A

THERAPEUTIC PLAY WITHIN INFANTPARENT PSYCHOTHERAPY AND THE

TREATMENT OF INFANT FEEDING DISORDERS
BRIGID JORDAN

Murdoch Childrens Research Institute and Royal Childrens Hospital Melbourne

This clinical article presents an infant mental health approach to the treatment of feeding disorders in infants and toddlers that involves the
infantparent psychotherapist directly working with the infants representations within infantparent psychotherapy sessions. The treatment is informed
by an assessment of the infants emotional development, subjective experience, and the dynamics of the infantparent relationship. This model involves
therapeutically using play and words with infants and draws upon concepts from D.W. Winnicott and attachment theory as well as principles from the
psychodynamic treatment of posttraumatic stress disorder in infants. The model was developed from clinical work over 2 decades in a tertiary pediatric
hospital with infants who presented with feeding disorders ranging from breast or bottle refusal, refusal to wean onto solids, feeding aversion, tube
dependency, and failure to thrive.

ABSTRACT:

Abstracts translated in Spanish, French, German, and Japanese can be found on the abstract page of each article on Wiley Online Library at
http://wileyonlinelibrary.com/journal/imhj.

* * *
The complexity of the dynamics that lead to the symptom of
feeding refusal is evident in the six subcategories of feeding disorder in the diagnostic manual DC:03R (ZERO TO THREE, 2005).
Etiological factors range from infantparent relationship dynamics
(Chatoor, 2009, Chatoor, Ganiban, Colin, Plummer, & Harmon,
1998; Daws, 1997) to traumatic responses to physical illness or
medical intervention (Chatoor, 2009). Treatment approaches include targeting the infantparent relationship using infantparent
psychotherapy (Daws, 1997; Emanuel, 2008) or interaction coaching (Benoit, Wang, & Zlotkin, 2000). Many treatment models
recognize the impact of maternal (and medical system) anxiety
and suggest principles for structuring the feeding experience in
ways that support developmentally appropriate autonomy (Chatoor, 2009; Duntz-Scheer et al., 2009).
Although posttraumatic feeding disorder is no longer a diagnostic entity (having been replaced in revision of the DC:03
(ZERO TO THREE, 1994) with feeding disorders secondary to
medical condition or insult to the gastrointestinal tract), it remains
a clinically useful construct. Some infants have a traumatic stress
response and feeding aversion following maternal force feeding in
response to a feeding disorder that started as infantile anorexia or
disorder of state regulation. Conceptualizing the infants relationship to feeding and food as a posttraumatic stress response enables

us to draw on the treatment literature for infant posttraumatic stress

responses arising from other circumstances (Appleyard & Osofsky,
2003; Drell, Siegal, & Gaensbauer, 1993; Gaensbauer & Siegal,
1995), which may be more helpful to infants than the behavioral
approaches often advocated in the literature (Solter, 2007).
THE INFANTS REPRESENTATIONS AS PORT OF ENTRY

In this article, I describe a therapeutic approach to feeding disorders

that involves targeting the infants ideas about feeding and refusal
as the port of entry (Stern, 1998, p. 134). This approach draws
on the tradition of the baby as subject (Thomson-Salo, 2007,
p. 961), is informed by attachment and psychodynamic theories,
and involves the use of play within infantparent psychotherapy
sessions to address the infants representations. Key elements of
this approach to infantparent psychotherapy include treating the
infant as an equal partner in the dyad or triad during therapy, with
the therapist working actively to establish an emotional connection with the infant and to communicate their interest in the infants
subjective experience. The aim with parents is to help them understand the infants emotional dilemma. This work includes holding,
containing, and unhooking projections, creating space for ambivalence, and making links between the infants experience, the parents experience, and their experience of their relationship with
their infant. In the treatment of feeding disorders, this approach
involves addressing the infants aversion to feeding by engaging
with the infant about the unique meaning of feeding for him or her.

Direct correspondence to: Brigid Jordan, The University of Melbourne Department of Paediatrics, 4th Floor Front Entry Building, Royal Childrens
Hospital, Parkville, 3052, Australia; e-mail: brigid.jordan@rch.org.au.
INFANT MENTAL HEALTH JOURNAL, Vol. 33(3), 307313 (2012)

C 2012 Michigan Association for Infant Mental Health
View this article online at wileyonlinelibrary.com.
DOI: 10.1002/imhj.21321

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B. Jordan

Behavioral Approaches to the Treatment of Feeding Disorders

Many published accounts of therapeutic work that directly targets

the infants representations in feeding refusal or aversion behaviors
have been limited to behavioral approaches (either desensitization
or flooding). An article by Solter (2007) in the Infant Mental Health
Journal opined that Treatment modalities for TSD [traumatic
stress disorder] that rely on exposure to traumatic themes through
symbolic representations such as language, images, or symbolic
play are therefore inappropriate for infants under 12 months of
age (p. 79).
Behavioral extinction therapy (flooding) considers the infants
feeding aversion to arise from classical conditioning (i.e., feeding
has been associated with pain), and thus rapid and intense exposure to the feared food is the treatment strategy with the aim
of decreasing the infants anxiety and reducing learned avoidance
of feeding. The therapist controls the rate of exposure and actively works to help the infant tolerate the anxiety associated with,
for example, food being placed on the lips or mouth (Benoit &
Coolbear, 1998). In this approach, the infants gag or refusal response is not considered a reason to stop the feeding. Flooding has
been described as intense exposure to the feared stimulus, while
escape behaviors are blocked (Solter, 2007, p. 79), and the treatment is often associated with intense crying by the infant (Solter,
2007). Benoit (2000) cautioned that behavioral extinction therapy
is not a panacea (p. 349). In one trial, although more effective
than was nutritional intervention alone in discontinuing enteral tube
feeding, behavioral treatment was effective only in half the cases
and did not cure feeding-resistance behaviors (Benoit et al., 2000).
Chatoor (2009) advised that behavioral treatments require skilful
handling to avoid retraumatizing the infant, and Solter (2007) also
warned of this risk.
Different therapeutic approaches to the treatment of feeding
disorders share the goal of the infant eating in a developmentally appropriate manner and regulating food intake by feelings of
hunger and satiety. An infant mental health perspective also needs
to focus on the infants emotional development, the infants subjective experience, and the dynamics of the infantparent relationship,
including the feeding relationship. Behavioral approaches such as
flooding are problematic for the mental health of the infant regardless of the skill of the therapist, especially given the infants acute
distress during the treatment and the subjugation of the infants autonomy. The therapist controls the rate of exposure, and the infant
thus is feeding to comply with the wishes of another and not in response to internal regulators. The treatment impinges on the infant
and employs strategies that are the opposite of behaviors known
to promote a sense of security and healthy emotional development
(e.g., sensitivity, contingent responsiveness, attunement).

Psychodynamic and Attachment Theory Informed Principles for

the Treatment of Feeding Disorders

Attachment theory, psychodynamic understandings, and current

evidence about infant memory and cognition offer ways of under-

standing some of the reasons behavioral approaches have limited

efficacy and can inform alternative therapeutic approaches that
involve working directly with the infants subjective experience.
Winnicott (1988) wrote that It is not possible to take for granted
that the infants psyche will form satisfactorily in partnership with
the soma, that is to say with the body and its functioning. Psychosomatic existence is an achievement. . . (p. 12).
Behavioral treatment approaches deal with the outsides of
behavior, and the unique meaning of feeding for the individual
infant is bypassed, as are intrapsychic conflicts about feeding (e.g.,
anxieties about oral aggression), which may have implications for
current emotional functioning as well as risk of future relapse. The
distress involved in behavioral treatments and the adult-led rather
than infant-led approach represent a missed opportunity to harness
the infants developmental pleasure in exploration and mastery as
an avenue for addressing the feeding difficulty.
Attachment theory offers a framework for thinking about the
feeding interaction and the infantparent relationship as well as for
conceptualizing the infants relationship with food as a relationship
with the environment. Feeding involves negotiating the boundary
between the insides and the outsides.
The importance of assessing and addressing infantparent relationship issues, including attachment security in all subtypes of
feeding disorders, is recognized by many authors (Benoit et al.,
2000; Chatoor, 2009; Daws, 1997; Emanuel, 2010), and the feeding disorders arising from early derailments of the infantparent
relationship are well described in this literature. Assessment of
the infantparent feeding interaction needs to include the emotional availability of the mother, comfort-seeking behaviors and
responsiveness of the infant, what is dished up with the milk
(anxiety, despair, depression, frustration, grief), the accuracy of
the mothers perception of feeding behaviors, the infants development (including emotional development), the infants intentions,
and the negotiation of issues of dependence versus autonomy.
The following discussion will focus on how attachment theory
offers a way of understanding the infants relationship with food
and subjective experience of feeding. A key tenet of Bowlbys
(1958) theory of attachment is that the attachment relationship
is cybernetically organizedwhen attachment behaviors are activated, exploration shuts down, and exploration is possible when
the infant has a secure base. Behavioral extinction therapies (e.g.,
flooding) that cause severe anxiety will escalate attachment behaviors (e.g., crying) and reduce exploratory behaviors. From this
perspective, it is logical that a fear-inducing treatment with the
escape route blocked will have limited efficacy in tube weaning
and curing feeding-resistance behaviors.
Attachment theory principles suggest that treatment approaches to feeding disorders need to provide a secure base for
the infant to explore food, harness their curiosity about the world,
support autonomy and optimal emotional development, and restore
what Von Hofacker and Papousek (1998) termed intuitive parenting (p. 183). Exploratory behaviors are likely to increase when
the infant feels safe, and interventions that wobble the infants
secure base (e.g., by inducing severe hunger or by impinging on

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Therapeutic Play and Infant Feeding Disorders

the infant) will cause the infant to shut down exploratory behaviors
and lead to more entrenched refusal.
If feeding is conceptualized as an exploratory behavior, that
involves using a secure base to turn toward and gradually explore the environment in small doses, certain treatment principles
become evident. Many of these recommendations are already in
the literature, although not explicitly articulated as an attachment
theory informed intervention. If food is either a novelty in the environment (e.g., when solids are first introduced) or frightening,
then the infant needs a secure base from which to explore. Any
infantparent relationship issues that threaten the infants sense of
security and autonomy need to be addressed in tandem, but the
intervention does not stop there.

POSTTRAUMATIC FEEDING DISORDERS

Many feeding disorders that have their origin in dynamics other

than traumatic medical conditions end up having the characteristics
of posttraumatic feeding disorders due to misguided interventions
attempting to cure the feeding aversion (e.g., oral/facial stimulation, frequent feeding, force feeding, feeding while the infant is
asleep, etc.). Treatment recommendations for posttraumatic stress
disorder include the reinstitution of a safe, stable, and nurturing
environment, developmentally appropriate stimulation, contingent
responsivity, and affect attunement (Appleyard & Osofsky, 2003;
Drell et al., 1993; Gaensbauer & Siegal, 1995).
These principles need to be implemented at multiple levels in the treatment of posttraumatic feeding disorders, including
the meal time setup and medical, nursing, allied health, and psychotherapeutic interventions that directly target the infants feeding
behavior. The treatment regime needs to be responsive, sensitive,
contingentresponding to the infants need and communication
and not adult imperative, respectful of the autonomy of the infant, supportive rather than intrusive and impinging, and accepting
of the infant and not aggressive. Interventions such as scheduling
feeds (Chatoor, 2009) may be helpful for infants who are not able
to recognize hunger, have not linked feeding with satiating hunger,
or who have been subjected to around-the-clock feeding or force
feeding. Scheduling feeds; a ban on tricking the infant to eat or disguising food; having a limited, consistent duration of time for the
feed; and stopping the feed when the infant indicates a wish to stop
are all important for maximizing predictability and contributing to
a sense of security. These strategies also give the infant space to
feel a bit hungry, to establish a link with hungerfeedingsatiety,
free up some time in the day for interactions between mother and
infant that are not about feeding, and reduce the infants vigilance
so that they are more likely to approach rather than avoid food.

WORKING WITH INFANT REPRESENTATIONS ABOUT

FEEDING USING THERAPEUTIC PLAY

There has been a debate in psychoanalytic infantparent psychotherapy about whether psychotherapeutic work needs to take

309

place around observation of actual feeds and mealtimes or whether

relationship work is sufficient (Daws, 1997). My approach is to
incorporate observation of actual feeds and work with the infants
ideas and fantasies about feeding within the dyadic infantparent
psychotherapeutic work.
Sessions always involve at minimum mother and infant (unless
the infant is admitted to the ward and the mother is not present), but
often also include fathers and siblings, and at times, grandparents.
In classic infantparent psychotherapy, discussion between the
therapist and parents moves between the baby and his needs and
problems, and the parents and their needs and their problems, especially those that have bearing upon the baby (Fraiberg & Bennett,
1978, p. 229). In the approach outlined in this article, there is an
additional, third dimension of direct communication between the
infant and psychotherapist. Feeding is the site of highly charged
conscious and unconscious transactions between the infant and
parents. In sessions, parents may discuss concerns about their infants emotional development and behavior (other than feeding
behavior), their relationship with their infant, including normal
maternal ambivalence, the meaning of the infants feeding refusal
for them (e.g., it may be experienced as a rejection of their mothering), feelings of anger and frustration toward the infant and the
guilt that such feelings may give rise to, and feelings about the
infants autonomy and moves toward separation. The therapist and
parents work in partnership to help the infant; part of this involves
the therapist being available to help them articulate and process the
feelings, fears, wishes, and conflicts aroused by and contributing
to the infants symptom.
Direct engagement with the symptom of feeding refusal is an
integral part (but not the whole focus) of the therapeutic work. The
infant has his or her own experience, anxieties, and fantasies about
feeding. Play is a medium to engage with the infant in a conversation about feeding, and provides opportunity to play with the idea
of feeding. Some of this happens with real food at meal times (e.g.,
when an outpatient session coincides with lunchtime), and some in
the domain of the symbolic or representational. In this approach,
representational toys (doll, tea set, dolls bottles, plastic food) are
used by the infant (from about 6 months of age) to represent his
or her experience and by the therapist to visually express to the
infant what he or she understands the infants experience to be.
This work has some similarity with that described by Gaunsbauer
and Siegal (1995) in work with older infants with posttraumatic
stress symptomatology.

CASE EXAMPLE 1
I was called to the ward to see Rose 7 months old, a solemn-faced Chinese
baby who had been in the hospital for several days with bronchiolitis. She
had been on an intravenous drip, her illness had resolved, but she could not
be discharged home as she was not drinking enough to remain hydrated.
When I arrived on the ward, Rose was sitting on her mothers lap in a chair
by the cot. She sat passively with an immobile face while her thoughtful,
gentle mother told me about the course of the illness and her concern that
Rose would not drink. There seemed to be no major psychopathology or

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B. Jordan

preexisting distress in this motherinfant relationship. I found a doll, a

dolls bottle, a toy cup from a tea set, a couple of spoons, a bowl, and a jar
of pureed apple. When I returned to the bedside, I started to feed the doll
with the dolls bottle. This piqued Roses interest, and she looked intently
at what I was doing. I said in a matter-of-fact way that dolly was hungry
and having a drink. She reached out and took the dolls bottle from me
and started to suck on it. After a while, I brought out the empty bowl and
a spoon and pretended to feed the doll imaginary food. Rose reached out
for the spoon, which I gave her to hold. I put some apple puree in the bowl
and started to feed the doll, whereupon Rose opened her mouth wide. I
handed the pureed apple and spoon to Roses mother, and Rose ate the
whole jar. That night, she drank her usual number of bottles and was able
to be discharged home the next morning. Telephone follow-up indicated
no new problems. In my clinical experience, babies as young as 5 months
of age reach out for the dolls bottle and suck on it even if they scream at
the sight of a real bottle of milk.

prescription formula has been introduced. Thus, instead of feeding

relieving the discomfort of hunger, the infant has an experience of
feeding causing pain. If food is experienced as an attack on the
body, it makes sense, as a survival response, for the infant to refuse
to feed.

In this consultation, after initially listening to Rose and her

mother, I actively set up a scenario with toys that represented Rose
with her dilemma in a three-dimensional way. The infants reactions to the doll, the bottle, and the play feeding of the doll are
important parts of assessing what feeding might mean for this infant. Creating the play representation of the problematic feeding
situation communicates to the infant that I have some idea about
what the dilemma or problem is, and that my task with them is
thinking about the problem. Experiments in recent years with deferred imitation and the role of mirror neurons have demonstrated
how infants form representations from observation and the infants
abilities to detect the intention of the other and use these representations as a basis to organize further action (Meltzoff, 2004). My
play with feeding the doll communicates to the infant the stance
with which I approach conflicts about feeding (my degree of empathy, how anxious or relaxed I am about refusal). I am outside
the web of anxiety enveloping the mother and infant, and bring
an opportunity for the infant to play with the idea of feeding at
his or her own pace. The displacement onto the doll allows what
Winnicott (1941) called the full course of an experience (p. 246).
There is sufficient space for the infant to explore and find his or her
own desire to eat and to face conflicts about eating. Daws (1997)
noted the similarities between infant anxieties about feeding and
the spatula game employed by Winnicott (1941), who used the set
situation of the spatula on the table during a consultation to elicit
the infants interests and fantasies. Winnicott (1941) described how
the first stage is hesitation due to the infants anxieties. The next
stages of the spatula game also have a parallel in the therapeutic
possibilities of the play I am a describing (In the second stage, the
infant has the spatula and can bend it to his or her will, or use it as
an extension of his or her personality. In the third phase, the infant
experiments with getting rid of the spatula.) (Winnicott, 1941).
Doll play can enable an exploration of the anxieties about
feeding in displacementone step removed. This has often been
helpful for infants with a posttraumatic feeding disorder secondary
to severe food allergies. Symptoms of severe allergy include vomiting; explosive, watery diarrhea; inflamed lining of the gut; and
acidic reflux, which causes abrasions on the lining of the esophagus. It can take a couple of weeks for the gut to heal even after

Sally and her mother attended together for weekly outpatient infantparent
psychotherapy sessions. Sallys mother felt that she did not know how to
help Sally overcome her aversion to feeding and wanted assistance to
understand Sallys feeding refusal. In addition to the focus on understanding Sally, core themes of the work of the sessions included the legacy of
mothers attachment history (including a hospitalization in infancy); her
ambivalence about the dependency needs of Sally; her feelings of frustration and at times, despair; and sadness about the losses (e.g., of her
career) that she attributed to Sallys illness and reliance on the nasogastric
tube. Sally had initially made good progress with outpatient work and
was drinking some formula, but had severe allergic reactions when many
of the usually safe solids were introduced. The allergic reactions usually
involved severe rashes and episodes of violent vomiting, following which
Sally would refuse all oral feeds. Sally had had a bad winter with many
bouts of the common cold and tolerated the symptoms poorlyfeeling
unwell reduced her interest in feeding, coughing led to vomiting, and she
resorted to total feeding refusal. The following vignette occurred about 40
min into a session with Sally and her mother when Sally was 9 months
old. Sally was crawling on the floor playing with toys on the floor while
her nasogastric feed was running. I made a pretend nasogastric tube out
of transparent sticky tape from my desk and stuck it to the face of one
doll, which I placed sitting on the floor. Sally crawled over to the doll and
sucked on the end of the tube. After some minutes, I sat another doll
(the one Sally played with more often) on the floor with a dolls bottle in
front of it. Sally sat up, looked from one doll to the other back and forth
for some minutes, and then crawled over to the doll with the bottle. This
felt like she had made a considered choice. She picked up the dolls bottle,
sucked on it, and then fed the doll, then herself, back and forth, until her
nasogastric feed was finished. Sallys mother mused on how much the
tube had become part of Sally . . . she loves that tube.. . . Its part of her
body.. . . She sucks it like sucking a toe. This led to a discussion about
what it might feel like for Sally to give up being fed by the tube and her
possible ambivalence about being weaned from the tube. Sallys mother
decided that it might be a good time to re-introduce having the bottle
available for Sally to drink while the nasogastric tube feed was being
prepared.
Following this session, there was a marked change in Sallys attitude
to her own bottle of milk. At home, Sallys mother put her bottle next
to her doll and pretended she was going to feed the doll. Sally crawled
over and snatched the bottle away from the doll. Her mother thought she
was very angry and jealous that mother would feed the doll the bottle
that belonged to Sally (although until this point, she had been steadfastly
refusing to orally drink any milk). Later that day, her mother had left the
bottle on the coffee table after getting Sally up from a nap, and while
getting equipment ready for tube feed, Sally had crawled over to the table
and got the bottle. Her mother thought she was contemplating drinking
from the bottle, and she started to chew her nasogastric tube.

CASE EXAMPLE 2

Sally was referred at the age of 3 months during an admission to

the hospital to investigate feeding refusal and failure to thrive. She
was diagnosed with severe food allergies and had a nasogastric
tube inserted during this admission, and was referred to our infant
mental health service.

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Therapeutic Play and Infant Feeding Disorders

I think that by placing the two dolls side by side, one with a
tube and one with a bottle, in front of Sally, I had provided a visual
representation of, and an enactment of, her dilemma. In addition
to conveying that I understood her dilemma, I provided Sally with
the space and the tools to play with the idea of feeding, and the
differences between tube feeding and oral feeding. Doing this in
the context of a therapeutic session which has as its focus understanding her emotional life, her experiences, and her dilemma, and
where the anxiety-laden problemthe idea of food and feeding
was present, engaged with, and thought (and played) about in a
freer space without any pressure, encouragement, or praise, enabled Sally to move closer to embracing the possibility of oral
feeding. I was very active in setting up the scenariofollowing
the lead from Sally. I think Sally felt that this tableau spoke to her
and was representative of her experience. She carried this home to
her experience with her real bottle of milk at home. However, this
play seems to have enabled her to think about and reflect on her
experience. Meltzoff (2004) described how . . . infants understand
the world in ways that change according to the data obtained and
the experiments they perform. . . Infants have changeable theories
of the worldnot sensorimotor reactions (p. 148).
This play experience offered new data that helped open the
door to a new relationship with the idea of drinking. Therapeutic
play enables a shared encounter between the infant, the therapist,
and the infants mother with the aspects of the problem that are
lodged in the infant.

CASE EXAMPLE 3
Rachel was referred to our infant mental health service at 3 months of
age during an admission for failure to thrive and feeding refusal. She
had had a nasogastric tube in situ from 3 weeks of age after failure to
gain weight on breast-feeds. She was seen with her mother weekly for
outpatient infantparent psychotherapy.
At 6 months of age, Rachel (who had a history of severe food allergy which had been undiagnosed for 3 months) was vomiting 3 of 5
daily nasogastric feeds. She recently had a heavy cold, and the increased
mucous secretions led to her vomiting every feed out of her nose. During
this illness, she refused to put anything in her mouth, including her pacifier, and afterward, her vomiting seemed to have a voluntary aspect. She
dry-retched after the first 30 ml of nasogastric feed went down the tube,
and then vomited the whole feed. Her parents thought this was intentional
and were concerned that if all nasogastric feeds were vomited, a percutaneous endoscopic gastrostomy tube would need to be inserted. Apart
from feeding, she seemed to be doing well and was a happy baby, interactive and meeting developmental milestones. The active vomiting might
be understood as a repetition or reenactment and a way of dealing with
the trauma, and perhaps anger, at the illness that caused such relentless
vomiting. We arranged for Rachel to be admitted to the hospital for more
intensive treatment. On the first day of the admission, I went to the ward.
Rachel and her mother were sitting on the floor playing when I arrived
(Her mother stayed with Rachel throughout the admission, sleeping in a
bed next to the cot.) I joined them and discussed with mother how they
were both settling in. It was time for Rachel to have her nasogastric tube
feed, and her bottle of formula was ready. I decided to drink some of
Rachels formula in front of her to reassure her that it was not poison. I
shared my thinking with Rachels mother.

311

This decision occurred to me in the moment while I was

sitting with Rachel and her mother. It was not a predetermined
strategy, and I have not done it with any other patient before or
since despite having treated many infants with severe food allergies who have refused to drink. It was an intervention that emerged
spontaneously in the context of not knowing what would be helpful but being in a thinking space, where her mother and I were
reflecting on Rachels experience.
I was sitting on the floor facing Rachel, took the top off the bottle, poured
some into a glass, and took a sip. Rachel frowned, looked very worried as
I lifted the glass to my mouth, and then suddenly went as white as a sheet
with red-rimmed eyes as I took a sip of the milk. This was a very dramatic
reaction, and it seemed a bodily memoryliterally a shocking memory.
It conveyed to us the extent of Rachels fear of the milk. Rachels mother
said with great empathy She is really frightened. We discussed Rachels
fear, the source of that fear, and my thought that Rachel was frightened
that I would come to great harm. This was a turning point, as that evening,
Rachel drank some milk for her mother from a cup.
The next day, I saw Rachel away from the ward in my consulting
room. She sat in a high chair with a tray table, with her mother sitting
close to her on a chair perpendicular to the high chair and me sitting
opposite with the tray between us and further away from Rachel than her
mother was. I placed a dolls bottle manufactured to look as if it was filled
with orange juice on the tray of the high chair and held a dolls bottle of
milk and pretended to feed a small doll. I fed the doll with pauses and
breaks and made sucking noises when the bottle was at the dolls mouth,
presenting a scenario where the doll had autonomy, in contrast to the
desperate attempts to feed Rachel prior to referral. Rachel picked up the
other dolls bottle, started to tentatively suck it, and then chewed on the
teat and eventually started to bite it quite hard. She babbled, talking to me
and showing pleasure in playing with the bottle. After some minutes, she
reached out for the bottle I was playing with, and I gave it to her holding
out my hand for her bottle as I expected her to exchange her bottle for
mine. However, she held onto both bottles and put both in her mouth with
beaming smiles.

In this exchange, Rachels mothers presence provided a secure

base for Rachel to focus on the play with me and exploration of the
idea of drinking. Her mother commented She is not confronted
by this at all, is she?
Rachels play with the dolls bottle was an opportunity to
play with the idea of drinking from a bottle, and her chewing and
biting on the teat was a more active and aggressive attitude to the
bottle than we had seen before. It seems that she was working
through her anxieties about drinking. It is my clinical impression
that posttraumatic feeding disturbances may disrupt the infants
working through his or her (oral) aggression, compounding an
inhibited approach to feeding and eating. Winnicott (19541955)
used the example of feeding to illustrate the normal developmental
progression of the infant from an initial excited ruthless drive for
instinctual satisfaction, without concern for the other, to achieving
the depressive position or the stage of concern (p. 264).
The individual child becomes concerned not only with impact on his
mother of his impulses but also notes the results of his experiences in his
own self. Instinctual satisfactions make him feel good, and he perceives
intake and output in a psychological as well as a physical sense. He
becomes filled with what he feels to be good and this initiates and maintains

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B. Jordan

his confidence in himself and what he feels he may expect from life. At
the same time he has to reckon with his angry attacks, as a result of which
he feels he becomes filled with what is bad or malign or persecuting.
(Winnicott, 1950, p. 207)

I think that infants (e.g., those with severe allergies) whose

feeding has led to pain may have never fed (from breast or bottle,
in sucking or eating solids) in an uninhibited, excited (or to use
Winnicotts termruthless) way. Although a careful, timid, approach makes sense at the reality level (until the infant has worked
out if a new food will cause harm), this inhibition may be compounded by the infants anxieties about his or her aggression. I
hypothesize that if greedy drinking or eating has led to severe
pain, rashes, and vomiting, the infant may become muddled and
feel that excited feeding, or biting, is always dangerous. My clinical hypothesis is that some infants project their aggression into
the food and may feel that food has actively aggressive qualities.
I have observed infants behaving as if they had to kill the food or
tame it before it can be ingested (e.g., infants who beat the food
with a spoon before tasting it, a 14-month-old boy who would hold
mandarin segments in each hand and squeeze them with great force
and a ferocious expression on his face before eating them). Rachel
showed pleasure in chewing on the dolls bottle. She vocalized
about the bottle and tried to reengage me in a conversation when
I turned to say something to her mother. This play is a chance in
displacement to deal with what has not been able to be dealt with
in realityplay as the bridge between the internal world and the
external reality (Winnicott, 1974). I think the two bottles in her
mouth at the end involves playing with greed and the possibilities
of drinking in an uninhibited way. The play allowed the full course
of an experience that was truncated in reality by the extreme physical reactions of vomiting, rash, and pain when Rachel attempted
to satisfy hunger with feeding. This was a significant and hopeful
shift for an infant who had progressed from total oral-feeding refusal to taking one sip at a time of milk from her cup and then going
into a trance before taking the next one and who had approached
all feeding with such caution.

CONCLUSION

This article offers an approach to the treatment of feeding disorders

that includes direct engagement with the infants anxieties, fears,
and fantasies about feeding, within the context of infantparent
psychotherapy with the infant and his or her parent(s). Feeding
behavior is conceptualized as an exploratory behavior, and the importance of a secure base for the infant (within the infantparent
relationship and as part of the treatment regime) is outlined. Consistent with an attachment theory informed approach to the treatment
of feeding disorders with its emphasis on autonomy and exploration, therapeutic play within infantparent psychotherapy is used
to create a free space for the infant to explore the idea of feeding.
Winnicotts (1974) ideas of play as a bridge between internal and
external reality inform this technique, and his conceptualization of
the relationship between instinctual drives and the depressive po-

sition are drawn on to understand the possible fantasies behind the

extreme inhibition of feeding and biting in infants with traumatic
feeding disorders. The stance that the therapist needs to bring to
direct play with infants is, in many ways, similar to the receptivity,
deep listening, and attention to transference and countertransference elements that one needs to bring to all psychotherapeutic
work. Although I have described being quite active in play in the
case examples, this activity arises in the context of an ongoing
therapeutic relationship with the infant where he or she knows that
I am interested in his or her subjective experience, and it grows
out of the development of shared meanings and understandings
about the situation in which the infant and mother and family find
themselves. The theoretical literature on the nonverbal aspects of
change in psychotherapy with adults can be helpful in articulating
the mechanisms of change in this direct work with infants. Infant
imitation has been described as a like me bridge which enables
the infant to
read(ing) other peoples states of mind, especially intentions; resonating with anothers emotion; experiencing what someone else is experiencing; and capturing an observed action (vocal as well as visible) so
one can imitate itin short, sympathizing with another and establishing inter-subjective contact. (Boston Change Process Study Group, 2008,
p. 133)

I am suggesting that this intersubjective contact can work in

the other direction as wellfrom therapist to infant using play
which is more than imitation, but still a nonverbal medium of
communication. As with spoken words and verbal interpretations,
it also is the experience of another thinking mind and the emotional
language, facial expressions, and gesture that also convey to the
infant the experience of being understood or misunderstood.
In contrast to behavioral treatment approaches, this article outlines a model of direct work with the infant as part of dyadic infant
parent psychotherapy that involves working with the insides of
the infants feeding disorder with their subjective experience and
their representationsof themselves, their body, their experience
of their body, themselves with their mother, and in the world. Representational play is a means of engaging directly with the infant
in a dialogue about the meaning of their feeding difficulties and
the emotional work that needs to be done.

ACKNOWLEDGEMENT

I would like to acknowledge Michele Meehan (Matenal and Child

Health Nurse), Sue Morse, Libby Ferguson, Katherine Ong and
Rachel Pinczower (speech pathologists) who contributed much to
my understanding of feeding disorders while undertaking joint
clinical work. Ann Morgan, Campbell Paul and Frances ThomsonSalo and others in the RCH Infant Mental Health group have contributed much to my understanding of infants. Julie Stone gave
very helpful advice when I was drafting the outline of the paper.

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Therapeutic Play and Infant Feeding Disorders

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