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The therapeutic team

The team of therapists that carries out these home-based treatments consists of six specialist paediatric nurses (puericultrices). In addition to their basic training these nurses have also had the benefit of a two year training in Infant Observation as developed by Esther Bick. Some, but not all, have also undertaken some personal psychotherapy. I shall begin by describing their work setting, then I shall endeavour to illustrate the impact that the training in Infant Observation has had upon the work of these therapists.

The work setting

Each therapist sees five or six children for either one or two sessions per week. Towards the end of a treatment these sessions may often be reduced to one per fortnight. The setting for each of them is precisely the same as for observations carried out during training: one hour of close attention in a state of mind that is open and receptive to all that might be expressed by those family members present, whether verbally or non-verbally.

Very soon after the treatment session, the therapist makes detailed notes of all that he has observed and heard during the session. These notes are then discussed in a meeting that takes place three times per week, for two hours, between the therapy team and a number of psychoanalytically trained psychiatrists or psychologists. The aim of these meetings is to think through the significance of the material that has been collected. Included in the material to be discussed are the reactions of the therapists during the course of the session. At times the therapists experience extremely powerful feelings, even to the extent of somatic responses (feelings of nausea, headaches, dizziness ...), which are linked to the projections targeted at them. It is of vital importance to consider the reactions that have been prompted and which are, very often, of profound significance.

In parallel with these home-based observations, parents are required to meet regularly with a consultant, usually on a monthly basis. The aim of these meetings is to follow the child's development, to help the parents, as far as possible, to extend their thinking and to respond to any questions that parents may raise, for instance concerning the child's treatment. In cases of especially severe psychopathology, individual psychotherapy for the child is advised from the time of their second birthday; this is particularly the case for autistic and psychotic children.

In training in Infant Observation I lay great stress on the importance of developing the capacity for receptivity to its fullest extent. I believe that one of the values of Esther Bick's method, amongst others, is that of focusing the observer's efforts on all aspects of their mental receptivity. Three of these aspects may be distinguished:

i. receptivity at the perceptual level involving all that can be objectively noted about the conduct of the child and those nearby (gestures, imitation, changes in muscle tone, vocalisations, etc.);

ii. emotional and empathic receptivity, which allows the observer to experience within him or herself whatever the infant or those around him may be experiencing;

iii. unconscious receptivity, which manifests itself in the counter-transference through feelings, representations, ideas, even physical manifestations, which at the time may appear devoid of meaning, but which on closer analysis prove to be full of significance.

Of the three, it is undoubtedly the last which is the most difficult to acquire. I believe that the method devised by Esther Bick offers a particularly valuable way to gain, or at least to begin to develop, this capacity. I shall consider all three aspects in order.

At the perceptual level we are concerned with everything that can be either seen or heard. This is without doubt an important part of the technique devised by Esther Bick, who always insisted upon the importance of paying close attention, free of preconceptions, to all that could be observed of the baby or of the interactions between the baby and the carers. The therapists in my team quickly took to this demanding discipline, the more easily, no doubt, because their initial specialist paediatric training had prepared them well for this task. Without in any way wishing to detract from the importance of this aspect of mental receptivity, I should like to emphasise the need to beware of reducing infant observation to this aspect alone, and the attendant risk of making of it a reductionist method that restricts the psychic life of the baby to that which is objectifiable.

The second aspect, the empathic perception of the communications being conveyed by the infant and their carers, undoubtedly requires long experience, carefully developed with the help of a seminar group. The major obstacle that I have encountered in helping therapists to develop their empathic capacities has been a certain lack of self-confidence, not to say an excessive modesty in admitting to one's own feelings, something that is scarcely allowed in the training of those in the caring professions in France. I have to say, however, that the therapists took to this quite quickly, and indeed with some relief: finally they were able to take full account of the whole of their experience in situations involving relationships in which they were professionally engaged; no longer did they have to block out the whole subjective dimension of that experience. However some obstacles remain that are more or less difficult to surmount. These concern particularly those feelings that are tinged with erotism, anything relating to seduction or to those loving feelings that are the most difficult to express and to discuss. This may involve to some extent the relationship with the infant, particularly in the Oedipal phase. However it involves much more the relationship between the adults and especially those situations where a female therapist is conducting the therapeutic observation in the father's presence and with the mother absent.

The third aspect, that of unconscious receptivity, is undoubtedly the most difficult to exercise and to sustain. It is this aspect which, to my mind, Esther Bick's method helps to develop in a specific way. This requires tolerating having an experience of situations that may at times be extremely painful, anguished, irritating, depressing without having an understanding of them and without foreclosing them by a move into action (leaving early, giving advice, opinions, judgements etc.). This links with the concept of "negative capability" that Bion (1970) took from Keats to describe the state of mind necessary for mental creativity: tolerating non-sense and chaos until some sense of meaning begins to emerge. It is often only after the event that the therapist, with the help of the supervision group, can begin to gain a sense of the latent meaning of that which was being projected into him or her and which, at the time, led to them having to experience a situation at the limit of what was tolerable. It is not unusual for therapists to leave a session with a huge sense of dissatisfaction, anger, anxiety, even physical symptoms (the headaches etc. mentioned above). I should like to illustrate this point with some material from the treatment of a child who had neither autistic nor psychotic symptoms, but did show severe functional disorders in the context of a very depressed emotional climate compounded by major somatic difficulties.

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