Month: February 2017

  • Disorganized Attachment: The Search for Light Between the Cracks of Pain and Hope

    Disorganized Attachment: The Search for Light Between the Cracks of Pain and Hope

    When a child has a secure attachment, he or she can explore the surrounding world safely, trusting and knowing that their parent or primary caregiver will welcome him or her back with open arms. When she lived with her mother and father, Eva’s parents were her primary attachment figures whom she would turn to in times of distress for comfort and safety. However, Eva experienced and witnessed abuse and neglect at the hands of her parents until she was removed from her home at 27 months of age. Eva was caught in a terrorizing bind between the drive to seek safety from her mother and father, who at times were the root cause of the distress and unpredictable fear or harm she was experiencing. When a child must constantly live in this bind, searching for a way out and living in an unsolvable state of fear, disorganized attachment emerges.

    Both of Eva’s parents struggled with drug abuse, mental health concerns, poverty and their own trauma histories. These and many other factors put Eva and her older siblings at risk for abuse and neglect, as well as the development of disorganized attachment. After their home caught fire, Child Protective Services (CPS) was called. There had already been several other calls and a pending investigation, so CPS wanted to remove the children. However, the mother was willing to sign over guardianship to an aunt and uncle so the children did not have to go into foster care. She was also willing to go into an inpatient drug rehabilitation facility. The mother was also pregnant. CPS was not going to allow the new baby to go home with the parents; therefore, the aunt and uncle agreed to take the baby when mom gave birth. Eva and her siblings went to live with her aunt, uncle and their children, making a grand total of eight children under one roof. The aunt sought out services for the children shortly after their arrival. Due to Eva’s age, she was referred to infant mental health services. But this is only one part of Eva’s story. I want to tell you a little about where she was, but also about how far she has come.

    What About the Baby? Where’s Eva?

    MotherAndBaby_100I will never forget my first visit with this family. This was only my second or third case as a new clinician. I was eager and anxious for the opportunity to apply all that I had learned in school to the real experience of being with families. I remember walking up to the house on a crisp autumn day, leaves crunching at my feet and paperwork in hand. Gail, Eva’s aunt, greeted me at the door. She was a short woman, in her early 40s, wearing blue jeans and a grey hooded sweatshirt. She brought me to the kitchen table that looked as though it had been cleaned and well prepared as the place that we were to meet. I simply asked Gail to tell me a little more about Eva and what brought her to treatment at this time. As I listened to the story, I remained attuned to and curious about the matter-of-fact way in which she walked me through her experience of Eva and her behaviors.

    While working to remain present to the unfolding story, I noticed a question fighting for my attention, like a toddler tugging on my shirt needing me to see what he was seeing that instant. The literal question I had heard so many times before in the classroom kept popping into my head, “What about the baby? Where’s Eva?” For a new infant mental health clinician, mustering up the courage to ask a question—even one as obvious as this—can leave us wanting to run for the door. I waited, not only to take a moment to turn down my inner critic for not wondering this sooner, but for an opportune time to wonder out loud, “Where is Eva?” with genuine curiosity. Gail looked at me and then pointed underneath the table. I remember the high-pitched sound the chairs made against the hardwood floors as we pushed them out from the table in unison, still locking eyes with one another. It felt like an unspoken agreement between the two of us that neither would move first, that we would look together. I wonder, reflecting on this moment now, if we also silently and mutually agreed that from now on were going to be in this together.

    Eva, now 30 months old, was lying on her side at Gail’s feet under the table curled up in the fetal position. Her limbs were tightly tucked and woven into one another, covering her head, which was folded into her chest. Gail and I came back together above the table. I asked what seemed to work to pull Eva out of this? What did not work? Gail said that Eva could not tolerate physical touch, especially when upset. She had tried holding her, but she said Eva “just isn’t interested in that.” Gail said that she allowed her to sit there, because she was afraid to do anything that might cause Eva to go into one of her temper tantrums. I asked if she could describe to me what those temper tantrums looked like. She described how Eva would hurt herself and others. She bit, hit, kicked and threw herself onto the floor.

    I asked what she thought Eva needed when she was so upset, and Gail responded, “I don’t know…. Help. Someone there.” I reflected that Gail understood what Eva needed and tried to soothe her by picking her up, but that Eva acted as if she “just isn’t interested in that.” We explored ways Gail might be able to soothe Eva and let her know she was there without physical touch. I then asked if we could try one of her ideas in that moment.

    We both moved from our chairs to the floor to test our hypothesis. I sat near Gail and Gail sat close to Eva. I gently spoke first as the narrator, telling Eva that Gail was right there and that she would be there when she was ready. We sat together in silence for quite some time until Gail finally spoke. She said only two words, but two words that truly resonate with a child like Eva. Two words that would symbolize our work, and that we would continue to carry with us throughout our time together. Gail quietly said, “I’m here.”

    Some time passed after Gail spoke, and Eva slowly began to unfold and untuck herself limb by limb until, eventually, she peeked her head up. She stared at us with her bright blue eyes; her brown curls all swept up in a messy ponytail high atop her head. We sat there together, with Eva and Gail not moving. Stillness filled the air like a thick fog. The calm did not last long, and soon Eva was off into the kitchen. She got onto the counter and opened cabinets, grabbing at anything she could reach. Plastic cups, bowls and plates crashed to the floor around her. Then, Eva was on her tiptoes with her fingertips barely grazing a bag of chips that sat atop the refrigerator. She moved her hand continuously in a sweeping motion until she knocked the entire bag onto the floor, chips flying everywhere. This all happened in a matter of seconds. Gail ran to her and grabbed her off the counter. Gail and Eva quickly fell into the dance that Gail had earlier described to me, but now I was seeing the live version. When Gail firmly told Eva “no,” Eva froze like a statue. She threw herself backward onto the hardwood floor and banged her head so hard that just the thought of the thud still makes me shudder. She began to scream and tossed her body around on the floor while biting at her hands and arms, ripping at her flesh. She reached for her ponytail and began to frantically pull at her hair, removing pieces by the handful. Gail ran over to her and gently restrained her. I watched as pain and panic washed over Gail’s face like a tidal wave, leaving a blank stare as she held this screaming, flailing child. I left their home that day wondering, “How am I going to do this? This isn’t what I expected! How can I help this child and this family?” Were those some of the very thoughts and questions Gail had asked herself?

    Light Peeking out from the Darkness

    About a month and a half into our work together, in addition to developing Eva’s sense of safety, we had also begun to think about ways to help Gail become more attuned to Eva’s needs. This was important because we had identified that Eva, who had very little language, might not communicate, cue or signal her needs as clearly as other young children. I watched and wondered week after week as Eva and Gail showed me how they related to one another. The intensity and frequency of Eva’s behaviors were unlike any I had ever seen in a child before. Over time, a pattern that felt ritualistic in nature became apparent.

    When Eva became distressed—though the triggers were never predictable—she would run “to” and sometimes “at” Gail. Gail anticipated Eva’s arrival with learned hypervigilance, bracing herself, eyes open wide and locked onto her every movement. Eva arrived like a freight train but slammed on the brakes the moment she reached Gail. Going toward comfort and then freezing is a hallmark example of an incoherent strategy in a child with a disorganized attachment relationship. Although Eva momentarily sought out her aunt, she was afraid of being hurt based on many experiences with her biological parents. Anticipating anger and abuse, she faced a dilemma of both wanting and being afraid of her parents. By 27 months of age, this belief was well-solidified as her working model and continued in her relationship with her aunt.

    Eva would be momentarily frozen in time as Gail anxiously scrambled to restrain her in anticipation of what was to come. Eva would then begin to scream and hit Gail, trying to bite at Gail’s arms and hands. Eva thrashed around as Gail held her in hopes that she could keep Eva from hurting either one of them further. Eventually, Eva would shimmy herself to the ground and break free from Gail’s grip. Eva then alternated between biting her hands and arms and ripping at her hair. She would throw herself onto the floor, slam her head on the ground and repeatedly bang her head. Gail would try to restrain Eva, and the cycle would begin again. At times, Eva would run from Gail into the bathroom, lie in the fetal position in the dark and cry alone. Gail expressed feelings of confusion and frustration; she felt that Eva seemed to calm down better when left alone. When she tried anything, it “made things worse,” and she just felt exhausted.

    Although this had become an all-too-familiar scene that happened multiple times within our two-hour visits, one day something shifted. Eva was coloring at the table and dropped the box of crayons onto the floor. She became very distressed and initially looked to Gail and started to walk toward her. Then she froze, threw herself onto the ground and started screaming, pulling her hair and biting herself. Gail started to go to her, but before she could get there, Eva ran into the bathroom and lay on the floor in the fetal position, limbs tightly bound. Gail and I sat together in the moment. She broke the silence by anxiously saying something about Eva just needing to be in there. She said that she would come out when she was ready. She indicated that Eva did not want her and that, if she went in, it would just upset Eva further.

    I reflected about what had happened right after the box of crayons fell onto the floor. I wondered if Gail had noticed what Eva did first. Gail described the scene as Eva falling onto the floor and having a temper tantrum. I then described what I had seen Eva do first. She had looked to Gail and started walking toward her. I wanted to be careful of implying that Eva “wants you” or “needs you,” because this was early in our work and it might have been too much for Gail. I worried that my words might sound judgmental or ignite her inner critic for not noticing this herself. Gail laughed a little and said, “See! How can I ever know what she wants?” I empathized with how confusing and frustrating it must be when a child’s actions seem like they are pushing us away, but we know that they really need us. I wondered if, in this moment, Eva’s behavior was showing us one thing, while she really needed something else. Gail and I decided to move together and sit outside of the bathroom where Eva lay in the dark, alone.

    As we sat together, I thought out loud back to our first visit and wondered if Gail remembered the two words she had said to Eva underneath the table that day. Gail initially looked at me, puzzled, but I watched a shift happen, as if someone flipped a switch, and the words were suddenly there. “I’m here,” she said with a grin. She then turned towards the dark bathroom where Eva lay and said, “We are here, Eva, when you’re ready.” We sat outside of the bathroom for a long time before Eva moved. Her first movement was small. She slowly peeked out with one eye barely moving, just to make sure we were indeed still there. Gail and I looked at one another and smiled. Shortly after, Eva got up and moved over to Gail, placing her head on Gail’s lap. I wondered if a gentle hand on Eva’s back might feel ok to Gail and Eva. Gail gently placed her hand on Eva’s back and then quickly asked if we could all clean up the crayons together. Gail then placed her hands behind her, arching her back slightly and creating space between her and Eva, making me wonder what physical closeness meant to her as well.

    Thinking back to our first visit when she described Eva as “just not being interested in that,” I wondered if she was really telling me something about herself. I kept this on a shelf in my mind and brought it forward later in our work together when Gail opened up about not being a “touchy-feely” person. Gail opened a tiny window that day for me to begin to see her internal working model and to understand what she brought to the relationship. Learning more about Gail, I wondered about the challenges this dyad faced: a child who needed help to feel safe and secure and to accept comfort in times of distress, but who might not always be able to seek it; and a caregiver who struggled with being needed and being close.

    Eva shook her head yes in agreement to working together to pick up the crayons. She walked over to the table and picked up the crayon box. Gail and I picked up the crayons one by one placing them into the box that Eva held. Eva delighted in her responsibility of holding the box, and she gleamed with pride. I put words to this with a simple observation, and Gail was able to add, “Eva, thanks for holding the box.” After we finished, the two of them smiled at one another. Eva then walked over to Gail and gently pulled on her hand, bringing her to the kitchen to show Gail that she wanted something to drink.

    There is a window behind the shower in the bathroom in Gail’s home. That day, the shower curtain was closed almost all the way, allowing just a sliver of light from the sun to pass through. I remember the ray of light touching the top of Eva’s head and shining onto Gail’s body, connecting the two of them in some way in that moment. But this was not the only thing connecting the two of them. It would be several months later when Gail began to share her own history with me; telling me stories of a similar childhood. I realize now I was sitting with two children that day, afraid and alone in the dark, telling each one of them in my own way, “I’m here.”

    Hope for the Future

    I have been working with this family for over four years now, and our time together is coming to an end as Eva ages out of our program. When working with a child with disorganized attachment, it is easy to feel lost or hopeless, just as they might feel. Although Eva was removed from her parents where the abuse and neglect had occurred, this new dyad has had its own challenges and triumphs. Establishing a trusting working relationship was a slow process. As we sat outside of the bathroom door week after week, following Eva’s lead and letting her know Gail was there, a parallel process was occurring as I was showing up week after week letting Gail know I was there. This child (and seven other children) need so much from a caregiver who struggled herself with being too close or needed.

    Today Eva, now 6.5 years old, is no longer engaging in self-harming behaviors. She does not have extreme temper tantrums and is doing fairly well in her second year of school, with only occasional regressions. She frequently seeks Gail out for comfort in times of distress. Gail is working to be consistently available to her and is exploring what makes it difficult at times for her to do so. The greatest challenge and growing experience for me as a clinician was being patient as I worked with this family, not judging them and using their dance to guide my work. Through the process, I have experienced so much growth as a clinician, and I will continue to use what I have learned from my work with this family. Although there is darkness in the past experiences of this child and this caregiver, the light of hope for their future shines bright.

  • Diversity-Informed Infant Mental Health Practice in Our Current Context

    Diversity-Informed Infant Mental Health Practice in Our Current Context

    Active attention to diversity is essential to the field of infant mental health (IMH) where self-awareness and relationships are the core of our work. However, in light of the current ambiguous political context that highlights our need to protect threats to civil rights, fight the continued oppression of people of color and continue to advocate for quality services for those in the most high-risk environments, we are under particular obligation to consider how to not only enhance our active attention but also our advocacy efforts.1 In addition, the IMH Code of Ethics states that the Michigan Association for Infant Mental Health (MI-AIMH) service provider “understands and respects the uniqueness of each individual with respect for ethnicity, culture, individuality and diversity in all aspects of infant and family practice.”2 This ethical standard, in conjunction with the IMH value regarding the “importance of relationships,”2 suggests that IMH professionals must be willing to engage in practices that challenge discrimination and the propagation of stereotypes, advocate for policies that support greater inclusion for all families and seek to expand the diversity of the IMH workforce to establish authentic, meaningful and transformative relationships with infants, toddlers and their families. Such an active stance requires a willingness to thoughtfully and critically examine our relationships with families and systems and the ways in which we may actively or passively contribute to the maintenance of pervasive social and economic inequities that so negatively impact families with young children. Understanding what diversity means in the context of IMH practice with families in Michigan and examining the meaning of diversity-informed practice as it relates to IMH provides a beginning foundation to further explore our shared commitment to healthy, safe and equitable environments for infants, toddlers, and families.

    The families with whom IMH professionals in Michigan work today vary greatly in their expression of what makes up a “typical family.” Young children may be cared for by heterosexual or homosexual biological or foster parents, relatives, single parents or a home made up of many generations, all providing care together for the children. Families also vary in socioeconomic make-up, geographic location, racial and ethnic identification and the extent of legal and child welfare involvement. Moreover, the “identified client” to whom IMH professionals are assigned differs widely; this range is comprises pregnant mothers, infants, toddlers, preschoolers and children who are nearing school age.

    A teacher is sitting on the floor with two preschool children - they are playing with colorful lego blocks.

    The extent of the diverse ways in which families present themselves to IMH professionals necessitates that professionals continually examine their own thoughts about diversity and how their thoughts may assist or postpone the relationship and alliance building with the families they serve. The IMH professionals’ ongoing practice of evaluating their reflections about diversity will be challenged each time they meet with a family and engage in informal assessment specific to culture, including the ways in which they differ physically, culturally, spiritually, emotionally and cognitively from the families that they serve. As they take note of these differences, IMH professionals are encouraged to be responsive to those differences through sensitive discussions with the families and, when appropriate, conversations with reflective supervisors and consultants as well as documentation within assessments. We are hopeful that ongoing and careful informal assessment will lead to increased awareness and examination of the needs and challenges that exist in relation to differences between professionals and families. IMH professionals may find themselves wondering: How do I build a working alliance when I sense insecurity or mistrust from a family because of apparent differences (age, gender, race, etc.)? How do I respond when my growing self-awareness forces me to confront stereotypes to which I have perhaps consciously or unconsciously subscribed? How do I work within the IMH practice model when the intervention does not seem to address the family’s more pressing concerns that stem from cultural, racial and/or ethnic barriers such as fear of deportation? How can I best support a family who is geographically isolated and lives 2 hours away from their supports, including me?

    In reviewing some of the current literature regarding diversity-informed IMH practice, the IMH Diversity-Informed Tenets stand out as a comprehensive articulation of the practices that should be infused in our work with infants and families to combat oppression and advocate for social justice. In 2012, the Irving Harris Foundation Professional Development Network created these tenets to serve as guiding principles for IMH practice under the premise that, “in order to create a just and equitable society for the infants and toddlers with whom its members work, the field must intentionally address some of the racial, ethnic, socioeconomic, and other inequities embedded in society.”3 These tenets promote diversity-informed practice rather than simply advocating cultural competence, which traditionally focuses on the providers’ knowledge and awareness of the cultural experiences of consumers.3 By contrast, diversity-informed practice extends beyond this one-dimensional, static view of culture and includes the transactional nature of relationship-based IMH work including “the influence of intersecting forces of oppression on provider-family relationships, on shaping research designs or on systems of care more broadly.”3

    sisters and brother

    Diversity-informed practice requires the integration of IMH theories and interventions with focused attention on the unique experiences, needs, expectations, values and cultural identifications of the particular family. This integration may seem an obvious and matter-of-fact element of IMH practice as we have a history of highlighting the importance of understanding the unique contributions of an infant or toddler and their caregivers when working with a family. However, in diversity-informed practice, the integration is accompanied by the provider’s conscious awareness of the fact that, “family and care-giving structures have changed dramatically for all children over the 20th century and presumptions of shared experience are likely to cause difficulties, perhaps especially in families with whom one shares culture and language.”4 Paul Spicer suggests that a keen sense of self-awareness as well as a willingness to remain open to the diversity that exists in our work, including the diversity that exists within what may have been considered one cultural group, is essential to avoid culturally exclusionary practice. Spicer reminds us of our first and perhaps most important task in IMH work: “Here, then, the need to listen to the individuals in the room, and to understand their unique cultural experiences and priorities, needs to be the most important guidance.”4 Thus, listening to the words, tones, nonverbal cues, environment, history and ebb and flow of the relationship—while maintaining an understanding that there is much that remains to be known—provides the IMH worker an opportunity to engage with families with “a degree of humility about what may be in the best interests of the child and to continue to develop effective approaches to infant mental health for all children and families.”4

    Another element of diversity-informed practice in IMH inevitably includes reflective supervision, a cornerstone of all IMH practice. Barbara Stroud describes the obligation of reflective supervisors to support their supervisees’ engagement with diversity in their IMH practice.5 Self-awareness and the capacity for reflection are competencies that are honed during reflective supervision, and these competencies necessitate an awareness of one’s own beliefs, values and cultural experiences as well as the diversity professionals will encounter in their work with families. The supervisory relationship itself becomes a model for the ways in which diversity can be discussed, understood and explored. According to Stroud, the power dynamics inherent in all supervisory relationships must be acknowledged in addition to the power dynamics that emerge based on inequities tied to race, ethnicity, class, gender, sexual orientation, religion and other points of identification. The meaning of such differences must be explored and supervisors are charged with “hold[ing] the emotional tension that is present when diversity issues are explored”5 and modeling the stance of authenticity, transparency and curiosity that supervisees can use with the families they serve.

    The 2017 MI-AIMH Conference, “Integrating Mindfulness and Diversity in Practice: Nurturing Authentic Relationships with Infants, Young Children, and Families,” will examine diversity and the ways in which race, ethnicity, sexual orientation, geography, discipline, and other points of identity texture, enrich and challenge our mindful connections with families.  In her keynote address, “Walking the Walk: Implementing Inclusion and Equity Principles in Early Childhood Programs With the Aid of the Diversity-Informed Infant Mental Health Tenets,” Kandace Thomas, MPP, will expand on our understanding of the Tenets and will offer us ways to incorporate them into our practice with infants, toddlers and their families.  Keynote speaker, Marva Lewis, PhD, will also provide us with essential tools for our tool box through her keynote address, “Translating Culturally Valid Research into Evidenced-Based Community Interventions: Successful Steps Along the Nappy-Haired Road” by describing a research based intervention to support the relationships of infants and toddlers and families of color. We look forward to learning more about utilizing the Tenets with Kandace Thomas on May 8 and about new interventions for working with racially and ethnically diverse families from Dr. Lewis on May 9 at the 2017 Biennial MI-AIMH Conference in Kalamazoo.

    We hope to see you there!


    References

    1. National Association of Social Workers (November 9, 2016). NASW statement on Donald J. Trump as 45thS. President. www.naswdc.org/pressroom/2016/NASW%20Statement%20on%20Trump%20Election%20Final%20PDF.pdf. Accessed Feb. 8, 2017.
    2. Michigan Association for Infant Mental Health. Infant Mental Health Code of Ethics. http://mi-aimh.org/for-imh-professionals/infant-mental-health-code-of-ethics/. Accessed Feb. 8, 2017.
    3. John MS, Thomas K, Noroña CR (2012). Infant mental health professional development: Together in the struggle for social justice. Zero to Three. 2012; 33:13-22.
    4. Spicer P. Culture and infant mental health. Current Problems in Pediatric and Adolescent Health Care. 2011;41:188-191.
    5. Stroud B. Honoring diversity through a deeper reflection: Increasing cultural understanding within the reflective supervision process. Zero to Three. 2010;31:46-50.
  • An Ambivalent Attachment Reunification Story

    An Ambivalent Attachment Reunification Story

    Jacob was returned to his mother Kimberly’s care three days ago. They have had extended overnight visits for the past six weeks. This is my first visit since his return home. We met in the small living room draped off by a blanket in the doorway to keep in the heat from the space heater. Kimberly said the landlord promised he would be out later to fix the furnace that only sporadically puts out heat; she herself had thought of the idea to tie the window shut with rope to keep the cold air out. She sat on the small couch surrounded by large cardboard boxes filled with the things Jacob’s foster mother had packed up and sent with him when he came back home. Jacob ran between the boxes pulling things out—footie pajamas, bath toys, formula—and then throwing them across the room. Kimberly called his name, told him “calm down” and reached for him to come sit with her. Even at 28 months, his small body easily fit on her lap. He was diagnosed as “failure to thrive” as an infant and has remained in the lowest percentiles on the growth chart. Jacob cried and arched his back causing him to slip off his mother’s lap and down to the floor. I sat quietly observing them, holding the worries that have guided and directed our work together: “Is she ready?”, “Will he be ok?”, “Can they connect and thrive together?”

    It has been almost two years exactly since he was taken from her. Failure to protect. Failure to thrive. Kimberly has worked hard to get here. She broke up with Jacob’s father, but promotes their continued supervised visits. She went back to school and earned a certificate that allowed her to get a full-time job. She got a place of her own. She has consistently participated in infant mental health (IMH) sessions; these were supervised by the relatives Jacob was placed with in his first and second placements and then at the agency after he was placed in a non-relative home because the relatives could not adequately protect him and promote his healthy development. Jacob’s health has been central to his foster care case from the beginning, and watching and worrying when he was not taken to the doctor or fed the correct foods was difficult for me as his IMH therapist. The foster care worker and I advocated for these concerns to be addressed by Jacob’s first foster parent, Kimberly’s father. This advocacy created strain within the family and between myself and the family, especially after the foster care worker threatened to remove Jacob from the home. Ultimately, this step was taken and several relationships were in jeopardy, including Jacob’s strong relationship with his grandfather.

    During this time it was clear that Kimberly felt divided between her alliance with her father and her alliance with her son. Her own childhood history was defined by abuse and neglect from her mother, who Kimberly states she does not remember. She was removed from her mother’s care at age 3 after she was left home alone. After that, she was raised by her father and had no contact with her mother. He told Kimberly the whole story when she was 18, stating he thought she was old enough to know the truth and then make her own choice about whether to have a relationship with her mother. He said her mom had called him recently when she heard she had a grandson. Her dad said it would be ok with him if Kimberly wanted to meet her and talk. Kimberly said she thought it was too late for that, but said she is not angry with her mom. She says, “I know it’s hard to have a baby when you’re so young.”

    Portrait of a crying little boy who is being held by her mother, outdoors

    Hearing Kimberly’s story, I wonder about her own early attachments. Did her internal working model tell her she had to cry loud and long to be heard, or did she learn it was safer to keep quiet and act like she was wasn’t there? Maybe her fear of her mother made her stop and stare while also wishing she could run to her and be picked up. What did Kimberly learn from a father who knew she was being abused but didn’t remove her from the situation until she almost died? Is this the template that Jacob will carry, that you might not always be protected and maybe only saved in a crisis?

    Ambivalent/resistant attachment was researched and defined by Mary Ainsworth as an insecure attachment style characterized by clinging and needy behavior when engaged with the caregiver, but then an inability to be soothed or calmed by this caregiver. She theorized that this inability to be soothed comes from the child’s lack of confidence in his caregiver’s ability to consistently and/or adequately respond to his needs based on his experience with this caregiver. The child also learns to heighten their emotions to ensure the caregiver will respond.

    I have observed this pattern of heightened emotions and an inability to be soothed in this mother-son dyad. In the first few months of IMH visits when Jacob was 10 to 12 months old, he would crawl to Kimberly to be held, then almost immediately arch his back, start to cry and signal to get down. When his mother brought him in close for a kiss, he might bite her on the lips and face. When he got upset, he would scratch at his face, increasing his own distress and his mother’s concern for him as well as her feelings of helplessness.

    In a previous article about ambivalent attachment for the Infant Crier, Kate Rosenblum cited research findings that parents of ambivalent/resistant children are often highly distressed and preoccupied themselves. She states, “In my own research I have found that parents who are preoccupied have a particularly difficult time responding to their infants’ needs when their infants are distressed. Infant distress, it seems, heightened their own distress, making it very hard to respond with sensitivity. When their infants cried, these mothers often responded with their own displays of distress, including intrusive, angry and hostile behavior. It was as if these infants and their mothers were caught up in a tangled dance of strong emotions.”

    Kimberly has been observed responding to her son’s emotions by laughing at him or distancing herself by handing him over to others in the room. She would often tease him during play in early visits by holding out toys for him and then grabbing them away. As she and I have reflected together about these interactions, she has been able to wonder about Jacob’s feelings and open her perspective to his inner experience. We have wondered together about how her feelings and worries were responded to when she was a child. During Jacob’s relative foster care placement with his grandfather, I often wondered to myself if I was watching a replay of the level of care and attention Kimberly had received as a child. When concerns were raised about Jacob’s care from his grandfather, Kimberly defended her father and joined him in minimizing these concerns: “I was small too” and “He only throws up once in a while.”

    During IMH visits at his grandfather’s home, Jacob would attend to his grandfather’s voice from another room and crawl away from his mother whenever grandfather walked in. Grandfather would laugh and say, “I don’t want you. Go see your mom,” and when he was handed to her, Jacob would reach up and hit Kimberly in the face. In the beginning this would cause mom and grandfather to laugh. They would often laugh at his antics, like when he crawled so fast his face hit the floor. He learned that he could get attention by acting in a certain way, by being “the entertainer.” This seemed to be another way Jacob learned to heighten his behavior to get attention.

    Jacob’s placement in a non-relative home brought about a huge shift in the case. His nutritional and health issues were consistently addressed for the first time, and it was obvious from looking at him that he felt better. Jacob’s improved health allowed our work to have an increased focus on his inner world and the parent-child relationship. Kimberly mourned the loss of easy access to seeing Jacob now that he was not with relatives. However, her interactions seemed to reflect an increased appreciation of their time together. She was able to acknowledge feelings of jealousy and sadness over his relationship with his foster mother, who he called “Nana.” As time progressed, the foster mother became a sort of grandmother to Kimberly as well and offered her advice about helping Jacob calm down, eat his food and sleep better at night. Kimberly became more proactive in making and attending Jacob’s medical appointments. Parent-child interactions during visits became more complex and layered, building on earlier experiences and interactions. Their play together began to reflect the increased richness of their relationship as Jacob created scenarios of making food for himself and mommy.

    Jacob still cries loudly, screams in frustration and throws objects when upset, but now instead of teasing, Kimberly calls him over for a hug; instead of laughing at him, she talks softly and instead of yelling “stop”, she holds him close. Kimberly is beginning to open the door a little bit to her feelings about her own early childhood, and addressing her unresolved trauma will be an ongoing therapeutic goal. Kimberly is overwhelmed with working full time and caring for Jacob as a single parent. I wonder how she will withstand the stress with limited support. I wonder how I would fare under these same circumstances. I still have those worries about this mother and son and how they will do together, but Jacob appears to be thriving and Kimberly is following up on his nutrition and doctor appointments. She looks at him with pride and he looks to her for comfort. They have consistent daily routines, they play and cuddle together, and his antics regularly cause her to laugh. I am so grateful for everything they have taught me about the power of early relationships, and I look forward to our continuing work together.