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'The bodies and minds of babies in relationship': psychoanalytic contributions to Johannesburg's first infant mental health conference.

There is a growing pressure in South Africa, and internationally, to provide evidence-based, cost-effective and culturally-appropriate therapeutic interventions. It was therefore encouraging to see that many of the presentations at Johannesburg's first ever Infant Mental Health conference demonstrated the utility of psychoanalytically-informed parent-infant work within the South African context. The conference took place on the 30th and 31st of October 2015. It was co-hosted by the Gauteng Association for Infant Mental Health (GAIMH-SA), the University of Witwatersrand's School of Human and Community Development and the DST-NRF Centre of Excellence in Human Development. The conference aimed to raise awareness around infancy as a sensitive developmental period and to promote early interventions that target perinatal mental health. The interventions presented at the conference represented a range of disciplines, such as paediatrics and neonatology, psychology, psychiatry, occupational therapy, physiotherapy, social work, speech therapy and the NGO sector. The inclusion of the full range of infant mental health workers, from lay counsellors to local and international experts, allowed for a full picture to emerge of the work being done in the South African context. Intimate case studies detailing the very real impact of the trauma of poverty and violence on some South African mothers and babies, were interspersed with sophisticated research reviews and theoretical pieces.

The conference was originally due to be held at the University of the Witwatersrand, but due to student protests it was necessary to move the conference. Ububele's (a Johannesburg NGO) gracious agreement to host the conference at the last minute and their renowned hospitality made the conference not only possible, but a success. As the heart of parent-infant work in Johannesburg, Ububele felt fitting as the venue for the first-ever conference in Johannesburg on this topic.

Neuroscientific, biological, genetic and social science research has unequivocally demonstrated that the period up until the third year of life is foundational in terms of brain development (Mark Tomlinson, Stellenbosch University). It is also now understood that infant development unfolds within a relational context and that the quality of caregiving that an infant receives is instrumental in setting the child on a particular developmental trajectory (Zeanah, 2009). While the developed world has known this for the last twenty years and established a number of early intervention programmes to support parents and facilitate positive development in their youth, the developing world has had a justifiable need to focus on issues of infant mortality and HIV. This has meant that much of the work done in the field of infant mental health in these settings, including in South Africa, has been initiated through university and NGO channels.

While the conference was largely multidisciplinary, psychoanalytically-informed contributions featured prominently. While Alessandra Pontelli (University of Milan) was sadly unable to travel at the last minute, her presentation was conducted via 'voice over powerpoint' and her lively sense of humour and fascinating visual material made up for lack of presence. She mentioned the old critique around psychoanalytic theory's tendency to 'adultomorphise' infants, however, this critique felt unfounded at this conference. The offerings from psychoanalytic therapists and researchers were highly relevant and often surprisingly practical. This trend began with Alessandra Piontelli's opening plenary, in which she gave a thought-provoking account of 'foetal myths'. Due to the fact that the prenatal phase is the developmental period in which we have the least access to researching the experience of the infant, foetal experience is prone to idealisation, projection and myth. Piontelli challenged a number of popular notions about foetal life and emphasised that our knowledge of foetal experience is still, at best, very uncertain. This captured the daunting, yet exciting fact that this field is new and that there is still much to be discovered.

Other psychoanalytically-informed presentations covered a range of topics: from understanding disability from the perspectives of mothers, the roles of fathers, the roles of nannies, the benefits of infant observation for professionals, to intervention in parent-infant relationships. These included more traditional parent-infant psychotherapies and a variety of creative community interventions. It was clear that psychoanalytic thinking has an important role to play in the growing field of infant mental health. Presentations offered poignant conceptualisations of the internal, emotional experiences of parents and infants within contexts of disability, poverty and trauma, thought-provoking commentary on broader social trends within the field, and highlighted on-going work in South African communities that is culturally-sensitive and contextually-responsive.

In relation to disability, sophisticated accounts of the subjective experiences of mothers of infants with disabilities were presented. Clare Harvey (University of the Witwatersrand), highlighted the 'deficit assumptions and apparent splits in the existing literature on mothers' experiences of raising a disabled child'. She highlighted how mothers of disabled children are 'forced to confront and tolerate their own preconceived notions and uncomfortable feelings of disability that they have introjected from society's deficit view of disability', leaving them with intense feelings of shame and guilt. These mothers have to tolerate society's projections toward the disavowed aspects of disability and mourn the loss of their fantasised ideal object, the non-disabled baby. To manage this complex and painful experience, she found that mothers engage in a number of defensive processes, including 'part-object relating (splitting), minimisation, denial, as well as engaging in compensatory and reparative impulses in order to manage the intense emotions of this mothering experience'. Lisa Saville-Young and Jessie Berry's (Rhodes University) paper took a psychosocial approach to the topic of maternal subjectivity in the context of infant disability. Their critique of the disability literature highlighted its tendency to 'either emphasize the social at the risk of emptying out the subjectivity of mothers and their disabled infants, or emphasize the relational and individual capacities of caregiver-infant relationships, at the risk of ignoring the broader social context which provides the conditions for this relationship'. They demonstrated how a psychosocial approach to investigating the experiences of these mothers can avoid this social-psychological dualism when researching caregivers and their disabled infants. They emphasised an approach that 'draws attention to the affective processes rooted in the particular intersubjective exchange ('here and now') of the interview and the particular socio-historical context ('there and then') in which the mothers and researcher are located'. They demonstrated the 'inextricability of the personal and the social' and how both these processes interact with the mentalizing capacities of both the mothers and the researcher. They reminded us all to 'remain committed to challenging disabling ways of robbing mothers of disabled infants of the complexity and locatedness of their maternal subjectivity'.

The increasing homogenisation of the field of infant development is a recent concern in the literature, with the notion of the 'global child' being critiqued (Pence & Nsamaneng, 2008). Taking a critical approach to sources of knowledge, Gillian Mooney (University of the Witwatersrand) conducted a meta-analysis of the journal Developmental Psychology, from the year 2000 to the present, and found that the focus in the developmental psychology literature remains on the experiences of white, middle-class American children and their mothers, with very little on fathers noted. The conference did not follow this trend, however, and the roles of fathers were tackled from a number of perspectives, from the theoretical to the applied. The marginalisation of fathers in the literature is an interesting phenomenon. Locally, high rates of 'father absenteeism' have been addressed in the literature in the past decade (Magruder, 2010; Posel & Devey, 2006; Richter & Morrell, 2006), and have been linked to historical disruptions in family systems that have left men bereft of their roles as providers and protectors. However, Tessa Baradon's (Anna Freud Centre, London) paper asked some pertinent questions with regards to the marginalisation of fathers, both in the practice of parent-infant psychotherapy and within much of psychoanalytic theory, where fathers are positioned as a support to the mother and infant, rather than as subject, with a relationship with their infants in their own right. She asked some questions that deserve some professional self-reflection, about the roles that clinicians play in the exclusion of fathers. While having a fourth person in the room for parent-infant psychotherapy practically is more difficult, the presence of the father also brings up further opportunities for therapist exclusion, as the sexual nature of the parental couple becomes unavoidable. The gender composition of the helping professions was also raised, and she questioned whether this was another manifestation of the exclusion of men from nurturing spaces. She stressed the need for a paradigm shift that engages fathers and invites them back into the caregiving space.

Taking a different approach, Nick Davies (University of the Witwatersrand) presented a paper on the paternal function (based on a paper co-authored with Gillian Eagle, University of the Witwatersrand), that highlighted the need to understand the paternal function as distinct from the role of the father, in the context of changing constructions of gender and family structure. He offered a critique of 'how the term is used in the literature with attention to what appears to be a pervasive tendency to conflate the paternal function and fathering, as well as to make certain assumptions about a link between the paternal function, maleness and masculinity'. When separated from the notion of fathering, a space is opened up 'to consider alternative sources of paternal functioning and the related importance of the position of third persons or objects in infant development'.

The notion of multiple caregivers is a widespread phenomenon in African settings and the allocation of caregiving duties to non-parental figures is common in many cultures. The role of the 'nanny' is one that has spanned generations, from notions of Victorian governesses, to the current roles of childminders. Nicola Dugmore's (private practice, Cape Town) presentation highlighted that many South African infants are co-reared by nannies, often employed as a domestic worker in the infant's home. She emphasised the lack of research into 'the impact of these caregivers on the infant's early life and development' and on 'the triangulated relationship that develops between infant, mother and nanny'. She presented material from multiple infant observations, offering thoughts on the relationships between infants and their nannies. Judy Davies' (private practice, Cape Town) paper also addressed the issue of substitute care and explored 'how psychoanalysis and the lessons drawn from infant observation can help parents choose appropriate substitute care and carers for their children'. Her presentation included literature on globalised child care, such as Jacklyn Cock's (1988) work, and current research on infants' needs in relation to sensitive caregiving. The links made to psychoanalytic studies, from the work of Jeanne Magagna (1987; 1997), to local psychoanalytic studies (Goldman, 2003; Wulfsohn, 1988), demonstrated the significant utility and application value of psychoanalytic thinking. This was crystallised in her description of her consulting role in the establishment of a Nanny Programme in Cape Town.

Infant observation, as well as being a rich source of research data, as seen in the presentations on nannies, is seen in several countries, as the 'gateway to the study of psychotherapy and other fields of infant and child health'. Lindy Harris (Director: Flying Children) and Lesley Strous (private practice, Johannesburg) presented a paper that explored the experiences of those who have undertaken infant observation in South Africa, in order to 'understand the value of this undertaking for clinical work in the field of mental health'. Although mostly undertaken by already qualified therapists in South Africa, the one to two year observation process, that includes weekly supervision, was found to offer a number of benefits. The process was found to 'take one to the very heart of the infant experience and the sometimes visceral understanding of the many and complex layers that make a human being who they are'. Those who had undertaken infant observation claimed the process had offered opportunities for personal processing that allowed for a deepened understanding of their own reactions and experiences in the therapy room.

The intensity of countertransference reactions, in their broadest sense, in practitioners in relation to parent-infant work also featured more broadly at the conference and was addressed in a number of the presentations on clinical intervention. Louise Emanuel's (Child and Family Department, Tavistock Clinic, London) paper on clinical work with families where the toddler's hatred of his/her new sibling is murderously intense, evoked fairly intense countertransference reactions in the audience, and left some non-psychology professionals outright shocked. Her paper explored 'states of persecutory anxiety, sadism and rage in young children towards a younger sibling--the new baby in the parents' mind'. She explored the technical dilemmas faced when these conflicts are enacted in the therapy room. Using Freud's (1917) description of how 'the shadow of the object falls on the ego', Emmanuel linked these sadistic attacks to the trans-generational transmission of unresolved parental loss and trauma. She also drew on Donald Meltzer's (1968) paper: 'Terror, persecution and dread' to explore her own paralysing countertransference reactions.

Another paper that highlighted the need for thoughtful management of countertransference reactions was one given by Zanele Mokolutlo (NGO sector: Ububele) on her experiences as home visitor to a particular teenage mother. Initially positioning negative countertransference as a potential obstacle to the goals of a home visitor, she presented her ' struggle to maintain a non-judgmental and supportive stance while experiencing her own hard feelings of anger and disappointment towards the mother'. However, her ability to process these difficult feelings in supervision and persevere towards the creation of a 'thinking', supportive space with this mother, in spite of the uncomfortable counter-transference feelings evoked within her, attested to the importance of self-reflective capacities in home visitors and the importance of a supervisory space in which to process inevitable countertransference reactions.

Astrid Berg's (University of Cape Town and Stellenbosch University) plenary presentation also highlighted the importance of reflective practice in clinical work. She emphasised the presence of a number of 'potential barriers, such as language, different world cosmologies, as well as hardships of daily living' that exist in multicultural intervention contexts. She advocated for a stance of inner and out reflectiveness and detailed observation, in order to allow the dynamics of the case to be uncovered and understood. This stance was evident in a number of presentations that considered local contexts, understandings and practices around infancy and child-rearing. Creative interventions that accommodate language and other cultural and contextual factors were presented, such as Ububele's Baby Mat service (Frost, 2012), which is a mat on the floor of (currently seven) Baby Wellness clinics in Alexandra and Hillbrow, staffed by psychologists and trained counsellor/translators. Mothers in the waiting room are invited to bring their infants to sit on the mat to discuss any concerns they may have. The service aims to provide mothers with a space to reflect around their experiences and those of their infants, and functions as an effective short-term intervention, screening and referral service. Nicola Dawson and Jade Richards (Ububele) explained how staff on the Baby Mat adopt 'a non-judgmental stance toward the concerns brought to the mat by the dyad' and that 'the culturally-informed frames of reference' that are brought by mothers are 'neither elevated nor dismissed', but rather engaged with from a wondering and curious stance, which 'helps those who visit the Baby Mat to find symbolic meaning in the presenting problem by exploring the internalised meanings of cultural attributions and reflecting on these'. Their presentation afforded an excellent example of psychodynamic theory's ability to accommodate and integrate cultural meaning systems in order to make sense of a presenting problem.

The Baby Mat presentations by Michelle Nortje, Mamikie Rumo, Oscarina Majokweni and Hayley Haynes-Rolando (Ububele) continued in this vein and highlighted the complex layers of meaning-making involved in cross-cultural interventions that involve multiple cultural, language and racial configurations on the mat. They demonstrated that 'meaning-making is a collaborative process between the caregiver-infant dyad's cultural beliefs and experiences' (Tronick & Beeghly, 2011), 'the bBaby Mat couple's relationship, knowledge and skills' (Nkosi, 2014), as well as the 'additional minds of the multicultural supervision group' (Falender, Burnes, & Ellis, 2013)'. Ideas around contextually-bound and culturally-informed conceptualisations of good-enough mothering were explored and the importance of considering mothering in light of historical racial experiences when intervening was emphasized. The complexities of the navigation of cultural differences was most pronounced in Cora Smith's (University of the Witwatersrand) fascinating account of the ethical dilemmas of attachment and custodial rights in baby swop cases. The immense task of balancing the best interests of the children and their respective parents in this case, was complicated by various parental cultural beliefs. A thoughtful account of the process of differentiating between 'valid' beliefs and those manufactured for the purpose of manipulating legal outcomes was addressed. Also, importantly, the court's finding that the children's attachment needs (for their psychological parents) required prioritising over the parents' constitutional rights for control over their biological offspring, is an important recognition of children's needs for consistent, on-going relationships to caregivers.

The need for consistent, ongoing caregiver-infant relationships was also highlighted in Jade Richards and Nicola Dawson's (Ububele) presentation entitled: 'Reflecting on the ghosts in babies' homes'. The importance of supporting the mental health of the primary caregivers of infants often neglects to include caregivers of infants that work in shelters for abandoned infants. Their work with caregivers from shelters in parent-infant psychotherapies encourages thoughtful reflection around the infant's experiences, traumas and individuality, in addition to the influences of the caregiver's own attachment history on the relationship. With high numbers of children in care, the promotion of attunement and reflective function in Child Care workers in shelters is another example of how psychoanalytically-informed interventions can be contextually responsive and preventative.

Presentations on the Ububele Mother Baby Home Visiting Programme by the home visitors themselves (local women from Alexandra Township trained as mother-baby home visitors) also provided compelling evidence with regards to the utility of psychodynamic understandings when intervening in parent-infant relationships compromised by current and historical trauma. Makhosazana Sithole's (Ububele) presentation told the story of a mother initially surprised by the intensity of her emotions associated with a past trauma and who managed to process her experiences within the mother-home visitor relationship. Her increased awareness of the effects of her pain allowed for an increased sense of coping and an improved relationship with her baby. Mireille Landman's (Parent Centre, Cape Town) paper on the successes, challenges and lessons learned from 20 years of running a community-based parent-infant home visiting attachment intervention in Cape Town, Thula Sana, provided a hopeful, yet realistic overview of community-based interventions. Her account of emotionally taxing, yet essential work with mothers and infants living in contexts of poverty, substance abuse and trauma, being done by underpaid lay counsellors, who are supported by supervisory staff burdened by funding uncertainties, provided a glimpse into the difficulties faced by these organisations. In the current financial climate, it is concerning that much of the early intervention in South Africa is carried by NGOs who function under tenuous financial circumstances.

However, there were presentations by public hospital staff that indicated a growing recognition of the need for infant mental health services in this sector. Helen Clarke's (Head: Child and Adolescent Psychiatry, Baragwanath Hospital, WITS) presentation emphasised the 0-3 age period in the formation of neurodevelopmental trajectories. She highlighted epigenetic risk factors that surround children from third world settings and the effects of deprivation on parenting. She highlighted a common tendency toward an external caregiver locus of control in parents presenting with their young children at Baragwanath. She explained how this tends to place the focus on the child as the problem, as opposed to the child-caregiver relationship, increasing the demand for a child based intervention. She supported the need for interventions that focus on the parent-infant relationship and announced the establishment of a 0-3 clinic at Baragwanth Child Psychiatry Unit from 2016.

Due to the complexity of the confluence of biopsychosocial influences on development, the importance of transdisciplinary treatment was emphasised throughout the conference. Janice Cowley (Occupational Therapist, Gauteng DOH), Bianca Veira (Speech and Hearing Therapist, Gauteng DOH) and Melanie Esterhuizen (Psychologist, Gauteng DOH) gave an inspiring presentation that described the development of an early intervention multidisciplinary team at South Rand Hospital. The team comprises Speech Therapy and Audiology, Occupational Therapy, Psychology, Physiotherapy and Dietetics. Monthly clinics allow for infants and caregivers to receive a number of treatments in the same visit, and the shared space and effective communication between disciplines allows for easy cross-referrals. Their case study of a disabled child with feeding difficulties highlighted how the various disciplines can complement and assist each other. Psychological intervention allowed for increased containment of the mother and infant and an increased sensitivity towards the child's experiences, which then allowed for specialised feeding education for the dyad. Overall, the service was shown to minimise travel costs for patients, improve service delivery and outcomes, to empower parents, and to provide cross-discipline learning for professionals. Again, this was a wonderful example of how creative integration of psychodynamic interventions into already existing services can enhance outcomes for patients.

Finally, Mark Tomlinson's (University of Stellenbosch) plenary presentation highlighted the need for further research into early intervention, particularly in order to determine more clearly who benefits from what kind of early intervention, and why, in order to streamline types and costs of interventions. Going forward, in order for the field of infant mental health to continue to grow and gain space on the agendas of developing countries, interventions need to take into account the harsh realities of limited government funding. The needs for basic healthcare already far outweigh government's capacities to meet them. Thus, the responsibility falls onto communities, NGOs and the professions themselves to find practical solutions.

This conference showcased a number of excellent examples of psychoanalytically-informed interventions being used in culturally appropriate and context-relevant ways. The challenge is to continue to demonstrate their utility and relevance. Presenters were encouraged to publish their work in order to keep infant mental health in the spotlight and in order to contribute to the building of a local evidence base. Zanele Twala, the Director and Sector Expert on Early Child Development in the Department of Planning, Monitoring and Evaluation in the Presidency, who gave the conference opening address, emphasized the importance of local research in order to direct and inform future policy in the departments of Health and Social Development. The conference closed with a call to action and in particular, for more collaboration between private, public and NGO sectors.

GAIMH-SA is an affiliate of the World Association for Infant Mental Health (WAIMH). WAIMH promotes education, research and study of the effects of mental, emotional and social development during infancy on later normal and psychopathological development through international and interdisciplinary co-operation, publications, affiliate associations, and through regional and biennial congresses devoted to scientific, educational and clinical work with infants and their caregivers. For more information, please visit the GAIMH-SA website at www.gaimh.co.za.

Katherine Bain

University of the Witwatersrand

References

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Falender, C. A., Burnes, T. R., & Ellis, M. V. (2013). Multicultural clinical supervision and benchmarks: Empirical support informing practice and supervisor training. The Counseling Psychologist, 41(1), 8-27.

Freud, S. (1917). Mourning and melancholia. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 14, pp. 237-258). London: Hogarth Press.

Frost, K. (2012). The Ububele Baby Mat Project: A community-based parent-infant intervention at primary health care clinics in Alexandra Township, Johannesburg. South African Journal of Psychology, 42(4), 608-616.

Goldman, S. (2003). White boyhood under Apartheid: The experience of being looked after by a Black nanny (Doctoral dissertation). University of Pretoria, Pretoria.

Magagna, J. (1987). Three years of infant observation with Mrs. Bick. Journal of Child Psychotherapy, 13(1), 19-39.

Magagna, J. (1997). Shared unconscious and conscious perceptions in the nanny-parent interaction which affect the emotional development of the infant. In S. Reid (Ed.), Developments in infant observatioln: The Tavistock Model (pp. 33-56). London: Routledge.

Magruder, J. R. (2010). Intergenerational networks, unemployment, and persistent inequality in South Africa. American Economic Journal: Applied Economics, 2(1), 62-85.

Meltzer, D. (1968). Terror, persecution, dread: A dissection of paranoid anxieties. The International Journal of Psychoanalysis, 49, 396-400.

Nkosi, N. S. (2014). The Baby Mat Project: Similarities and differences between the experiences and perceptions of mothers and therapists (Doctoral dissertation). University of the Witwatersrand, Johannesburg.

Pence, A., & Nsamenang, B. (2008). A case for early childhood development in Sub-Saharan Africa. Working papers in early childhood development, No. 51. Bernard van Leer Foundation. PO Box 82334, 2508 EH, The Hague, The Netherlands.

Posel, D., & Devey, R. (2006). The demographics of fathers in South Africa: An analysis of survey data, 1993-2002. Baba: men and fatherhood in South Africa, 38-52.

Richter, L. M., & Morrell, R. (Eds.). (2006). Baba: men and fatherhood in South Africa (pp. 155-172). Cape Town: HSRC Press.

Tronick, E., & Beeghly, M. (2011). Infants' meaning-making and the development of mental health problems. American Psychologist, 66(2), 107-119.

Wulfsohn, D. R. (1988). The impact of the South African nanny on the young child (Doctoral dissertation). University of South Africa, Pretoria.

Zeanah, C. H. (Ed.). (2009). Handbook of infant mental health. New York: Guilford Press.

Katherine Bain has a PhD from the University of Pretoria and works as a psychotherapist, researcher and senior lecturer at the University of the Witwatersrand. She teaches on the Clinical Psychology Masters and PhD by Publications programmes. Her interests are predominantly in the fields of psychoanalytic theory and infant mental health. Katherine.Bain@wits.ac.za
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Author:Bain, Katherine
Publication:Psycho-analytic Psychotherapy in South Africa
Article Type:Report
Geographic Code:6SOUT
Date:Dec 22, 2015
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