Working with vulnerable children: therapeutic observation and Watch Me Play

Размещено на http://www.allbest.ru/

УДК 347.64:616.89-008.454:616-053.2

Working with vulnerable children: therapeutic observation and Watch Me Play

Jenifer Wakelyn

Tavistock Clinical in Haringey, London, Great Britain SOVREMENNAYA PEDIATRIYA.2018.2(90):14-25; doi 10.15574/SP.2018.90.14

Infants and young children who are taken into the care of the state are likely to have experienced multiple adversities with potential ongoing effects that may compromise their future life chances. Foster placements in early childhood provide unique opportunities to mitigate the sequelae of maltreatment: the preschool years are a critical time frame for early intervention to prevent emerging mental health disorders from becoming persistent. However, the care given to some infants and young children in foster placements, as the result of a range of complex factors, may be under-involved, developmentally inappropriate or lacking in emotional warmth, thereby compounding the impact of early trauma.

This talk describes and illustrates two linked approaches that aim to support, validate and deepen the foster carer-child relationship in order to mitigate the impact of early trauma and improve placement quality for children and their carers: therapeutic observation, based on the psychoanalytic model of infant observation, and a briefer intervention, Watch Me Play! Both are flexible and responsive ways of supporting infants and young children during legal proceedings or during a move from one placement to another . Watch Me Play! has also been found useful with children and their adoptive parents, and for birth parents who have experienced difficulties in their parenting. Links are made to contemporary neuroscience and child development research and to Freud's discussion of attention as 'observing thought', and a form of psychic energy.

Key words: vulnerable children, Foster placements, therapeutic observation, psychoanalytic model, psychological trauma.

Работа с детьми из приемных семей: терапевтическое наблюдение и «Смотрите, как я играю!»

Jenifer Wakelyn

Tavistock Clinical in Haringey, London, Great Britain

Дети раннего возраста, находящиеся на попечении государства, часто подвергаются жестокому обращению, последствия которого могут негативно отразиться на них в будущем. Воспитание в приемной семье дает уникальные возможности для смягчения последствий перенесенного жестокого обращения: дошкольные годы представляют собой критические временные рамки для раннего вмешательства, когда можно предотвратить формирование новых психических расстройств, которые могут принять персистирующий характер. Однако в некоторых приемных семьях дети, по ряду причин, могут не получать достаточно внимания и душевного тепла, что может усугубить последствия ранее перенесенной травмы.

В этом сообщении описываются и иллюстрируются два взаимосвязанных подхода, целью которых является поддержка, укрепление и углубление взаимопонимания между опекунами и детьми, а также устранение последствий ранее перенесенной травмы у детей и улучшение качества совместного пребывания в приемных семьях: терапевтический подход, основанный на психоаналитической модели наблюдения за детьми, и подход быстрого вмешательства под названием «Смотрите, как я играю!» (Watch Me Play!). Оба метода являются гибкими и эффективными, особенно при поддержке детей раннего возраста во время судебных разбирательств или во время смены приемных родителей. Метод «Смотрите, как я играю!» также был признан полезным для детей и их приемных родителей, особенно для родителей, которые испытывают трудности в воспитании приемных детей. В статье автор ссылается на современные исследования в области нейробиологии и детского развития, а также на учение о психоанализе Фрейда и формы психической энергии.

Ключевые слова: дети, лишенные родительской опеки, приемная семья, терапевтическое наблюдение, психоаналитическая модель, психологическая травма.

Робота з дітьми з прийомних сімей: терапевтичне спостереження та «Дивіться, як я граюся!»

Jenifer Wakelyn

Tavistock Clinical in Haringey, London, Great Britain

Діти раннього віку, що знаходяться під опікою держави, часто зазнають жорстокого поводження, наслідки якого можуть негативно позначитися на них у майбутньому. Виховання у прийомній сім'ї дає унікальні можливості для пом'якшення наслідків жорстокого поводження: дошкільні роки є критичними віковими рамками для раннього втручання, коли можна попередити формування нових психічних розладів, що можуть набути персистуючого перебігу. Однак у деяких прийомних сім'ях діти, з ряду причин, можуть не отримувати достатньо уваги і щирого співчуття, що може поглибити наслідки перенесеної травми.

У даному повідомленні описано та проілюстровано два взаємопов'язані підходи, метою яких є підтримка, зміцнення та поглиблення взаєморозуміння між піклувальниками і дітьми, а також усунення наслідків перенесеної травми у дітей та покращення якості сумісного перебування у прийомних сім'ях: терапевтичний підхід, заснований на психоаналітичній моделі спостереження за дітьми, та підхід швидкого втручання під назвою «Дивіться, як я граюся!» (Watch Me Play!). Обидва методи є гнучкими та ефективними, особливо у підтримці дітей раннього віку під час судових розглядів або під час заміни прийомних батьків. Метод «Дивіться, як я граюся!» також було визнано корисним для дітей та їхніх прийомних батьків, особливо для батьків, що зазнають труднощів у вихованны прийомних дітей. У статті автор посилається на сучасні дослідження у галузі нейробіології і дитячого розвитку, а також на вчення про психоаналіз Фрейда і форми психічної енергії.

Ключові слова: діти, позбавлені батьківської опіки, прийомна сім'я, терапевтичне спостереження, психоаналітична модель, психологічна травма.

family children mental disorder

In this talk I want to discuss how clinical approaches using psychoanalytic observation can contribute to therapeutic support for a particularly vulnerable group of children, those who cannot be looked after in their birth families. The work setting for the examples I will give is a mental health service for children in care, but the ways of working we

have developed can also be applied in other contexts where there may be concerns about development and relationships, or following adoption.

This painting by William Hogarth from 1746 (c. The Foundling Museum, London) may help us to think about the experiences of infants and young children in care today: it shows a young child, the infant Moses in the bible story, facing a move into a new family. He is being presented to the Egyptian princess who became his adoptive mother. The painting is still on display in the room for which it was painted in London's Foundling Hospital, the first home for orphans to be established in England (McClure, 1981) [19].

Hogarth was one of the first supporters of the Foundling Hospital, and he and his wife acted as foster carers for babies before they were moved to the hospital as young children. He seems to have brought all of this experience to bear in the way he has shown the child Moses, pale and hesitant, clinging to his mother's robe, and facing a great divide into a new and different world, one that he must cross alone. For me, this highlights a central aim of therapeutic work with children who are in temporary foster placements: to provide companionship and support continuity in order to help the child to be less alone with their experience.

Continuity

Winnicott defined continuity, the feeling of 'going-on being', as the core of a sense of identity, essential to psychological health. He also describes repeated disruptions to 'going-on-being' as leading to fragmentation and the 'active production of chaos in defence against ... unthinkable ... anxiety' (Winnicott, 1965:61) [36]. The continuity of a relationship with a reliable adult can be a lifeline for children whose primary attachments have been disrupted. Receiving responsive nurture from reliable caregivers allows children over time to internalise experiences of adults as helpful and attentive, laying the foundations for the internal continuity that sustains the self when there are breaches in external continuity. Developing a degree of internal continuity is essential for making relationships and learning;

without these capacities, the quality of life for children and their life chances are severely compromised. What happens, and what can help, for children who have neither external nor internal continuity, who experience placement changes and changes of social worker as they progress through the care system, is the subject of this talk.

The 'free psychical energy' of attention

Attention has a particular role to play in the development of internal continuity. Little discussed in its own right -- we hear much more about attention deficit -- attention is a topic to which Freud returned many times in his theoretical writings. In his first publication, the Project for a Scientific Psychology (1895), he describes attention as 'a free psychical energy', and draws a distinction between 'ordinary thought', directed towards finding a satisfying object, and 'observing thought', directed towards the internal world. 'Observing thought' relies on attention and asks 'What does this mean? What does this lead to?'

In later writings, Freud highlights two different aspects of attention, the active and the passive. On the one hand, he describes attention as actively 'meeting the sense-impressions half-way, instead of awaiting their appearance' (1911). But he also describes a stance of free-floating or evenly-suspended attention, passively receiving rather than selecting from the material, which he recommends to psycho-analysts as allowing more direct contact with the patient's instinctual life (1912; 1923) [7,11]. These ideas about attention as energy, about 'observing thought' that looks for meaning, and the duality of active and passive aspects of attention are particularly relevant to clinical work based on psychoanalytic infant observation.

The work context

I work as a child and adolescent psychotherapist in a psychological health screening and assessment service for children in care. The task of the service is to assess psychological need and offer brief intervention for all children and young people entering the care of the commissioning local authority. When we are notified that a child has entered care, we send screening questionnaires to their foster carer. A child whose questionnaire score is in the clinical range, or any child about whom concerns are expressed, is followed up in consultations with their social worker and foster carer: we explore the sequence of events that led to the child coming into care and reflect on how this may have shaped the child's expectations of adults, their relationships and their therapeutic needs. We work closely with health, social care and education professionals to facilitate a containing network around the child and foster carer. A consistent focus on the child's development and communications is used to inform discussions about care planning, placement needs and transitions.

One of the strengths of this system is that it does not rely on referral; this is particularly significant for infants and young children, who are rarely referred to mental health services and are often expected to recover spontaneously from unimaginable traumatic experiences. In the service, over time, we see or hear about many children who remain in care and find security in loving foster families, but also about a smaller group of children whose needs are not met, who fall through the net and move ineluctably towards the 'brick mother' of the criminal justice system and prison.

Adversities for children in care

Many children who reach thresholds for entering care have experienced abuse and neglect, for months or years, and may have had to turn to unpredictable, hostile or dangerous caregivers for their most basic care. These experiences are associated with significantly increased risks of mental health difficulty in infancy or later childhood. Neurological studies report that patterns of brain activity in children exposed to family violence are similar to those of soldiers exposed to combat (McCrory et al, 2011) [18]. «Toxic stress» has been proposed as a mechanism underlying severe and enduring emotional and self-regulation difficulties that affect many children who have experienced maltreatment (Center for the Developing Child website). «Complex trauma» is another conceptualisation of pervasive difficulties that may compromise all aspects of development without reaching diagnostic thresholds, meaning that criteria for mainstream mental health services are not met (DeJong, 2012) [5].

Another aspect of the adversity faced by maltreated infants and young children is denial. When a child's suffering is denied, it is not witnessed, and cannot be addressed or mitigated, leaving the child alone with their trauma. Underrecognition of infant mental health difficulties was highlighted in the first systematic studies of childhood trauma in the 1940s and has continued despite the influential work of Bowlby and the Robertsons in the UK during the 1960s, and the subsequent wealth of studies from attachment research, child development and neurobiology (Robertson and Robertson, 1989; Gerhardt, 2004) [23,15]. It seems that a different language is found in every decade to block out awareness of suffering and harm to the most vulnerable children in our society: a recent study of adoption breakdown found 'a prevailing view that infants do not have needs, other than basic physical ones' (Selwyn et al., 2014) [26].

Children who suffer maltreatment at the hands of their parents endure the trauma of a breach in their parenting and 'the breaking of the continuity of the line of ... existence' that Winnicott defines as the essence of trauma (1986, 22) [37]. A further aspect of adversity for children who enter the care of the state is the inevitable disruption or severance of their primary caregiving relationships. For some children, this happens repeatedly, both before and after entering care. The care system in the UK has four main placement pathways for young children, each bringing risks of disrupted caregiving and prolonged uncertainty. Re-unification with the birth family and care by members of the extended family are the preferred options where these are judged to be safe for the child, but they are also associated with the risk of receiving care that does not fully meet the child's needs, and of re-entering care later in childhood. Failed family re-unification and breakdown of kinship placements are more common than adoption breakdown. Maltreated children who return to their parents have been found to be more likely to experience further abuse or neglect and to have poorer psychosocial outcomes than those who remained in foster care or were adopted (Biehal, 2007; Sinclair, 2005; Ward et al., 2006) [2,27,34]. Adoption and long-term foster care may provide greater stability, but both are associated with lengthy legal proceedings, resulting in prolonged uncertainty during the formative period of infancy when the need to bond with a stable and nurturing caregiver is paramount.

While many children thrive and show impressive signs of recovery from their first days in foster care, for a number of children, the traumas of maltreatment and family dysfunction may be compounded by receiving uninvolved, emotionally detached foster care. This type of adversity increases the likelihood of developing a mental health difficulty and of adoption breakdown in later childhood. Abrupt, unplanned transitions are another risk factor following entry into care for later mental health difficulty and placement instability (Hillen and Gafson, 2011; Selwyn et al., 2014) [12,26].

The range and the severity of the adversities facing children before and after entering care form the rationale for developing interventions with the specific aim of understanding and mitigating difficulties and distress for infants and young children in temporary foster care.

Therapeutic observation

Therapeutic observation is an intervention model that applies the principles of psychoanalytic observation in training to a clinical context (Houzel, 2008; Rustin, 2014) [14?,24]. It offers a home-based, non-intrusive approach with minimal disruption to family life and has been applied with infants at risk of autistic spectrum disorder and young children at psychosocial risk (Rhode, 2007; Rustin, 2014; Houzel, 1999) [22,24,13]. In hospital settings, observation-based approaches have been used with premature babies since the 1970s (Negri, 1994; McFadyen, 1994) [21,20] and there are published accounts of the applications of psychoanalytic infant observation in a range of institutional settings including orphanages and children's homes (Urwin and Sternberg, 2012) [31].

In this model, the clinician, who has previous training in infant observation, visits the family home for an hour at a regular time each week. The observer's stance is one of aiming to provide a friendly, receptive presence, attentive to each family member who is present while maintaining a focus on the infant, and responding to rather than initiating interactions. A close and detailed focus is kept on the movements, expressions and vocalisations of the infant and the emotional atmosphere of his or her interactions with others during the hour of the visit. During the visits, the therapeutic observer draws on repeated close observations to promote connection between the infant and the caregiver at moments when a signal from one or the other might otherwise go unnoticed.

Detailed notes are written after the visit and discussed in supervision, with particular attention to the fine detail of interactions and the observer's feeling responses. Regular supervision from an experienced clinician is essential to this way of working; it involves a close exploration of the infant's communications and development, together with a focus on the emotional experience of what it is like to be with the infant in the home. Supervision also provides a companionship that is particularly important in a way of working that brings greater closeness to the emotional experiences of babies and young children in transition, which at times may be profoundly harrowing or bleak. In this way, the observational model separates out the dual aspects of attention identified by Freud: the regular visit and the circumscribed role of the observer create the conditions in which as much information as possible can be received. The active aspect of attention, the observing thought that asks 'What does this mean?' comes into play later, in the discussion in supervision and the ongoing processing and reflection in the clinician's mind that it facilitates.

I had the valuable opportunity to carry out research looking at how this model of therapeutic observation might be applied with an infant in foster care (Wakelyn, 2011, 2012) [32,33]. When I discussed the project with social workers, it was welcomed. There was a general idea that it would be helpful to understand more about the experiences of babies in care. Relatively little has been written in the research literature about the youngest children in care and social workers were aware of a lack of practice guidance. Ethical permission was obtained and I was able to observe a baby boy, 'Rahan', for ten months during his time in foster care until he was moved to his adoptive family.

In the account that follows, all names and identifying details have been changed to protect confidentiality. The foster family and social workers let me know when I fed back to them after the project ended that they are pleased that findings from the research are being disseminated.

'Rahan'

Rahan was born to a teenage mother who gave up her baby to be adopted. The young mother's pregnancy was overshadowed by fears of violence from her boyfriend as well as from her family and their religious community. He was brought up in the same foster family, from the day of his birth until he was adopted at the age of thirteen months. He had a different experience of foster care from that of most infants in care. He is likely to have been exposed to prenatal stress due to his mother's fears and her frequent moves, and he experienced the loss of his mother on the day of his birth, but he was not exposed to maltreatment or to any change of caregiver during his first year of life. This meant that my research provided an unusual opportunity to examine a temporary caregiving relationship in the absence of other compounding factors.

The weekly observation visits began when Rahan was three months old. My overriding impressions in the first weeks were of disarray and disconnection. A lack of communication between the foster mother and social workers at times seemed to resurface in the interaction between a very caring foster mother and the three-month old baby. I learned that no one had been present to mediate the coming together of the foster carer and the baby she was to care for. Rahan was passed to Nadira at the door of the hospital ward after she had shown her identification. There were very bleak moments during the observational visits when Rahan seemed psychologically unheld, when I found it shocking to see how very pale and remote he could become in moments when I felt repelled by something that was ugly, that I felt I should not be seeing. In these early stages, the task that occupied both me and my supervisor seemed to be to absorb, take in and process powerful experiences of fragmentation, of 'no link'.

Joining up

Gradually, experiences of connecting came more to the fore. The routine of the weekly visits became established and Nadira helped me to join up in my mind the Rahan of today with the Rahan of the previous week. Here are some notes from a visit when Rahan was four and a half months old: as he became more mobile, his upper and lower body were drawn into the linking of his left and right sides:

Rahan lies on his back, draws up his knees, and takes hold of one foot in each hand. He drops the left foot, almost cries, and then again holds a foot in each hand. He repeats this movement several times. He murmurs and makes some repetitive humming sounds ... His stare moves from my face to my feet and back to my face again. When I then move my feet, he watches with a fascinated expression, and then as if in answer, moves his own feet.

While he dropped and picked up his left foot, and alternated this with picking up both feet, Rahan provided himself with a background continuity with the humming sounds that bring together the lips and the front and back of the mouth. As he became more linked up with himself, he was then able to link up with me and become curious, making full, active eye contact.

It took time to assimilate the reality of being a foster parent. It seemed that now Nadira was more able to treat Rahan like one of her own children. The significance of the game of peekaboo, as she recognised, is that it allows experiences of separation to be repeated, experimented with and explored, and to some degree mastered, allowing a degree of control and agency to the infant: all the multiple and mysterious ways in which play, as Freud (1920) [10] observed with his young grandson, allows the ego to come to terms with and encompass previously indigestible aspects of reality.

Nadira was not alone as a foster carer, I think, in finding playfulness in relation to the comings and goings of ordinary family life, a step too far as regarded the infant for whom she was providing heartfelt but temporary care -- an infant who, as so often, the foster family did not know if they would ever see again after he was taken to his adoptive family.

After a long period of limbo, when time felt suspended and it seemed that development was on hold, an adoptive family was identified for Rahan. This is a time when, with the approaching reality of a long-awaited move, emotional contact may be lost with the child's experience and, in particular, the significance of the relationship with foster carers may be effaced (Lanyado, 2003) [16]. A momentum can set in to move fast, close down thinking and cut off connections with the past. Recognising a child's previous attachments and relationships can then be perceived as a hindrance, rather than as strengths to build on. Even the current foster carer may be left out of the planning for this momentous transition for the child, and considerations about future contact with the carer can be dismissed as irrelevant or unhelpful. My task as the therapeutic observer included advocating for Rahan's emotional needs at this time and the central role that Nadira was able to play during the move to his new family.

The following excerpt is from my second to last observation visit:

Rahan looks towards me with a distant expression. Nadira tells me he is «very day-dreamy» at the moment. She asks him if he is looking at the leaves blowing in the wind. He goes up and down the alleyway with the boys from next door as they kick the ball for him and he follows it. Rahan half-closes his eyes as the wind ruffles his hair; he puts his hands over his ears, and rubs his tummy. He says, 'Hoarrhhh', making a sound like the wind.

During this time of high tension and anxiety, I was encouraged to see how child and foster mother now seemed able to move in and out of contact, as if Nadira were practicing in her mind to let Rahan go, and allowing him to practice leaving her. I came to feel that my role as a therapeutic observer was in part to be a companion on the journey, someone who could to some degree enter into, understand and, perhaps, contain something of the emotional experience of the foster mother and the baby. The focus on providing as much attention as possible during the visits and searching for meaning later, in supervision, seemed to help to regulate some of the pain of being emotionally in contact with a child who was soon to go and a close relationship that was being severed.

I visited Nadira several times after Rahan left. I felt relieved to hear about a close relationship that gradually developed between the adoptive and foster families. It seemed that the observation may have provided an additional layer of containment and helped her to remain emotionally available to Rahan during the transitional period both before and after he was moved. However, the adoptive family chose not to meet me and this meant that I was not able to ask them about continuing to observe Rahan in his new home.

'Trauma-driven' and 'developmental' organisation

In the analysis of the observation notes, using grounded theory methodology (Strauss & Corbin, 1990) [28], I extracted themes that were prominent throughout the observations and related to different types of organisation. It seemed that, at times of transition and high anxiety, organisation was more likely to be driven by the dynamics of trauma - dissociation, fragmentation, panic and de-personalisation. Vicious circles of dysfunctional interaction are generated by the escalating impact of undigested psychic pain in this type of organisation. The result is loss of contact with the emotional reality of the infant. Particular aspects of trauma-driven organisation were identified: 'tornado', 'machine', and 'limbo', each more prominent during different periods in the life of the temporary foster placement.

The research also highlighted a different type of organisation, which I call 'developmental'. In developmental functioning, the child's experiences and states of mind occupy a central place in the adults' thoughts, preoccupations and feelings. This more integrated type of organisation shapes conditions in which emotional contact with painful realities -- for the child, the foster carer and perhaps too for the adoptive parents -- can be sustained.

Another finding from the observation project was the crucial role of play in mitigating the impact of experiences of discontinuity, rupture and provi- sionality during the infant's time in temporary foster care (Alvarez & Phillips, 1998) [1]. The research also showed that the observational approach was welcomed by social workers and the foster carers, while also highlighting moments when the integrating function that the observer comes to represent may be powerfully resisted. This became particularly apparent in a therapeutic observation which I supervised, with an infant whose start to life was severely compromised and whose first months were overshadowed by tragedy.

'Aisha'

Therapeutic observation was used to provide a closer acquaintance with Aisha, an infant whose early development was causing concern, to promote the nurturing bond between foster carer and child, and to inform care planning and preparation for a transition to a permanent family. The therapeutic observer, my colleague Martina Weilandt, is an experienced clinical social worker and mental health practitioner trained in psychoanalytic infant observation.

Aisha's mother suffered from mental health and substance abuse difficulties. Born four weeks premature after her mother had taken a high dose of heroin, Aisha received specialist care but inevitably she was looked after by a rotation of changing nurses in the neo-natal unit. Her withdrawal from foetal exposure to heroin required treatment with morphine. Her father wanted to look after here but was unable to because of his own difficulties with substance abuse. On discharge from the neo-natal unit, Aisha was first placed in a foster family where there were already two young children. This placement broke down after six weeks, when the carer found the demands of all the children more than she could manage. Aged two and a half months, Aisha was moved to the care of Sharon, an experienced foster carer for babies. Sharon had no other children in her care and had the support of her back-up foster carer.

Aisha's social worker requested a consultation with the mental health service after the statutory health assessment highlighted a significant developmental delay. This sensitive social worker was also worried by Aisha's withdrawn states, which alternated with shrill, inconsolable crying. She gave a vivid description of Aisha as: 'a tiny baby with rigid muscle tone, tense and screaming in a high-pitched tone that would go on and on until she would suddenly stop.' An open-ended observational intervention was agreed, with fortnightly visits to the foster placement and regular meetings with the professional network. The complexity of Aisha's needs and her situation meant that the intervention went on to last for two years.

In her first visit, Martina's impressions of Aisha were of an infant who seemed very far away:

Aisha seemed rather pale and stiff ... when Sharon left the room, Aisha did not look at me. I felt very uncomfortable with the situation of being alone with her. The silence and aloneness after a time seemed too long and I moved to sit nearer, and talked to her quietly. Aisha stretched up her left arm until it was rigid, making her hand into a fist. She remained in this tense position until Sharon returned.

In the second visit, Martina was again left alone with Aisha for a few minutes. This time, Aisha made a very gentle, tentative movement towards the observer:

Aisha stared at me with blank eyes for what felt a very long time. Then she slowly moved her arm and placed her hand on my wrist. I was taken aback by Aisha's deliberate movement and by the lightness of her touch, like a feather, as if I had to hold my breath in not to blow her away. Aisha looked into my face, her eyes brighter. I stayed very still and talked quietly to Aisha until Sharon returned.

Martina learned that making contact with Aisha had to be achieved slowly and gradually: too much movement or sound could make her instantly withdraw; but, once established, the contact between Martina and the three month-old baby felt very intense.

Over time, Martina noticed a similar pattern in her interactions with Sharon. Many of her visits were cancelled or postponed; sometimes, Martina waited several minutes after ringing at the door, leaving her wondering if the visit had been forgotten or was unwelcome. But once she had been let in, Martina was warmly welcomed and left in no doubt that she was expected. We puzzled over this. It was as if a layer encircled the foster-carer and baby couple, requiring a particular persistence from Martina in order to get through and make contact.

Martina had been visiting for two months when Sharon received the shocking news that Aisha's mother had died, from causes that remained unknown. During her next visit, there was a profound sense of contact between Martina and Aisha:

Aisha sat in front of me, looking at me seriously. She took hold of my hand and held it. I spoke gently in a quiet voice. As Aisha continued to look into my eyes, I responded by stroking her hand. Every now and then Aisha made a big sigh with her shoulders and chest moving. There were long periods when both of us were silent... I felt a deep sense of connectedness with her.

The impact of Aisha's mother's death seemed to be devastating, fragmenting the cohesion of the previously well-established professional network. It now seemed as if Sharon were in a vacuum: her calls and emails to professionals went unanswered. Once again, Martina's experience with the network was that re-establishing communication was difficult and time-consuming, but once contact was made, it was valued, and further meetings were welcomed. Martina's role in addition to convening the meetings, was to validate Sharon's observations of Aisha's development, share her own observations and to advocate for Aisha's psychological needs to be kept at the centre of the planning for her future care.

As the working group of professionals once more began to cohere, Martina noticed a new arrangement of furniture in the living room. Sofas and armchairs were now arranged in a circle in the middle of the room, a small table forming a movable doorway into the enclosed and cushioned space within. This seemed both to represent a womb-like space and a protective buffer for Aisha against an external world felt to be harsh and dangerous -- and against a future that will bring Aisha a cruel knowledge of her mother's death.

Just as Martina had needed to persist in reaching out in order to cross the boundary between outside and inside and to establish the regular routine of the visits, so too getting inside the circle of couches took an effort- in this case, a physical one; but once inside, the feeling was one of «now you were in, now we could actually just be». The protective zone of the circle of couches seemed to both symbolise and concretely provide a place of reprieve from feelings of shock and grief, where Aisha could be kept safe and the impact of her bereavement could be gradually processed and, some of the time, set aside.

Over the next six months, plans for Aisha's future took shape. Her father's parents, who were living in another country, came forward to adopt her. Remaining within her birth family seemed to offer potential for hope, alongside anxiety about whether her needs could be met by her grandparents. There was prolonged uncertainty as assessments continued, while the potential move to another country threatened an absolute severance of the close bond Aisha had formed with Sharon. Martina describes Sharon's task during this transitional period as 'living in a stuck transition and managing the complexity of caring for a child with an uncertain future, balancing the need to provide a loving home and allowing a close bond to develop, whilst at the same time knowing that she will move on'.

'You have seen it'