and
  interaction with the mother.
• Provides a therapist who can function as a
  secure base for the dyad.

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OTHER INTERVENTIONS Support

• Assist mothers to access community resources,
  such as housing, work, child care.
• Counselling the mother or teaching social skills.
• Therapist is resource.

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OTHER INTERVENTIONS Developmental
Guidance

• Provide information to the mother on infant
  abilities, developmental milestones and needs,
  and practical caretaking issues individually or
  in group format or informally during infant
  medical check-ups.
• Therapist is resource.

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OTHER INTERVENTIONS Relational Guidance

• Help mothers increase knowledge of and experience
  with infant in the context of spontaneous
  interactions.
• Mothers helped to attend to their infants
  idiosyncratic cues.
• Therapists provide feedback directly or by
  reviewing videotapes with the mother.
• Therapist may also model parenting behavior.

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OTHER INTERVENTIONS Psychotherapy

• With help of therapist, the mother gains access
  to repressed early experiences, re-experiences
  feelings associated with them, and achieves
  insight into the relational difficulties with her
  infant.
• Infant included as a catalyst for change.
• Repetition of the mothers past primary
  relationships in her relationship with the
  therapist
• Therapist interprets and helps mother make links
  between past and present.
• Therapist may guide mother to interact in a
  different way.

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In spite of our current knowledge that infants
contribute to relationships, all of these
therapies focus on the mother and assume that the
work needs to be done with her before the infant
can benefit. None of these therapies have as
their goal that the infant should be able to use
the time therapeutically himself.
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• Although it is the infant who is the greatest
  clinical concern, the actual focus of treatment
  is usually the mother. In our work, we have
  focused on how best to include the infant in
  infant-parent dyadic therapy directly through the
  infants activity.

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You be this way or else you will cease to exist
in my eyes.The mother can only see certain
behaviors. The dilemma for the infant is that if
he is himself he loses his mother. If he loses
his mother he loses himself. Ironically, if he
keeps his mother he also loses himself. The
outcome of this experience is separation anxiety.
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HOW DO WE INCLUDE THE INFANT IN PSYCHOTHERAPY?

• Allow the infant to explore and show his
  curiosity about the environment. through
  sensorimotor activity and play.
• Use observation of the infants spontaneous
  gestures as a reflection of his innate potential.
• Use a medium in which infants can seek and
  establish relatedness.

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WATCH, WAIT, AND WONDER SESSIONS

• Infant-led activity
• Discussion

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SUGGESTED LIST OF TOYS FOR WATCH, WAIT, AND WONDER
New born baby anatomically correct dolls with bottles and diapers an blankets Stacking cups
Dolls crib that is large enough for child to crawl into, or set up a space on the floor with a pillow and blanket defining a bed Blocks
Bean chair Small cars including ambulance
Two telephones Medical kit with stethoscope
Mirror, (shatter-proof) Sets of vinyl family dolls (black and white
Activity board Set of tame and wild animals large solid variety
Soft ball Bowls and mixing spoons
Stacking rings Train set
Policeman helmet or some other official hat Heavy duty blue vinyl (Pool manufacturers)
Undermatting polypropylene for padding
NOT ALL OF THESE TOYS ARE REQUIRED. IN FACT,
WWW CAN BE DONE WITH VERY FEW TOYS IF NECESSARY
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INSTRUCTIONS FOR WATCH, WAIT, AND WONDER

• Get down on the floor with your baby.
• Follow your babys lead at all times.
• Do not initiate activities yourself.
• Be sure to respond when your baby initiates but
  do not take over his activities in any way.
• Allow your baby freedom to explore whatever he
  wants to do is okay as long as it is safe.
• Remember to Watch, Wait and Wonder.

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DISCUSSION

• What did you observe?
• What was your infants experience?
• What was the play about?
• What were your thoughts and feelings?

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RESEARCH OUTCOMES KEY AREAS OF MEASUREMENT

• Symptom reduction
• Mother-infant relationship
• Infant competence
• Maternal distress and confidence

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RESEARCH OUTCOMESPRE- TO POST-TREATMENT

• Both treatment groups exhibited symptom
  reduction, improved quality of mother-infant
  interaction, and reduction in parenting stress.
• Greater gains were made from the beginning to
  the end of treatment in the WWW group in
  attachment, infant cognition and emotion
  regulation, and maternal depression and
  parenting efficacy.

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RESEARCH OUTCOMESPOST-TREATMENT TO FOLLOW-UP

• Improvements that were observed at the end of
  treatment were maintained.
• In some respects, further improvements were
  observed six months after treatment ended in
  reduced infant symptom severity, maternal
  intrusiveness, and dyadic reciprocity and
  parenting stress.
• Changes emerged in WWW and PPT at a different
  pace. Dyads receiving PPT showed gains in
  infant cognitive development, attachment, and
  maternal depression at follow-up that had been
  observed in dyads receiving WWW at the end of
  treatment.

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WHAT MIGHT ACCOUNT FOR DIFFERENTIAL TREATMENT
EFFECTS - 1

• Watch, Wait, and Wonder maximizes the
  requirements for forming a secure attachment
  relationship by providing psychological and
  physical accessibility to the mother and
  enhancing her capacity to respond to the infant
  reciprocally and without intrusion.

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WHAT MIGHT ACCOUNT FOR DIFFERENTIAL TREATMENT
EFFECTS - 2

• In PPT, the primary focus is on the mothers
  representations and the transference
  relationship. The latter focus may delay changes
  as the mother needs to work through earlier
  relationships before new insights can influence
  the relationship with her own infant.

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CONCLUSION

• All roads lead to Rome but taking some roads
  takes less time than others.