Infant Observation (Therapeutic)
INFANT OBSERVATION (THERAPEUTIC)
The method of observing the infant in its family environment, from birth to age two, using the rigor of the analytic framework, was conceived by Esther Bick. The observer visits the infant at home for one hour once each week and maintains a strict neutrality. The field of observation is the relationship that is established between the baby and its mother, within the context of the transference instituted between the mother and the observer, and between the mother and her baby. The objective is training the observer in analytic work rather than the fabrication of an instrument for research. This method, used for the training of psychoanalysts and childhood specialists, later proved to be a remarkable tool for early treatment.
In 1948, at the request of John Bowlby, Bick developed a method of infant observation in a family context. As Bick explained in "Notes on Infant Observation in Psycho-Analytic Training" (1964), the aim was to provide an opportunity for practical experience as a part of first-year training for therapists at the Tavistock Clinic.
In 1963, Bick presented her method of observation to the British Psychoanalytical Society (BPS). A consensus was established among the various English schools that this method would be integrated into the first-year curriculum; the attentive observation of an infant's development enables the future analyst to live out a number of fundamental emotional experiences, then to think them through within the framework of the work group. It was Sigmund Freud's grandson, W. Ernest Freud—the "child playing with the spool"—who promoted this method for therapists at the Anna Freud Center, as he related in "Infant Observation: Its Relevance to Psychoanalytic Training." (1975). Bick's method of observation is a part of analytic training within the Spanish and Belgian psychoanalytic societies. Bick herself recommended training in this method for all categories of professionals involved in children's mental health.
In France, André Green strongly opposed the use of direct observation, noting in "Entretien avec Pierre Geissmannà propos de l'observation des bébés" (1992; Interview with Pierre Geissmann on infant observation) that it carries the risk of externalizing psychic life and confusing the infantile with the actual infant, which runs contrary to the work of representation and the spirit of psychoanalysis.
Bick's method was a conceptual innovation, described as "a stroke of genius" by Martha Harris. It is a precise technique used in a fixed framework, whose goal is the training of the analyst. The observer must be able to find a space within the family that is sufficiently neutral, yet not rigid, to enable him or her to experience the emotional impact of the baby's presence, without taking action. He or she must come unburdened by theoretical preconceptions, and be receptive without interfering. After the observation, the observer writes a report that conveys his or her experiences to a work group, which keeps an eye on methodological ethics and helps to make sense of the observed material. Observing a baby presupposes an ability to identify with the different points of view of family members; this flexibility makes it a sound preparation for analytic work. Through the analysis of his or her countertransference in relation to both the mother and what he or she feels from the baby, the observer can understand the impact of the mother's fantasies on the baby's mental space and perceive the manner in which the baby responds to this. Thus, the specific type of affective and counter-transferential opening up inherent in observation makes it an aid to the development of the future analyst's capacities for free-floating attention.
The observer's presence is a source for change. It often has beneficial effects for most families: helping the mother emerge from postpartum depression, developing the parents' attention-giving abilities, modulating the effects of repetition of the mother's past on the baby. Bick's method opened the way for new therapeutic possibilities. Infant observation in day-care facilities, hospitals, and in the home has been developed to sensitize staff, as a preventive measure against early disorders, and with a view to therapeutic intervention in cases of autistic or psychotic pathologies.
In day-care facilities, the main indicators for setting up observation are:
- Mental dysfunction in the mother. The containing effects of observation serve as a protective shield and allow for a reshaping of the imagos;
- Children who have to be entrusted to a series of foster care situations owing to inadequacies on the part of the parents can benefit from the presence of an observer who follows them from one place to the next;
- When a child has a disability that is traumatic for the parents. The observer tries to get them to recognize the child's performances and the support he or she needs;
- Early autistic or psychotic disorders. The observer serves as a support for child-raising and the parents. He or she identifies the sources of suffering, defense mechanisms, and factors that hinder the child's development, and helps to improve the family's responses in the form of caregiving and listening skills.
In hospitals, in obstetrics wards and neonatal intensive care units, attention given to the baby, especially when he or she seems to be disorganized, enables both medical providers and parents to "think" the baby, to find meaning in interactions, and to avoid functional repetition.
Observation is a remarkable tool for prevention and treatment. It is an aid to the baby, who is helpless in the face of its intense anxieties, to the mother in need of solicitude, and to other caregivers.
See also: Archaic; Infantile psychosis; Infant observation; Infant observation (direct); Premature-prematurity; Tenderness.
Bick, Esther. Notes on infant observation in psycho-analytic training. International Journal of Psycho-Analysis, 45, 558-566.
Freud, W. Ernest. Infant observation: its relevance to psychoanalytic training. Psychoanalytic Study of the Child, 30, 75-94.
Green, André. Entretien avec Pierre Geissmannà propos de l'observation des bébés. Journal de la psychanalyse de l 'enfant, 12, 133-153.
Haag, Michel, and Geneviève Haag. L'observation des nourrissons selon Esther Bick (1901-1983) et ses applications. L'Information psychiatrique, 1 (1995): 7-17.
Pérez-Sánchez, Manuel. (1981). L'observation des bébés. Paris: Clancier-Guénaud.
Infant Observation (Direct)
INFANT OBSERVATION (DIRECT)
The direct observation of babies is a way of learning about the developing human mind.
In "The Psychogenesis of a Case of Homosexuality in a Woman" (1920), Sigmund Freud stated that if direct observation were sufficient to provide us with information on the origins of human sexuality, he would not have bothered to write his books. Arguably, we observe nothing that we do not already know, and vision, although closely linked to the scopic instinct—the foremost tool of curiosity and inquiry—is not a productive way of investigating psychic reality. Nevertheless, his observation of Little Hans, related in "Analysis of a Phobia in a Five-Year-Old Boy" (1909), provided him with the essential elements of his theory of the libido and castration anxiety. He believed he was able to see directly in the child "these sexual impulses and these formations built by desire that we have such difficulty uncovering in the adult." His observation of an eighteen-month-old child playing the Fort!/Da! game with a wooden reel, related in "Beyond the Pleasure Principle" (1920), by establishing the basis for his theory of the death instinct, played a role not only in his theorizations of narcissism, but also because it provided a paradigm for numerous currents of thought in child psychoanalysis.
Freud and Melanie Klein, working within different perspectives, encouraged their students to observe infants, but without making this a separate field of study. It was Donald Winnicott who, in "The Observation of Infants in a Set Situation" (1941), defined that field by envisioning infant observation as a "set situation" capable both of providing information about the infant carried by its mother and of establishing an authentic therapeutic relationship with the infant, working in a nonverbal mode. Winnicott proposed his own reading of Freud's "game of Fort!/Da! " and helped us to see what distinguishes his interpretation from pure behavioral observation. He analyzed the sequence of the baby's behaviors in three stages: (a) hesitation, which he interpreted as a "sign of anxiety about something" and a symptom of a conflict between the infant's desire and its interiorization of a threatening maternal imago; (b) then the expression of self-confidence—which is close to what he called "omnipotence." In some cases, this phase can lead to the world of make-believe and shared play; and (c) the game of appearance/disappearance of the object, in which the infant, emerging from its depressive mood, expresses its ability to restore the object through the game.
Winnicott thus establishes a difference between the primitive processes, as they can be directly observed, and the deeper processes that are already a reconstruction and elaboration of the primitive processes, linked with experience of the environment. He made it possible to utilize direct infant observation to better understand psychic reality in the process of being constructed.
The postwar period, in which psychoanalysts were faced with the problem of early psychopathologies, renewed interest in observation. René Spitz and John Bowlby, borrowing their methods from genetic psychology and ethology respectively, proposed new developmental models focused on, respectively, the concept of organizers of the ego and attachment theory. An important research trend then developed, mainly in the United States, that interpreted the baby's nonverbal behaviors as genuine mental acts. Her work informed by the theories both Klein and Wilfred Bion, the British investigator Esther Bick, in "Notes on Infant Observation in Psycho-Analytic Training" (1964), for her part upheld the idea that the infant's mental life unfolds in a projective mode that must be contained by psychic structures that are sufficiently developed to support the emergence of the processes of introjection. Originally conceived as a contribution to the training of child psychotherapists and psychoanalysts, this method has been extended to other objectives: research on the beginnings of the infant's mental and relational life, prevention and treatment techniques used in families and in various institutional settings (treatment and other centers for young children, nurseries, neonatal care services).
From an epistemological point of view, Didier Houzel (1997) underscored the difference between an ethological approach and observation that he characterized as psychoanalytical, which sticks to the proposed framework both internally (coming as close as possible to the baby's somatopsychic experiences) and externally (type of contract established with the family, means used by the various parties to abide by or transgress the conditions, and finally the observer's capacity for empathy). Observation thus takes place in two stages: encounter with the subject, and the deferred working-over of transferential and counter-transferential material.
See also: Infant observation (therapeutic).
Bick, Esther. (1964). Notes on infant observation in psychoanalytic training. International Journal of Psycho-Analysis, 45, 558-566.
Freud, Sigmund. (1909b). Analysis of a phobia in a five-year-old boy. SE, 10: 1-149.
——. (1920g). Beyond the pleasure principle. SE, 18: 1-64.
——. (1920a). The psychogenesis of a case of homosexuality in a woman. SE, 18: 145-172.
Winnicott, Donald. (1941) The observation of infants in a set situation. International Journal of Psycho-Analysis, 22, 229-249.
Infant observation has long been considered an important training exercise for child psychotherapists and for psychoanalysts (Bick, 1964). This has led to certain theoretical developments commonly associated with the work of Esther Bick (1968, 1986).
Bick began this work in 1948, shortly after Melanie Klein had described the paranoid-schizoid position. In Klein's view of the paranoid-schizoid position, the ego has a primary sense of a boundary between itself and the external world. Bick described a variant of this process, in which boundary of the ego is not primary, but comes from the sensations arising from skin contact. Sufficient skin sensations are necessary to give the experience of a boundary.
One of the processes she noticed interpersonally was that the breaking of skin contact appeared to be experienced by the infant as a hole from which it could leak. She noticed the frequency with which infants become incontinent of excreta, as well as loosing tears from the eyes, and screams from the mouth. She believed she was watching just that process which Klein had described as the disintegration of the ego in the early stages after birth. The fragmentation takes the form of an experience of leaking into empty space.
Bick described various methods by which the infant seemed to operate to plug that leaky gap. It might grasp with the mouth so that literally the hole is filled. Alternatively the hands may grasp as the mouth does; or more distantly the eyes may become fixed upon a point of light or some discrete object, as if clinging like the clenched hands. In addition the infant may fix aurally upon sounds, including the sound of its own crying. These processes of filling, grasping, fixing, and hanging on represent a method of completing a boundary. However, the mother's contact with the baby's skin remains the most potent, and perhaps natural, means of completing the boundary.
The theoretical ideas concerning the skin are related to the notion of the "skin egos" developed by Didier Anzieu (1985) and Pierre M. Turquet's "skin-my-neighbor" (1975).
Bick's view was that the boundary between ego and external world was first of all a phenomenon of the body ego, and specifically the skin. Also, it is not a given structure at the outset of life, but instead has to be achieved through the experience of the mother "giving" the infant a sense of being enveloped, through the mother's innate understanding of the baby's need for skin contact. Thus the primary object that stabilizes the ego is not Klein's good internal object internalized inside the ego boundaries, but is the ego boundary itself. The skin is thus a bodily component of the stability of the ego, and it is gained passively, at first, from the external object (mother).
Bick thought she was extending Klein's theories, by displaying a psychic level prior to and beneath Klein's paranoid-schizoid position. However, this has not been generally accepted.
Robert D. Hinshelwood
See also: Adhesive identification; Child analysis; Good-enough mother; Infant observation (direct); Lebovici, Serge Sindel Charles; Processes of development; Symbiosis/symbiotic relation.
Bick, Esther. (1968). The experience of the skin in early object relations. International Journal of Psycho-Analysis, 49, 558-566.
——. (1986). Further considerations on the functioning of skin in early object relations: findings from infant observation integrated into child and adult analysis. British Journal of Psychotherapy, 2, 292-299.
Pérez-Sánchez, Manuel. (1990). Baby observation. Perth: Clunie Press.
Bick, Esther. (1964). Notes on infant observation in psychoanalytic training. International Journal of Psychoanalysis, 45, 558-566.
Boyer, Diane, and Sorensen, Pamela. (1999). Tavistock model of infant observation in neonatal intensive. Psychoanalytical Inquiry, 19,146-159.
Freud, Anna. (1953). Some remarks on infant observation. Psychoanalytic Study of the Child, 8, 9-19.
Spitz, Rene A. (1950). Relevancy of direct infant observation. Psychoanalytic Study of the Child, 5, 66-73.