Description of a Relationship Focused Mother-Infant Group Program: Mother-Baby Nurture

Abstract

Mother-Baby Nurture is an innovative group program that focusses on strengthening the mother-infant relationship through enhancing reflective capacity within mothers and their infants. We describe the unique combination of the features that are central to this program and present comparisons with other early parenting interventions. Infancy is a unique period of acute developmental vulnerability and dependence on a caregiver. As the caregiver is the critical regulator between infant and their environment, disturbances in the caregiver-infant relationship have heightened potential to interfere in the infant’s developmental trajectory and lifelong wellbeing. Mother-Baby Nurture is a 10-week targeted group program that is currently being implemented in Western Australia, for infants and their mothers experiencing relational or emotional distress. This program provides an emotionally containing space for a mother and her infant to explore mental states. We foster curiosity in the thoughts, feelings, and behaviour (of the baby, the mother, and others), as well as reflection on attachment relationships (past and present). This therapeutic approach shares common ground with parent-infant psychotherapy and mentalization-based treatment, and is informed by attachment theory and the neurobiological science of infant development.

1. Introduction

Early infancy, more than any other time in the human lifecycle, is a time of unprecedented developmental capacity and vulnerability. During this time, experiences powerfully influence brain architecture and subsequently provide the foundation for all future learning [1, 2]. Adverse early experiences during the formative months of infancy, if not addressed, can have lifelong consequences for the developing person [3] and can be transmitted the next generation [4]. A critical experience during infancy is the relationship with caregivers, and for most infants the relationship with their mother is particularly influential.

In 1940, Winnicott declared “there is no such thing as an infant [on his or her own]”, the infant exists “as a unit” in relationship with a caregiver [5]. Bowlby [6] described how ideally, the caregiver-infant relationship provides the infant with a secure base from which they can explore the world and return to have their needs met. A central means by which a parent influences the security of their relationship with their child is the capacity of mentalizing [7]; also referred to as reflective functioning [8]. Parental mentalizing helps the infant to make sense of their ‘self’ and their external world, as the caregiver provides a conduit for sharing, understanding, and regulating internal mental states including thoughts, feelings, longings, and desires. The capacity to mentalize and provide this secure base for the infant may be distorted or enabled by the caregiver’s organisation of their own past childhood experiences of their caregivers, that informs their internal working model [9]. The transmission of secure infant-caregiver attachment across the generations provides the context for optimal psychological, social and emotional development of the infant, and is predictive of future social-emotional and cognitive functioning throughout the early years and into adulthood [10, 11]. This premise, that social, emotional and cognitive development during infancy occurs within the context of the infant-caregiver relationship, is an anchor point for the field of infant mental health [12], psychodynamic early intervention [13], and the central rationale behind Mother-Baby Nurture (MBN).

We provide a description of the MBN program and the nuanced role of the group facilitators. Following this is a discussion of the key distinguishing concepts at the heart of MBN: the importance of early relational experiences, infant as participant, the group as a containing space, and enhancing mentalizing [14]. The outcomes anticipated for the mother and for the infant are reflected upon. In this discussion paper, caregivers are described as ‘she’, and for ease of reading, infants will be described as ‘he’.

2. Description of Mother-Baby Nurture program

Mother-Baby Nurture is a brief reflective group program for mothers and their infants (0–6 months of age) facilitated by two infant mental health clinicians over a 10-week duration in a community setting. Weekly 2-hour sessions take place with the facilitators and six mothers forming the outer circle, with babies held in mother’s arms or within reach on baby rugs in the circle centre. It is an experiential group, where the pace is slow and spacious, and responsive to the felt needs of the babies and their mothers. Together, we agree on group guidelines to help create a safe space, where mothers and babies are invited to take time getting to know one another. There are predictable weekly rituals that invite curiosity, observation, and reflection. These include the mother-baby check-in, watch-with-wonder, infant observation time, nursery rhymes, and the use of imagery, metaphors, poetry, and music. The rituals are offered as gentle entry points for reflective discussion. Dedicated attachment-relationship themes are introduced and explored in an effort to bring to mind past and present patterns of relating. Reflecting on mother-infant interaction helps to illuminate patterns of relating that may not have been previously noticed or thought about. Throughout the group, the infants’ communications are welcomed, held in mind, and responded to, which significantly shapes the content and pace of the group process.

The primary intervention aim of MBN is to strengthen the mother-infant relationship. A central strategy to improve the relationship and infant outcomes is to foster and strengthen the mother’s mentalizing capacity. A secondary strategy of the program is the reduction of symptoms of maternal postnatal depression and anxiety as well improving the mothers’ parenting confidence and feelings of attachment with their infant [15].

We acknowledge that every family exists within the context of broader caregiving systems, with unique family, community and cultural expectations and structures [16]. Issues highlighted in the mother-infant relationship may also be relevant to father-infant relationships or other caregivers and family system level relationships [17, 18], although these dynamics are beyond the scope of this paper. In response to community demand, this program has been adapted for the unique needs of Aboriginal, culturally and linguistically diverse as well as adolescent mothers and their families. Presently, MBN is provided at ten locations across Western Australia, delivering 40 10-week groups per year, servicing approximately 240 vulnerable families every year.

2.1 Role of the MBN facilitators

Facilitators are recruited from different disciplines including psychology, social work, counselling, midwifery, and other relevant fields of allied health. Each facilitator has undertaken a three-day manualised MBN training process [14] and participates in ongoing monthly reflective supervision. Each group has a lead and co-facilitator, and over time through the process of mentoring, the co-facilitator may become the lead facilitator when the opportunity arises. Reflective supervision is a vital ingredient when working with young children and their caregivers in the shared exploration of the emotional content [19, 20]. Reflective supervision offers an emotionally containing relationship that mirrors the role of the facilitator with the mothers; this is vital to keep the thinking and feeling alive on behalf of the group. The main focus of this supervision is “the shared exploration of the emotional content of infant and family work as expressed in relationships between parents and infants, parents and practitioners, and supervisors and practitioners” [21, p. 63].

The role of the MBN facilitators is to create an emotionally containing environment for the mothers and infants while making mentalizing explicit through maintaining a stance of curiosity and reflection. The facilitator holds the baby in mind as a separate being whose experience and behaviours are meaningful while holding the mother’s experience, even though these may seem intolerable or distorted at times [22]. To sufficiently hold the powerful projections and primitive processes in the mother-baby group, two facilitators are recommended [23].

The facilitators narrate their observations aloud in the group, at times making sense of differences of perspective, modelling not knowing the other’s mind as well as sharing co-joint intent to work together to support group members [24, 25]. There may be minor misunderstandings and differences in the facilitator’s perspectives, and these distinctions are talked about to model “good enough” parent relationship to the mothers. Facilitators may stop and rewind, slow the pace or seek clarification in an effort to reflect upon a shared moment when a member responds in a particular way. Emotional reactions are noted; sometimes explicitly identified and explored, perhaps acknowledged and explored at a later time, or simply noted for facilitators’ shared reflection after the group. We acknowledge and celebrate moments of attunement and delight as well as offering a kind and curious presence in moments of distress and mis-attunement. As the facilitators work together in an unhurried pace, thinking aloud about the affects and processes encountered in the group, whilst holding each member in mind, they attempt to embody the qualities found in a collaborative parenting model for the members to experience [23]. Facilitators work together to support one another to develop a reflective stance and to help provide a clearer lens to observe group processes and model mentalizing as a way of being together. In addition, co-facilitation can represent alternate perspectives, such as a father’s experience or other siblings [23].

On becoming a mother, a woman’s relationship with her own mother may be thrown into sharp relief, with mixed and often ambivalent feelings surfacing unexpectedly. In the MBN group setting, the facilitators may find the mothers relating to them in ways that echo these ambivalences. By maintaining consistent, thoughtful, compassionate, and accepting stance, facilitators offer a potentially new experience for mothers where these qualities may have been longed-for but not experienced in their relationship with their own caregivers. Once experienced, these mothers may become able to draw on an internal representations of a ‘good grandmother’ [26] facilitator to help contain and make sense of thoughts and feelings in a new and enriched way.

3. Key distinguishing concepts of MBN

There are four key concepts that we have identified as underpinning the Mother-Baby Nurture model: early relational experiences matter, infant as participant, the group as a containing space, and enhancing mentalizing.

3.1 Early relational experiences matter

The first six months post birth is a time of profound transition for both infant and mother. It is a highly sensitive period in the newborn infant’s neurobiological development whereby exposure to early stressful experiences (such as an emotionally dysregulated mother) may alter the developing hypothalamic pituitary adrenal (HPA - stress response) system, sensitising the individual to future stressful life events and psychopathology [27]. It is also a vulnerable period of neuropsychological development where repeated relational experiences between mother and infant, over time accumulate to inform the infant’s internal working model, shaping the patterns of attachment behaviour in response to the mother [2, 28]. The quality of these early attachments is understood to contribute significantly to a child’s long term socio-emotional development [29].

Described by Stern [26] as the “motherhood constellation”, the presence of the infant typically activates the mother’s attachment system, preoccupying the mother’s mind and body with the survival and nurture of her baby. It can be an intense period of psychological reorganisation that may involve reshaping of the mother’s perceived role, identity, internal working model and attachment patterns. These formative early months of motherhood can be a time of significant foment, evoking reflections on past and present attachment relationships precipitating surprising and strong affective responses to “ghosts” from the past [30] as well as more positive “angels” [31]. Being a new experience, the mother’s thoughts and feelings towards her newborn baby and her new caring role are less established and likely to be more flexible. The mother’s patterns of behaviour are still in formation and responses are not yet predictable and anticipated, allowing opportunity for flexibility and change. Consequently, the MBN program is offered within the first six months post birth to seize this opportunity of flexibility in the mother-infant dyad.

3.2 Infant as participant

From birth, the infant has capacity for primary intersubjectivity; to be engaged as a person in their own right [32, 33]. More so, the infant’s subjective sense of self is actually dependent on the quality of the interactions with those they relate to [33]. Engaging the mother in isolation misses an opportunity to directly contribute to the infant’s development, the quality of the mother-infant interactions and the promotion of infant mental health [34]. Paradoxically due to neuroplasticity, the vulnerable infant is the most receptive and adaptive member in the dyad, making them a potent agent of change in the relationship. Stirred by the enlivened infant, the mother’s attachment systems can be activated, creating opportunity for reorganisation of internal representations, role and emerging attachment patterns [26], as well as inhibiting disorganised attachment in infants [35].

During the MBN group, facilitators express curiosity and interest in the infant’s experience, marking moments of brief exchange with curiosity and delight, which serve to legitimise the infant’s experience. This sensitive and responsive exchange over time, supports the infant’s developing sense of self and capacity to regulate emotions [36]. For example, while holding the infant’s gaze and providing marked mirroring of the baby’s expression the facilitator may say, “I wonder what you might be feeling as your mother shared that story? I think it makes your mummy feel sad; does it make you feel sad too?” The embodied act responding to the infant and holding him in mind as a thinking, feeling being is a central aspect of MBN. Such interventions support the mother’s capacity for perspective-taking, beyond her own experience and adult concerns, to consider the perspective and experience of her infant [37].

As we (facilitator, mother, and group) practice holding a reflective stance, wondering aloud about the baby’s efforts and shared moments of meeting, we consider how the infant’s external behaviour is informed by his internal experiences. We acknowledge times when the infant and mother share joyful moments, as well as acknowledge (without judgement) shared moments of uncomfortable affect. The infant serves as the ‘honest’ member of the dyad, enacting feelings that are shared but not necessarily expressed by the mother [38, 39].

Infant-focused moments occur spontaneously, as well as formally through a weekly group practice derived from the Irish Gaelic definition of curiosity, ábhar le ionadh, which translates “to watch with wonder” [40]. Mothers quietly watch their baby, invited to wonder about what the infant may be experiencing, reflecting on their possible thoughts, feelings, urges and bodily sensations. The curious, ‘not-knowing’ stance is both an important marker of all mentalizing interventions and core component in the child-led psychotherapeutic program, Watch Wait and Wonder [41]. Exercising a state of presence and attention with the infant is especially powerful for mothers that may ordinarily withdraw (absorbed in their own internal world) or for the mother preoccupied with their infant’s externalised behaviour (feeding, sleeping, or crying). It may also bring intrusive patterns of attachment behaviour to light, that are observed and held in mind by the facilitator. Reflecting on ‘in-the-moment’ experiences can illuminate past narratives and distortions that inform the mother’s internal working model, shaping the way she responds to her infant [42]. It can offer a window into the mother’s activated internal world that, if the infant were not present, may have taken longer or remained hidden from sight.

3.3 The group as a containing space

The MBN facilitators seek to provide a supportive relationship for the mother and the babies much like the role of a mother for an infant; described by Winnicott [5] as a necessary “holding” and Bion [43] as “containing”. Scaffolded by agreed group guidelines and processes, the group can form a kind, non-judgemental space for the mother and infant to express distress, anxiety, and pain. Once expressed, these projections can be returned in a modified and palatable form [44]. The group provides a safe container from which its members (mothers and infants) can begin to trust in the observations and feedback made by other members and become more receptive to new learnings. The experience of authenticity and openness can support the mother to develop an experiential understanding of social environments and interactions, a process defined as epistemic trust [24]. The benefits of epistemic trust are expected to continue well after the facilitated group ends, leading to sustained supportive relationships between group members, which act as a steppingstone to wider social contexts.

The role of the MBN facilitators is to hold both the mother and the infant in mind as thinking, feeling beings whose experiences and behaviours are meaningful. The facilitators scaffold the dyads experience, noticing strengths in both infant and mother, creating opportunities for brief attuned interactions to be acknowledged and amplified. The role of the group then, is to offer the infant enlivening experiences that will support his engagement with others, in his exploration as well as providing an emotionally containing presence when the infant is seeking support to regulate emotions. The facilitators are also offered containment from their regular supervision, which completes a nested set of relationships much like a babushka doll, one contained within the next: supervisor, facilitators, mother and infant (A similar ‘Containment Model’ is presented in [45]).

The group process acts as a holding environment for the vulnerable mother [46] as facilitators carefully narrate changes and absences in the group, including preparation for the eventual group closure, as thoughts of separation can activate strong feelings [23]. When disruptions are repaired, it helps inform the members by providing suggested scripts on how minor family ruptures and repairs can be managed within trust relationships. When a member of the group shares an affective state, the containing experience of marked mirroring can be amplified and nuanced as the multiple members provide a “hall of mirrors” response that offers differing affective intensity and hues [47]. The group can also offer some distance when a member listens to another’s experience, she can gain insight into aspects of her own internal world that may have been previously obscured. The process of identifying one’s own experience within the story of another member is both validating as well as normalising, alleviating feelings of isolation and shame. Establishing the service within the community instead of hospital setting, also helps destigmatise their experience.

3.4 Enhancing mentalizing

Mentalizing is a concept that has origins in psychodynamic theory, attachment theory and cognitive psychology [5, 43, 48, 49, 50]. The concept of parental mentalizing provides a well-established theory and mode of relationship-focused intervention (Mentalization-Based Treatment) that is accessible across disciplines [51, 52, 53, 54]. Evidence suggests that parental mentalizing is a central process in the intergenerational transmission of attachment patterns [55, 56], with poor parental mentalizing predictive of children’s insecure [57] and disorganised attachment [58]. The way a mother cares for her infant is informed by her own experience of being parented, explicitly in behaviours, and implicitly through enacting her internal working model [30]. A recent study of these processes [59] found that mothers’ poor mentalizing of their own early attachment relationships was predictive of negative parenting behaviours, which were strongly related to attachment insecurity and disorganisation. Interestingly, promoting maternal sensitivity behaviours alone (via psychoeducation) has not been found to mitigate the transmission of the caregiver’s adult attachment patterns to the infant [60].

Time in each session is dedicated to supporting mother-infant play and experiencing or ‘being-with’ the emotions and mental states of the infant. Conversations are facilitated so mothers reflect on attachment relationships - both representations from her childhood and her current perceptions of her baby. Through facial expressions, gestures, talking or vocalising, and actions (including play), a mother can support her infant to recognise his own internal state and regulate his emotions. It is through experiencing a mother’s mentalizing that a child can ‘make sense’ of his environment, supporting him to develop affect regulation, mitigating against stress arousal, and promoting the development of secure patterns of attachment and sense of personal agency [61, 62]. This engagement also contributes to the develop his sense of subjective self [63]. The MBN facilitator thinks about and relates to the mothers and babies as thinking, feeling beings. Through repetition, modelling curiosity about internal states is transmitted to the mothers, encouraging them to consider their own and their infants’ internal states.

This curiosity and openness in thinking helps to develop the skill of metacognition, so rather than being ‘in it’ the mother is able to think ‘on it’ which enables her to examine her internal working model and how she views the intentions of her child and her own self [60]. Through practicing this type of perspective taking, the mother’s mentalizing capacity is stretched and strengthened. This way of being, once nurtured in the group can continue to develop beyond the life of the group and is passed forward through the infant-parent relationship.

4. Outcomes

4.1 Intended outcomes for the mother

As the mother seeks to care for her infant, the facilitators may notice that the mother expresses strong emotions, ambivalent or negative feelings in what she says about her infant or in the way she responds or handles him. The facilitators emotionally contain the expressed state, allowing the mother to talk about her experiences, without fear of abandonment, intrusion, or criticism. A mother who is able to articulate her longing, or to mourn her loss or express her anger or despair within the context of a nurturing relationship may become clearer about her relational history and more emotionally available and sensitive to her infant [30, 64, 65]. In the safety of the supportive relationship, the mother may become more able to mentalize emotionally charged events and this lowers her epistemic vigilance [24]. This capacity will supports her to revisit the difficult experience in a more resourceful way, giving her opportunity to better understand and integrate the feelings that threaten the developing attachment relationship [24, 30]. Well-regulated affect between the dyad can be internalised into the child’s developing internal working model and ‘secure base’ attachment relationship [66], reducing the risk of intergenerational transmission [57, 67]. The mother learns how to provide contingent responses to the infant, so the infant can register his mental states as a coherent part of himself, rather than as random or alien [68]. This learning is possibly through the development of epistemic trust [24] and is then applied in everyday life. Based on these principles and understandings, the outcomes of MBN for the mother are summarised in Figure 1.

Figure 1.

Mother-Baby Nurture outcomes model.

4.2 Intended outcomes for the infant

The infants developing sense of subjective self, as a separate entity from the caregiver, is a central organising process of psychological development [63, 69]. The group provides a transitional space for the infant [70], where he can observe those around him, noticing similarities and differences, and feel safe enough to explore new experiences of self. This can be a powerful learning opportunity especially for a socially isolated mother and baby, as it offers a space in which alternate expressions of thinking and feeling can be experienced and offered [37].

Ways of being together become imbedded in the infant’s procedural memory, forming an internal representation of how others relate to him and how he relates to others. These repeated “serve and return” experiences between the infant and others, most especially their caregivers, form the infant’s internal working model [66]. Although able to be revised and elaborated on, the internal working model is largely established early in infancy and acts to inform future ways of relating [71]. The emotionally containing and contingent interactions of the group support the infant to foster their developing subjective self, sense of agency, and capacity for emotional regulation and secure attachment (see Figure 1).

5. Conclusion

We have outlined four key aspects of the Mother-Baby Nurture group program. Firstly, the early parent-infant relationship is understood as central in supporting better health and developmental outcomes for the developing child. Then we described how the infant is welcomed and included as a participant in the group, using moments of interaction as material for shared pleasure and reflective discussion. Within the safe environment of the group, the mothers are able to reflect on their relationships present and past, allowing distress and distortions to become seen and contained. Finally, the facilitators model a mentalizing stance of curiosity, supporting the mother to reflect on feelings and longings, as well as considering the experiences of her baby and other group participants.

This program offers a therapeutic experience for vulnerable families. Prioritising the infant-parent attachment relationship in tertiary services can prove difficult where treatment of acute maternal psychopathology can overshadow the experience of the infant. Mother-Baby Nurture delivers a unique targeted service for vulnerable families during a critical window in the infant’s development while the tender caregiver relationship is in formation. This relationship-focused program can be delivered by infant mental health clinicians from all disciplines. It gives a family an experience that can foster a sense of trust, providing a stepping-stone to other protective support services, as well as engagement with the community at large.

Acknowledgments

The authors express gratitude to the infants and their mothers’ who inform and inspire this program and who were willing to watch with wonder with us. Thank you to the Mother-Baby Nurture facilitators and supervisors whose reflections continue to shape the program and the brave pioneers that piloted the first group more than ten years ago.