Containment and contentment

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Containment and contentment Robin Balbernie

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Child & Adolescent Service Cleeve House, Horton Road, Gloucester Version of record first published: 24 Sep 2007.

To cite this article: Robin Balbernie (1997): Containment and contentment, Journal of Child Psychotherapy, 23:2, 245-253 To link to this article: http://dx.doi.org/10.1080/00754179708254544

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J O U R N A L OF C H I L D PSYCHOTHERAPY Vol. 23 NO. 2 1997: 245-253

Containment and contentment

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R O B I N BALB E R N 1 E ,

Gloucester, England

SUMMARY In this paper I examine the importance of the smile as an emotional nexus between infant and mother. A series of observations seems to suggest that the infant is almost immediately able to appreciate when the mother, as a special and separate person, is ready to receive such communication. I consider how a mother’s physical and mental embrace may have been altered by the presence of an observer in such a way that the necessary conditions were created for her baby to feel that it was then the right time to use the ability to smile, and so become an active initiator of meaningful interaction.

KEYWORDS Contentment; smiling; containment; infant observation.

Begin, baby boy, to recognize your mother with a smile. Eclogue, Publius Vergilius Mato (70-19

BC)

INTRODUCTION The baby’s smile is a major conductor of emotional contact with the mother. There is the first smile, which just happens autonomously when conditions are right and is joyfully received, then the social smile and next the smile as the carrier of interpersonal delight, usually in the context of play. Whenever the baby smiles at his mother he can initiate an amplified exchange, giving a bit of himself but getting a lot more back. When there is postnatal depression this positive feedback loop never gets going. If we accept that the baby somehow wants to encounter the mother in this way then there must be present a mental representation, or at least a working sense, of each being a separate person. By what may have been more than just coincidence I was witness to the 0 Association of Child Psychotherapists 1997

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first expression of all three of these stages of smiling in a baby that I had first seen in the intensive care baby unit, where I make myself available on a regular basis. This made me wonder if such a coincidence could be explained.

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BACKGROUND Sam was born at just under 27 weeks’ gestation, weighing 1% lbs. He had been induced, as an emergency, as the placenta had malfunctioned. Consequently his developmental age was only 22 weeks. The inaugural holding situation had been withdrawn far too early; and gravity had been added. I first met him when, at the invitation of the consultant, I began to visit the intensive care baby unit. He would then have been 17 weeks old, by birth age, but developmentally still premature. He was almost lost in his perspex cot which was crowded with small soft toys, an unfolded cloth frieze of black and white shapes and two miniature loudspeakers used to replay the sound of his mother’s voice reading fairy tales. There was a festoon of tubes and wires and an oxygen line taped to his cheeks with the prongs up his nose. He had developed an oxygen dependency which meant he needed a continual stream of it pumped into his lungs. It was very bright and there were several monitors showing graphs, flashing lights and occasionally bleeping wildly. It seemed like an awful lot of stimulation if he dared to be alert. He was asleep. His mother arrived and I introduced myself and asked if it would be all right if I came in to observe Sam, explaining that I was interested in getting an idea of what it might be like for him. She was intrigued by this and asked relevant questions, and I said I would be around if there were things that she wanted to talk about. She took advantage of this; and later, when Sam was discharged, I was able to follow his development by making home visits. He continued to be small for his age, gaining weight very slowly (on average of about 3%oz. a week) partly because he had to put so much effort into breathing even with his permanently attached oxygen supply. I will describe Sam when I first saw him in the intensive care baby unit. This gave me the overall impression of how boundaryless his experiences were compared to those of an infant in its home environment where care has nothing to do with technology. This is the background to the following three observations that coincide with Sam’s developing use of smiling.

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FIRST O B S E R V A T I O N AT 18 WEEKS OF A G E , N O T H I N G TO S M I L E A B O U T Sam was asleep, lying on his right side. He was tiny. My presence seemed to disturb him and he opened his eyes and looked at me. He became agitated while I was explaining why I was there to his nurse, waving his arms and turning his face towards me. I said my voice may have disturbed him and she talked to Sam, saying ‘It‘s not your Mummy’s voice, it’s not your Dads’, which reflected the sense of being unprotected and rather vulnerable that I got when looking at him. He had only been a couple of weeks in a cot without a lid, and the extra pressure of oxygen he required was supplied directly to his nostrils by a small line; hearing, touching and smelling had all been almost erased by technology. Sam settled but still left me feeling he needed to be snuggled up or held. One arm remained outside his blanket. After a bit a monitor bleeped and he jerked, then his right hand went up to press the dressing that held his oxygen tube in place and he began to pant and then settled. His left hand splayed out and it seemed to me he was almost looking for something to grip. The only firmness he could use was provided by the pair of small loudspeakers which he now had pushing up against his back and bottom. He continued to cycle in and out of sleep, usually in response to noise. His hands moved up in front of his face and he began to look at them and his eyes opened wide. Then he stared at the edge of his cot which, as it was perspex, was the best defined part. After this he closed his eyes and looked sad and gave a whole body shiver. He whimpered and thrashed round with his arms, opening his eyes and looking away from me. I felt as if I should pat or hold him, but did nothing. He began to grunt and move about more, setting off a monitor as his blood oxygen level dropped. He opened his mouth as wide as he could, not a yawn, and closed it when his hands came up to his face. Similar movements continued for some time, then he was suddenly awake. Both hands shot up to his face and he waved his left arm around. He yawned and blew a bubble of spit and then rubbed his face. Although he must have been at least partially habituated to his oxygen tube, which was taped to both cheeks to keep the prongs in place, I reflected on this continual hard ‘otherness’ always pushing on to such a sensitive area. He managed to shut the world out by covering his eyes, and then uncovered them to look rather alert, his left hand plucking at the tube. He moaned, stretched and then there was a burst of mouth movement.

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Sam then seemed to be trying to settle, which was complicated by an alarm going off whenever he exerted himself. He gave a small shiver, grunted and stretched out both his arms until he just touched the sides of his cot. He pulled back and began to half close his eyes. Another wriggle meant more noise, but Sam seemed to be getting sleepy now and his eyes closed. Again I felt his hand which was out flung on the sheet, should have had something to hold. He fell asleep and I left. I maintained contact with Sam and his mother, and she told the nurses that she had found my point of view helpful. At this stage she was managing to breast-feed although later this stopped as part of the drive to get Sam to put on more weight. There was a dilemma between wanting to get him home ‘where he belonged’ and a fear of being away from the intensive care which had kept him alive, against the odds, and nurtured him up until then.

OBSERVATION AT 2 1 W E E K S , T H E F I R S T AIMED SMILE When I came on to the unit Sam was in the process of being lifted out of his pram by his mother and a nurse. This was a complicated procedure as he was wriggling about trying to track the source of the three voices that now surrounded him, and the lines from his heel and his oxygen tube needed untangling. Eventually he made it into the arms of his mother. She described their walk, saying ‘he enjoyed it‘ and sounding pleased. Sam seemed to be straining to look at her, and when I pointed this out she gazed down and was rewarded with a huge smile. His mother was surprised and pleased in equal measure, and said that this was the first time he had ever smiled directly at her. This seemed to be a direct and rewarding response to his mother‘s attention; although it could have been a coincidental spontaneous smile. Shortly after this Sam’s mother had to leave, and he was transferred to the arms of a nurse. From being alert he instantly changed to being sleepy, and his eyes rolled up. However, the nurse chivvied him awake for his feed (expressed breast milk plus supplement) and he seemed to suck well. We chatted for a while, with Sam straining to look in my direction, before I had to go. As I left he was being burped and I thought he looked rather sad and vulnerable. A month later Sam was able to go home. This was a nervous and difficult time for both parents, who found it hard to relinquish the safety of the hospital. I continued to visit. At night Sam was whim-

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pering and crying without opening his eyes, and tears would stream down his face. His mother was startled at my suggestion that he might be dreaming. I wondered if this had happened in intensive care, but nobody had mentioned it; perhaps he had reason enough to be depressed.

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OBSERVATION AT 30 W E E K S , T H E SMILE AS B A I T This was the third time I had visited them at home. Sam’s mother continued to be very positive about everything which, given his obvious fragility, may have been a necessity to keep her going. Sam was now attached to a long plastic tube that snaked around the room and connected him up to his oxygen cylinder. So far this had been the most stable item in his life! It looked like an umbilical cord. This time I observed Sam using a social smile to get the sort of results that spiral into secure attachment. He made eye contact with me from the safety of his mother’s arms and smiled twice, and then looked away to fix on a brightly coloured toy. This was something he often did; his mother saw it as his preferred way of taking things in since, trapped in his intensive care perspex cot, he had, she thought, only really explored his environment visually for the bulk of his life so far. I wondered (to myself) if this was Sam’s way of avoiding a stimulus overload. Sam was being held in a standing position with his back against his mother‘s body as she talked to me. This seemed to support him, and he did not appear bothered by the oxygen tube stuck to his cheeks and up his nostrils. His head control was good, and as we talked he alternately looked at me and twisted around to gaze at his mother. He then made what I could only see as a bid to catch her attention by repeatedly smiling at her; and eventually his mother laughed and commented that this was a new trick, and was he fed up with her talking to this man and not to him? Sam squeaked and waved his arms around at this success.

O B S E R V A T I O N AT 3 8 W E E K S , T H E S M I L E

AS A SWAPPING OF JOY Sam’s weight gain continued to be low and this was a great worry for his mother. When I arrived she was feeding him with a bottle, he was

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lying across her thighs with his head cradled in her left hand. I suggested that she tried to give him maximum body contact every time she fed him. She did this and on a later visit said that it had helped. When I came in, I said hello from about 12 feet away and Sam tracked me across the room and then made eye contact. He looked solemn, but showed no anxiety. His mother interacted with Sam all the time she was talking to me, and he did not g& fussy at this new rhythm of attention. There was a lot of eye contact between them, and he turned to gaze at me again. I thought he was slightly floppy, but he waved his arms and legs around and made what looked like a positive grab for his mother‘s hair. This seemed to be part of a regular game between them. This playful mood continued and built up to Sam smiling as a broadcast of delight which entranced his mother and enveloped them both. After Sam had finished feeding he gave an enormous burp which his mother laughed at. She turned him around, supporting his head with her left hand and body with her right hand, so he was looking directly into her face from a distance of about one foot. Sam suddenly giggled at her. His mother reciprocated this instantly and Sam giggled again. This rapidly developed into a dialogue with Sam positively chortling and waving his arms around in glee and excitement. The exchange went on for nearly two minutes before Sam tired. His mother did not press it, and turned him around to give him a cuddle facing away from her; as if sensing that he needed a break after such an intensive experience. His mother then commented that this was the first time he had ever behaved like this and she seemed extremely pleased.

DEVELOPMENTAL ISSUES, A N A S I D E These three observations are an operational example of the ‘primary intersubjectivity’ described by Trevarthen (1 980) as the interpersonal activity of mutual adaptation to the other that goes on between infant and mother. This is powered by the built-in motivation to search for and maintain physical, emotional and mental closeness with the caregiver. Stern (1985) has elaborated on this, describing how the infant comes to develop a reciprocal relationship with a ‘self-regulating other‘ where such experiences as arousal and affect intensity depend upon the mother’s engagement. However, the first two examples (and the third if the 18 weeks of prematurity are subtracted) that I have given are prior to the seven-month watershed that Stern says marks the entry into ‘the

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domain of intersubjective relatedness’ (ibid.: 124); and so I am more inclined to go along with Trevarthen’s (1993: 73) assertion that dating intersubjectivity to the second six months of life is artificial: ‘A rich palate of emotions is there in the less-than-3-month-old, and is used in immediate regulation of interpersonal contact’. As he wrote earlier (1982: 78), ‘Only the mind of another person can be affected by a smile. To smile effectively, an infant must understand other persons.’ When I watched Sam net his mother with a smile these three times it was impossible not to feel that both had sensed ‘that an empathic process bridging two minds had been created (Stern, 1985: 126), although this may not have been intersubjectivity in Stern’s sense where an awareness of another’s capacity for thought and empathy, a theory of mind, is part of the definition.

DISCUSSION Each time Sam generated one of the special smiles he was being held by his mother, who was talking to me. But I was obviously not the only person around who poached her attention. My presence enabled his mother to focus simultaneously on Sam but away from him. This is the paradox of the interested observer, something that can happen only in the presence of a third person who is an involved outsider. Also, if you can think with someone else whose thoughts you may find different and interesting it encourages you to think for yourself. Perhaps Sam, in such a situation, could feel safe enough to take a risk. Containment here is the sense that somebody else has an understanding of experiences you know of but not about; someone who is seen to have a mostly reliable ability to give meaning to what goes on and thus protect you from muddle - a sort of mental bodyguard. Smiling is a programmed physiological ability, and this gives it an evolutionary significance which points to its importance as a signal which leads to an averagely predictable response. To continue in the same vein and use words like bonding, attachment and caregiving system seems relatively joyless. The important point is that a smile implies that someone is there to see it. And more than that, there is someone who has been wanting to see it. Space is necessary for smiling, one that has infant and mother at opposite sides of its boundary, and this distance is inherently a contained one which can be easily crossed. The smile is a form of irresistible visual reciprocity, almost invariably accompanied by the mother’s vocalization. There is more otherness in

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this than, say, the neonate’s rooting behaviour which signifies the search for a breast that must be present, where we have the hypothesis that there is a fantasy of possession. A baby’s smile demands response, it is the power of nake expectation - just try taking one shopping to see how few adults can avoid smiling back. Or, conversely, there is the ‘still face’ experiment which shows the baby’s distress and defence if lively responses from the mother are not forthcoming. There seems to be an anticipation that the person you smile at thinks, and shows, that you are worth looking at and responding to. In a way that we can never recapture, babies are intensely sensitive to subliminal body messages, such as grip, posture, muscle and voice tone, movement and smell. Sam’s mother was usually, and with good reason, worried stiff about him and about her own ability to give him the care he needed. This must have been transmitted on all channels. Perhaps just his mother speaking to me about him, knowing that I could attempt to appreciate how it felt for each of them, enabled Sam to go for the chance to draw them both together. The gift of containment is coherence. He was reaching out to the holding mother whose holding had just slightly changed. The signals he received which told him the quality of containment was more or less right may have been too subtle for an observer to notice, but (perhaps as a result of being waited for) they were immediately sported by Sam. I like the ambiguity of the word ‘feel’ here; we can just say that for Sam the feeling changed and it felt good - where, on a general level, what we feel is a matter of experiences that touch us, impressions, and an awareness associated with those judgements that may lie behind intuition, empathy and compassion. In my three examples Sam perhaps was more contained for the moments when his mother could feel that her own anxieties were being held by someone else. From this safe vantage he could then reach out to the object. A baby’s development is a bit like rock climbing: if you are safely belayed on it is easier to take risks, you get there faster and generally fall off less!

CONCLUSION Early smiling seems to confirm that from the very beginning there is an ability to appreciate the presence of the mother as an other; it is a cheerful signal of being (a) content. The smile implies the comfortable distance of a separate, responsive and important person whose

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behaviour is open to influence; the baby can be an agent, initiating changes that pay off. For this to occur conditions must be right so that it somehow feels safe or that there is a likelihood of success. Failure is not much fun. Perhaps babies are able to appreciate when the space that a smile bridges is not too great and not too precarious.

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POSTSCRIPT When I last saw Sam he was 20 months old. At the age of one year he had come off his oxygen supply, but as weight gain was slow he had, first, a nasal-gastric tube and then one directly to the stomach. He was making pre-speech noises. He had begun to walk a month earlier, which coincided with dropping food, nightmares and not wanting to let his mother out of sight. Perhaps because he really had needed the continuous presence of an extraordinary devoted mother, absences have become a problem. He has yet to find a transitional object.

Child & Adolescent Service Cleeve House, Horton Road Gloucester

REFERENCES Stern, D. (1985) The Inteprsonal World of the Infnt. New York: Basic Books. Trevarthen, C. (1980) ‘The foundations of intersubjectivity: development of interpersonal and co-operative understanding in infants’. In Olsen, D.R. (ed.) The Social Foundztions of Language and Thought. New York: Norton, pp. 31642. Trevarthen, C. (1 982) ‘The primary motives for co-operative understanding. In Buttenvorth, C. and Light, I? (eds) Social Cognition: Studies in the Development of Understanding. Brighton: Harvester. Trevarthen, C. (1993) ‘The functions of emotions in early infant communications and development’. In Nadel, J. and Camaioni, L. (eds) New Perspectives in Early Communicative Development. London: Routledge.

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