Sara and Matteo: a story of “power”

The first time we met Sara and Giacomo, they were pregnant with Matteo, their second born. It was during the third trimester in the pregnancy. In collaboration with the Department of Obstetrics and Gynaecology of a hospital in Rome, we provide a comprehensive evaluation of the mother’s psychological and emotional status, and we offer the possibility of support to all women who face a high-risk pregnancy. We also offer post-partum support and assistance in those cases that we believe show the possibility of perinatal risk. In these cases, our support can last up to one year and is conducted at the family’s home.

Sara had a relatively peaceful pregnancy, with the only risk being possibly developing gestational diabetes, which actually did not happen. Sara had in fact a long history of being overweight, even before pregnancy, which had become worse over time. During her gynaecological visits, she was told to follow a healthy diet, because her condition could have led to a series of complications and negative outcomes both for her and for Matteo, including early delivery, caesarean section, pre-eclampsia, and foetal macrosomia. In spite of the attentive care of the medical staff and in spite of our attempts to make her explore the causes of this behaviour and its possible consequences, Sara almost completely ignored the indications she had received, gaining weight, and exceeding the prescribed ranges during each trimester.3 As a consequence, Sara’s blood pressure greatly increased, and she delivered Matteo by C-section. Matteo was born a healthy baby but very close to being diagnosed with macrosomia, with a birthweight of 9.2 pounds (4.2 kilos).

With this in mind, we offered Sara and Giacomo post-partum support.4 Sara’s behaviour, of which eating represented a single element, seemed to be characterized by difficulties in impulse control and poor sensibility in taking care of Matteo, since before his birth.

One month after they went home, we contacted Sara, who described a “wonderful baby, who sleeps, lets me sleep, and breastfeeds without any problems”. She also told us that Giacomo would have to travel on business and would be gone for a few months. We therefore set up a meeting before Giacomo’s departure, in order to inform both parents of the process we would follow. Sara, however, kept postponing the meeting until after the husband’s departure, an event that appeared to trigger a depressive reaction in her. Then, she contacted us to agree on a date to meet, reporting somatic problems and an “insurmountable” tiredness.

We finally succeeded in meeting Sara and Matteo. We immediately noticed that the mother’s mind was completely absorbed in her own physical and psychological ailments, appearing to almost “forget” about Matteo and Margherita (her first bom). Matteo seemed to be facilitating his mother and her needs by being surprisingly calm even when awake and hungry. Six-year-old Margherita was showing a slight speech impairment, on the background of emerging depressive states.5 We briefly presented our procedure, but we postponed the beginning of the home visits to the following week. Sara, however, contacted us, again cancelling the appointment. In the following four weeks, she periodically contacted us to postpone the meetings with different excuses, but still “compulsively” talking about herself. We then decided to keep the telephone contacts, trying to offer a space that could welcome her need to be listened to, but with precise time limits to it. Our impression was in fact that Sara had a strong need for closeness, but was also very scared by it, as partly seen in the somatic complaints6 that followed her separation from her husband.

Six months later, it seemed Sara was ready to start the home visits and we met again. Matteo was eight months old and he was at the 85th percentile in the growth curve, an element of risk for developing overweight/obesity. During this meeting, Sara described a baby who “cries constantly for no reason”, who “never behaves well”, and who “fusses when 1 feed him”. Sara was convinced that Matteo’s main problem was his obstinate and irritable personality. This did not seem to cause eating problems, like rejection or selectivity of food, but it created a conflicting emotional environment, which was too difficult for Sara to manage on her own.

After this “new first meeting”, Sara contacted us again, saying that “this commitment is too much” for her at that moment and that she felt “too tired to be able to go through with it”. The prolonged absence of her husband during a trying time like the post-partum phase removed a fundamental source of support from her, increasing her sense of isolation and her depressive states. Unlike in the previous interruption, Sara was able to speak the truth about the reason she wanted to stop the meetings, leading us to believe that the relationship we had started was based on greater trust and on our flexibility in negotiating the right distances to keep.

For the next year and a half, Sara continued to contact us, without a specific schedule or routine, but keeping us always up to date about Matteo’s growth, and describing him again as a “good well-behaved baby, who does not cause any problems”.

In the meanwhile, Giacomo returned definitively home. Sara contacted us saying that she was ready to start the process with us, because Matteo had become “difficult” again. In light of our previous meetings and of the information we had gathered along the way, we proposed the video feedback intervention to Sara, hoping that this would give us a more immediate access to the conflict within the dyad, and would offer Sara a perspective through which to observe her relationship with her son.

Matteo, over two years of age, was showing the beginnings of overweight, which immediately reminded us of his relationship with Sara since pregnancy. We observed the feeding interactions, and the most striking element was the conflict between mother and child, which manifested itself in the form of protest. Matteo did not cry during these episodes, but he showed a strong opposition to the mother’s presence. Sara tried her best to feed Matteo and to seem adequate in our presence, but her sense of frustration was evident, as was the fact that the exchange we were observing was not the escalation of a problem within the dyad, but the consolidation of an emotional pattern that was reflected in many areas, of which eating was only one.

During our next meeting, thanks to the father’s assistance, we reserved a moment to watch with Sara an excerpt of the video recording. Right away, it was clear that the mother was struggling to understand the meaning of Matteo’s protest, beyond its immediate manifestation. Sara’s answers related to Matteo going against Sara, throwing almost vindictive tantrums. We found this explanation very interesting because it attributed a very subtle emotional process to Matteo, pointing us towards the hypothesis that Sara had been unknowingly treating Matteo, in the absence of his father, “like a little adult”, capable of plotting against his mother. We thus decided to keep our focus on this aspect: why was Matteo protesting? We tried to use our next two meetings to explore this question, observing Sara feeding Matteo, how Matteo responded to this, and how Sara reacted to Matteo’s behaviour. We tried to construct a logical chain of actions, in which we could see the connection between cause and effect, creating a space where Sara was free to take time and observe her son’s emotional expressions and their meaning, claiming back that time she felt she could not enjoy any longer, because of the continuous escalation of anger. Gradually, this space enabled the mother to mainly gain the emotional predisposition to notice different aspects in Matteo’s lunch experience. Tenderness, curiosity, distractions, and the relationship with his sister emerged. Sara started seeing Matteo as a child, making space for thoughts about his “needs”, and her role as regulator of them.

When we realized that Sara had brought her relationship with Matteo as the central element of our process, we shifted the focus on the meaning of their behaviours at that moment. Our objective was in fact to promote, in the mind of the mother, a focus on the present moment that could then be transferred to all their future interactions, enabling her to observe and listen to what is really happening, without fear of mistakes7 or of being judged by the presence of a “competent” female. At the end of our eighth meeting, Sara told us that she had noticed how Matteo assumed a specific posture right before she showed him the spoon and started feeding him. In fact, Matteo stiffened, clenched his fists, and when the spoon was in his mouth, he banged his hands on the table. Why? What did this sequence mean? In the following meetings, Sara reflected and shared her observations with us, gradually moving from the here and now to a dimension of temporal reconstruction, that could include all family members.

After this important passage, Sara began to be more empathetic towards Matteo’s protests, loosening those behaviours that previously led her to handfeed Matteo, instead granting him more freedom to touch, to play, and to try to eat on his own. As a result of this enhanced maternal availability and sensibility, Matteo started showing a wider range of emotions, more positive, which, even though still occurring in-between moments of irritability, were enough to reinforce Sara’s growing desire to take care of her son. Meals began lasting longer, in order to allow Matteo to perform the routine with autonomy. This change also altered Matteo’s regulatory abilities, and by the end of our meetings, he had started to interrupt the meal signalling his satiety.

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