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We would like to say thank you to all the members of the Association who contributed to the organisation of this successful event.
Our greatest thanks go to Nikki and Art. They were ideal partners in integrating two different ways of caring for children and adolescents in their work. Fortunately for those of us who attended on the day they were also able to convey this integrated way of working and engaged in a lively dialogue with the audience.
Nikki and Art work in the Child and Adolescent Mental Health Service (CAMHS) in Runcorn. Nikki is a qualified Child Psychotherapist, trained at the Tavistock in London and the Northern School in Leeds. Art has worked for the Five Boroughs Partnership Foundation NHS Trust as a consultant infant child and adolescent psychiatrist since 2004 and became accredited as an EMDR consultant in 2008. He has presented widely in the fields of trauma, the developing brain, attachment disorders, personality disorders, emotional dysregulation in ADHD and ASD diagnosis and management.
Nikki opened the day, literally at the beginning. She summarised research which showed, that from their time in the womb babies have particular ways of relating. Soon after birth they engage in interaction with the other people in their lives, particularly their primary carer.
She has trained in infant observation using techniques based on Esther Bick’s work at the Tavistock Institute. She will ask herself what it is like being this infant right now in this family, and attend to the baby’s relating in a very alive way. The observer can get a sense of the baby’s disturbance which we would normally be defended against.
Her psychotherapy training is based on psychoanalysis. Important aspects of the psychoanalytic tradition are :
Sigmund Freud believed that our memories stay with us, possibly not as conscious memories but within our bodies. He emphasised the tension between the life and death wish. Melanie Klein built on the ideas of life and death wishes and emphasised the unconscious splitting of love and hate which slowly become integrated during the process of infant development, although this is never fixed, but fluctuates throughout life. The British Object Relations School believed that relating between child and mother is present from birth. From the point of view of the neuroscience which Art later developed further, this is the emotional and preverbal, and literally unconscious, relating of right brain to right brain. Wilfred Bion developed Freud’s idea of repression into the powerful processes of knowing and not knowing. When thoughts are unthinkable they can become ‘acted out’ rather than modified through thought and words. When acted out, they can result in destructive and sometimes dangerous actions. He also suggested that babies are born with relational pre concepts, particularly the pre-concept of the nipple in the mouth which is then realised and becomes a concept during the experience of feeding. Nikki also presented ideas explored in psychoanalytic literature about the ‘absent object’, frustrations aroused by the absent breast, initially experienced as a ‘bad thing present’ (feelings of hunger), before it can be experienced as a ‘good thing missing’.
Donald Meltzer had ideas of different bodily areas of experiencing including intellectualisation that distances us from real emotional contact and painful awareness.
These psychoanalytic concepts were established decades before the findings of modern neuroscience. Art based his talk on the findings of the Dr. Allan Schore of the clinical faculty of the Department of Psychiatry and Biobehavioral Sciences, UCLA. He is the author of three seminal volumes, Affect Regulation and the Origin of the Self, Affect Dysregulation and Disorders of the Self and Affect Regulation and the Repair of the Self. His groundbreaking integration of neuroscience with attachment theory has lead to his description as "the American Bowlby.” Art talked about the evolution of the brain. The earliest part of the brain to develop was the reptilian brain, which is part of the brain stem and the right side of the brain. This deals with survival, fight and flight and the emotional functions and imagery. This was followed, around a hundred thousand years ago, by the mammalian brain. This is the left part of the brain that is involved with functions of language and rationality. The right side is activated by stress and responds faster than the left side of the brain (forty milliseconds as against five hundred milliseconds.) The right side may not then link laterally to the left side of the brain. The physiological link between the two parts of the brain is the corpus collosum. This link only starts to develop after the first six months of life, when babies start to crawl, and continues to develop up to the age of twenty five. The fastest growth of the brain is in the first two to three years.
Babies have predetermined knowledge of proto dialogue. They have a tacit understanding of how to get the attention of others, through eye to eye contact and tactile and bodily gestures. Shore believes that this attuned interaction between mother and baby fosters this development and the child’s capacity for emotional regulation and empathy. The process integrates the right side functions of reverie and processing unconscious information with the left brain processes of analysing information.
Highly stressed parents tend to block this development and this leads to attachment disorders. For example mothers suffering from schizophrenia are significantly unresponsive to their children and it has been estimated that mothers with borderline personality disorder are stuck at a two year old stage of processing information. It is possible for extreme neglect to lead to shrunken brains. However, and more optimistically, these deficient neural connections can be replaced by other connections and therapy can contribute to this.
The Watch Wait and Wonder approach (WWW) is very helpful to parents and can rapidly improve the mental health of infants. Mothers are offered between eight and eighteen weekly one hour sessions. The therapist helps the mother follow her child in its activities and be guided by what the baby wants. This can run counter to the mother’s usual behaviour of getting angry, throwing things or ignoring or leaving her child. Parent and child become more able to play together. Most mothers will have had some trauma in their lives. Art and his colleagues offer brief trauma focused work, eye movement desensitisation and reprocessing (EMDR) and various techniques which help processing between the right and left cortex of the brain. Art also gave a number of examples where his awareness of the link between emotional trauma and physiology meant that he was able to notice patient’s physical movements which then gave non-verbal clues to the otherwise unconscious memories of trauma. All these techniques help the mother and child to bond.
Nikki followed an established psychoanalytic psychotherapy training, and now works with colleagues, families or with children and young people individually; providing a brief intervention or a longer term therapy. What this day showed was that the established psychoanalytic concepts and techniques she used are often supported by modern developments in neuroscience. So they are ideal partners rather than reluctant bedfellows.
To put this in the scientific language of Allan Schore: “Psychoanalysis, the scientific study of the unconscious mind, is forging deeper connections with the other sciences in order to generate clinical models of psychic structural systems that are compatible with what is now known about biological structures as they exist in nature. In particular, neuroscientists are becoming intensely interested in the domain of implicit, non conscious processes. Neuro imaging technologies, that study brain functions as they operate in real time, processes so rapid that they occur in time frames beneath conscious awareness are providing data directly relevant to current psychoanalytic explorations of implicit processes.”
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