Finding Hope in Despair: Clinical Studies in Infant Mental Health (Book Review)

Author:  Birch, Marian
Publisher:  Zero to Three, 2008
Reviewed By:  Marilyn Charles, Vol. XXIX, No. 1, Winter 2009, p. 20

This is a powerful and important book for all practitioners, not only for those of us who work with young children. We all are faced at various points in our career with patients whose needs are such that we cannot fill them, who in turn fill us with the type of despair being written about in each chapter of this compelling volume.

The literature is full of stories of treatments gone well. It is far more difficult to talk together about those treatments that do not go so well, the ones we think back on with regret or sadness. We often feel as though “if only we were better practitioners. . .” or “if only there had been more resources. . .” then, somehow, things might have gone better. In this way, we create in our imaginations a perfect world through which we rescue ourselves from despair but also persecute ourselves in the process. More importantly, we work against what is perhaps the more fundamental dilemma: to help our patients to learn to cope more competently and with greater equilibrium with whatever challenges they face, and to be able to obtain some pleasure and satisfaction from even the small steps and milestones they (and we) are able to achieve.

To work with those in most need, we must be able to face the fact that, at some level, in this work we are always up against the limits of resources, both internal and external. Knowing that—and forging on in spite of that fact—is something we all can share. Failing to acknowledge that limiting edge, and the terrible price we and our patients sometimes pay in the face of it, leaves us each alone in our despair, feeling personally implicated by what we experience as an internal failure rather than an inevitable edge of therapeutic action.

In refreshing contrast, in this volume the authors come together to acknowledge that whereas work with infants and their families can be tremendously rewarding; it can also be intensely painful and disappointing. Each author offers a case history from his or her experience to “explore the limits of the tools of infant–parent psychotherapy and reflect on what can be learned from the sometimes excruciating distress of failures. This is not an exercise in despair, but an effort to grow our field into a new maturity, in which failures and limited outcomes can be acknowledged and endured without despair” (p. 8). Each case is then followed by a commentary by one of the other authors. In this way, the form of the book provides a conversation between the therapist, who is able to reflect back on what went well and what went badly, and an outside observer, who is able to bring another perspective to bear. While talking about our failures requires courage, it enables us to learn from those experiences and also to encounter the respect of other seasoned clinicians who can imagine being in a similar dilemma and inevitably struggling as well.

This volume counters the tendency to believe that “if we just knew enough” or “did it well enough,” that all would be right in the end. For those of us who work with more severely disturbed patients, or individuals in the types of dire straits described in this volume, this is simply not the case. While we always hope to alleviate pain and despair, we also come up against the very real damage and limitations of resources that bound our ability to provide assistance or relief. Failing to recognize the inevitability of our own limits provides an impossible model for our patients, perpetuating a manic fantasy rather than encouraging a more realistic coming to terms with limits, and finding satisfaction in what one is able to achieve.

The cases in this volume are all heart-breaking in some measure and yet we can also see that good work was done in spite of the limits which kept the treatment from coming to an optimal end. In each case, we can see how the therapist’s investment in providing care, recognition, and opportunities for learning provided support for parents or provided sustenance for a child in spite of whatever internal or external limits were also at play.

Editor Marian Birch’s ability to wonder about alternative methods provides a useful frame for the therapist who, while using the skills and conceptualizations available, must also be open to what he or she might be missing. For those who have been marginalized by social systems, it may be particularly important to affirm areas of competence by allowing the patient to lead and teach us rather than applying our theory in ways that may further dehumanize and alienate the patient from him or herself. Recognizing real limits and real strengths helps to provide traction for those who are feeling awash in impossible circumstances, offering the possibility of mourning losses rather than resisting them such that the resistance itself becomes a stopping point.

Birch ends the volume by addressing two central questions that run through all six cases. First, “What are the limits of a supportive, strengths-based approach?” and second, “what is it in work with infants that makes us so partial to being supportive and makes it so difficult to tolerate, metabolize, and use therapeutically the intense countertransference feelings that are evoked when we see children suffering and we cannot stop it?” (p. 255-257). In considering these questions, the reader is invited to think more deeply about some of the very complicated feelings engendered in us all as therapists who come up against the limits of what we can and cannot do for with individuals in our work. Further, we are invited to consider how our own difficulties in tolerating those limits impede our patients’ efforts to successfully mourn real losses and to celebrate developmental achievements.

The contributors to this volume have offered us a very rich and compelling invitation to think together about our successes and failures and thus to consider how to better support one another in this very difficult work we do.

Finding Hope in Despair makes a powerful and important contribution to the field, inviting the types of conversations that are likely to be valuable to practitioners at any level.

Marilyn Charles
Stockbridge, MA

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