Month: February 2019

  • What’s Going on in There? The Neonate Becomes an Infant

    What’s Going on in There? The Neonate Becomes an Infant

    ‘There is no such thing as an infant’, meaning, of course, that whenever one finds an infant one finds maternal care, and without maternal care there would be no infant.”  (Winnicott, 1960, p. 585)

    Abstract: In the first of a series of articles about early childhood development, the Michigan Association for Infant Mental Health’s (MI-AIMH) esteemed Michael Trout asked us to consider what is happening in the mind of expectant parents, particularly that of the mother. This article ponders the evolution of a neonate through the first year of life. Precisely because each baby is a being with unique biology, temperament, feelings, experiences, and ways of experiencing and learning, much is to be discovered and understood about them.  The question of “what is going on in there?” is especially salient given that the baby’s wordless communication requires adult caregivers to intuit, infer, hypothesize and experiment. As we walk alongside parents who struggle to come to know their infant, we are required to have conceptual knowledge of how a newborn becomes a fully awakened infant. Beginning with the influence of parental perception, eloquently described by Trout,  this chapter of our series will explore the development of attachment and how that influences relational expectations, communication, and social-emotional development. Each of these domains of development is impacted by factors other than attachment, but it is by now clear that babies grow in the context of relationship, and the quality of those relationships affects  the physiological and psychological organization of the baby.

    Isn’t She Lovely: The Birth

    “What a glorious conclusion to the amazing developmental/psychological work of pregnancy: to be able, at the end, to say “Goodbye” in the service of saying “Hello.”  (Trout, 2018)

    Who is this tiny being the parent(s) are greeting? We are accustomed to hearing the search for clues: Who does he resemble? How does she cuddle in? Do they1 cry immediately or are they an “easy” baby? For the parents, the “real” newborn is meeting the “imagined” baby (Stern, 1999) and that encounter introduces the first threads of the unfolding relationship. The way the baby has been perceived throughout pregnancy is not inconsequential. Caregiver representations of their infant exert a powerful influence on the manner in which the baby’s signals and cues are experienced, comprehended and responded to (Rosenblum, Dayton, & Muzik, 2019; Dayton, Levendosky, Davidson, & Bogat, 2010;) and are indicated in the development of attachment (Vreeswijk, Maas, & van Bakel, 2012). If, as in Trout’s  example  on the developmental tasks of pregnancy (2018), the baby represents the mother’s ‘irrational, perhaps, but no less profound’ sense of failure to protect the baby from environmental toxins, then worries of normalcy or loss, and fears of inadequacy are likely to color the initial greeting — saying “hello” to this new being.

    The transactional model (Sameroff, 2010; Sameroff & MacKenzie, 2003) elucidates the process by which parental perception is one pathway to infant outcomes. In a transactional way, first the “infants stimulate their parents, either through their appearance or behavior; second, the parents impose some meaning system on the input; and third, the parents then react with some form of caregiving (Sameroff & MacKenzie, 2003, p. 19). We can imagine a mother, already predisposed to conscious or unconscious worries about the health of her baby, selectively attending to behaviors that confirm her worry that she has irreparably harmed her baby. She may hear his cries as more intense or as signaling excessive fragility, and thus tend to him with a level of anxiety that is transmitted to him, intensifying his cries. Thus the cycle begins.

    It does not have to play out this way, of course. There are a myriad of ways their interactions might unfold. A kindly nurse might normalize his cries, appease the mother’s worries and set the parent-infant relationship on a different course. A grandmother might note “Oh, he sounds just like you when you were a baby,” thus linking the past and the present in a way that affirms health and survival. For the IMH specialist, what is salient is that listening for the meaning of the baby to the parent is worthy of our careful attention as it offers a port of entry when there is a distortion or withdrawal from the baby. With an awareness that the baby may represent an array of past people and experiences, we can intervene to help the caregiver come to know the real baby. 

    Getting to Know You, Getting to Know All About You: The Early Weeks

    In the first month of life, the neonate becomes increasingly physiologically adjusted to life outside the womb. They1 become familiar with the sights, sounds, smells, touch and movement that begin to shape their experience of the world. The physical and emotional nature of interaction with caregivers begins to develop the attachment relationship. Ainsworth, in her seminal work, spent hundreds of hours, first in Uganda, then in Baltimore, observing the developing relationship between babies and their mothers (Ainsworth, 1967; Ainsworth, Blehar, Waters & Wall, 1978). She identified four phases of the development of infant-mother2 attachment.

    ____________________

    1They is a gender-neutral term for a person and will be occasionally used in this article. In most instances, though, for sake of clarity, the parent will be referred to as she and the baby as he or they.

    2 Though Ainsworth and other early attachment studies focused on mothers, primarily because of the cultural context, “mothering” is non-gendered, and no inference is made that only females can be primary attachment figures.

    In the early weeks of life, the “initial preattachment phase” (Ainsworth, et al., 1978, p. 23), the baby orients to any person who is in proximity, seeming not to differentiate the mother from other people. His inborn care-seeking behaviors include crying, “rooting, sucking, grasping and postural adjustments” (p. 23) that allow him to signal or maintain contact with another. Later research noted that neonates recognize the sound of their mother’s voice (DeCasper & Spence, 1986) and the smell of her breast milk (Marlier, Schaal, & Soussignan, 1998) so even though the baby may settle for a variety of caregivers, the presence of their mother is still sure to be a source of familiarity.

    Once the newborn’s sensory systems begin to consolidate, they become increasingly capable of differentiating their primary caregiver from other people. Through smells, sounds and sight, they discern not only familiar from unfamiliar people, but between familiar people as well. It is in this phase, beginning between eight and 12 weeks and known as the “attachment-in-the-making phase,” that we notice the baby show differential smiles, settle for a few key caregivers more readily than others and more specifically orient and cue particular caregivers than others. A home visitor, asked to hold a baby for a few minutes while the mother attends to a toddler, might notice that they baby shifts his body in order to retain visual contact with the mother. In offering developmental guidance that supports the important emerging relationship with the primary caregiver, we have often been heard to say on a home visit, “Yes, yes, I know! You don’t know me and you want to be able to see your momma!”

    Once an infant is capable of rolling, scooting, and crawling (i.e., approximately six through eight months), he is now capable of taking a more active role in seeking out proximity to his preferred caregiver. He may still occasionally prefer to signal through crying, smiling or reaching, but now, especially as he becomes increasing motorically competent, he is also able to scramble up on the parent, bury his head into a lap when anxious or alarmed, or crawl to a parent for a quick snuggle and emotional recharge. The capacity to locomote signals the onset of the phase of “clear-cut attachment.” The same capacity to seek out the caregiver also allows the child the ability to more actively explore the environment. It is the balance of the capacity to explore the environment and to return to a “safe haven” when alarmed, tired, hungry or ill that differentiates the quality of the attachment relationship. As Bowlby noted,

    “All of us, from the cradle to the grave, are happiest when life is organised as a series of excursions, long or short, from the secure base provided by our attachment figures” (1988, p. 62).

    Mounds and decades of research have described, studied and elaborated the styles of attachment relationships shaped in the first year of life. Through day-to-day interactive exchanges, babies begin to form schemas, or expectancies of their world, including mental maps of the self, the other and the self-in-interaction-with-the-other. Bowlby described these “internal working models” (1988, p. 165) as meaningful and reasonable ways of understanding the world in order to predict others’ behavior and to “plan” accordingly (realizing full well that this is a nonconscious process in the first year of life). In an era where much therapeutic treatment was constructed on the idea that babies were capable of generating and acting upon fantasies about their parents (Abram & Hinshelwood, 2018), Bowlby held fast to the notion that infants were responding to and developing ways of interacting with the actual environment. In other words,

    if parents were accepting of the baby’s strong emotions or bids for interaction, the baby would begin to construct a sense of self as worthy of care and protection.

    More current research has also confirmed his hypothesis that responsive caregiving during the first year of life plays a critical, though by no means sole, role in  healthy development (Schore, 2005; Sroufe, Coffino & Carson, 2010 ).

    Baby Mine: Patterns of Attachment

    Books and papers abound that describe the typical patterns of attachment. Briefly, attachment theory describes four basic styles of attachment: three “organized” styles (Ainsworth et al., 1978) and one “disorganized” style (Hesse & Main, 1999).  In the organized patterns, the caregiver, during the first year of life, has responded in ways that are relatively consistent or predictable, allowing the baby to develop a mental map of what can be expected from their caregiver. Babies who by the end of the first year are coded as “secure” in standardized assessment procedures, most typically the Strange Situation Procedure (Ainsworth, et al., 1978; Sroufe, et al., 2010), have experienced reliable, predictable and sensitive responsivity from their caregivers (Bowlby, 1988). Their tender needs and their needs for exploration have been, on balance, accepted. They are confident in the knowledge that their parent is a source of safety, both psychic and physical, and thus they are free to explore their environment. These babies develop “positive expectations concerning relationships with others, beginning capacities for emotion regulation and object mastery skills because of how secure attachment promotes exploration” (Sroufe, et al. 2010, p. 46). For these babies and caregivers, relationships are a source of pleasure and joy. Home visitors may find themselves relieved to visit these families, noticing the sense of attunement and comfort in the parent-infant relationship. In the context of visiting families where poverty of resources, and sometimes poverty of hope, prevail, seeing babies who are secure is a welcome salve.

    Infants who develop insecure patterns of attachment lack confidence in the responsivity or availability of their caregivers. In one direction, babies who develop an avoidant attachment have experienced repeated rejection or rebuffing in times of heightened distress or fear. Their mothers, in home observations conducted by Ainsworth (Ainsworth, et al., 1978), were observed to experience irritability and anger in interaction with their baby far more often than mothers of secure babies. They showed a restricted range of affect and often did not enjoy physical contact with their baby. These babies, by the end of the first year of life, learn to minimize their displays of need by turning their attention away from caregivers, often toward toys or other inanimate objects.  In addition to having to hide their need for comfort in order to avoid rejection, they also must mask their anger, lest it provoke more parental anger and rejection. As Bowlby described, “When in marked degree such an individual attempts to live his life without the support of others, he tries to become emotionally self-sufficient…” (1988, p. 124).

    Infants who develop a resistant, aka ambivalent, attachment to their mothers are uncertain about their caregiver’s emotional availability. In the Minnesota longitudinal study (Sroufe, Egeland, Carlson, & Collins, 2005), mothers of future ambivalent children were the “least psychologically aware” of any mothers in the study. Ainsworth et al. (1978) found the mothers of ambivalent babies to be less rejecting of their babies than mothers of avoidant babies, but less sensitive to their babies’ signals than mothers of secure babies. While not averse to physical contact with their infants, they also were “inept” (p. 300) and awkward in their ministrations. These mothers appear to have difficulty consistently seeing and knowing “what is going on in there,” and the baby experiences a confusing array of unpredictable caregiving responses.  By the end of the first year, ambivalent infants appear preoccupied with their mother’s whereabouts and, uncertain that their mother will be able to assist in times of discomfort, alarm or fear, are unable to use soothing, even when the mother offers it. They are less likely to explore their world and seem to say “It is hard to let go when I do not know if you will be there when I need you” (Ribaudo, 2016).

    A fourth attachment pattern is labeled disorganized/disoriented. Identified later in attachment research by Main & Solomon (Main & Solomon, 1990), these babies show a collapse of their typical organized strategy (secure, avoidant or ambivalent) when faced with significant distress. Disorganized/disoriented infants are thought to have experienced frightened and/or frightening parental behavior (Lyons-Ruth, 2008) that is sporadic and unpredictable, or parental affective communication that is “disrupted and contradictory” (Lyons-Ruth, 2008, p. 675) such as mocking or teasing when the baby is distressed. When faced with distress, a disorganized baby tends to show contradictory behavior such as approaching a parent with averted head, or walking toward a parent as if to seek comfort but then walking past him or her. Parental withdrawal (directing the infant toward a toy when the baby seeks comfort) and disinterest in the baby (e.g., silent caregiving during daily routines) is a significant risk factor for the development of a disorganized attachment and later psychopathology (Lyons-Ruth et al., 2013). Disorganized attachment ranges from 13 percent in nonclinical samples to 90 percent in samples of maltreated children (Cicchetti, Rogosch, & Toth, 2006; Lyons-Ruth & Jacobvitz, 2008).  Highlighting the intergenerational nature of patterns of relating, disorganized attachment is more prominent in dyads in which the parent has a history of unresolved loss or trauma in his or her own childhood (Hesse & Main, 1999). Duschinsky (2018) recently clarified the range of experience of fear or alarm in the presence of the caregiver, elaborating, for instance, that the caregiver may not be the direct source of harm but may be associated with fear due to being a cue for danger, as in the case of being exposed to parental interpersonal violence.  In instances where the parent is a direct source of fear or threat to the baby, as in maltreatment, the home visitor is likely to experience moments of confusion, despair and helplessness as they watch dyads where the source of comfort (i.e., the parent) is at the same time the source of fear.

    Talk to Me Baby: Communication

    What is an infant trying to communicate through babbling sounds and coos? What does an infant’s extended eye contact with a caregiver reveal about their developing attachment? Infant communication starts at birth, and the ways in which infants and caregivers communicate in the first few months help build the attachment relationship.

    Infants are born with the biological hard wiring for connection and begin to attend to their caregivers at birth. The quiet, alert state of a healthy newborn, who quiets to the voice and touch of the parent, is already engaging in and contributing to communication by virtue of this initial awake state. At two weeks, infants are able to follow their mothers’ gaze to external objects. By weeks seven and eight, infants exhibit social smiling in interactions, sustained eye contact, vocalizations and cooing, lip and tongue movements preparing their mouths for speech, and the ability to explore a communication partner’s face and start to gather and mirror back emotional cues (Lavelli & Fogel, 2013). As infants interact with their mothers in this second month, there is growth in what is sometimes referred to as “mother-infant coregulation processes”: Infants start to engage in short “turn-like dialogues” involving vocalizations and facial expressions like eyebrow raising (Lavelli & Fogel, 2013, p. 2266). These face-to-face interactions can be sustained longer by three to four months when infants develop the ability to engage in ongoing back-and-forth communicative patterns and to smile with full open mouths to display positive emotionality (Beebe & Steele, 2013). Between seven and 11 months, infants start to mimic sounds and behaviors of others, especially their mothers. They can respond to directing and pointing during one-on-one interactions, engage in ongoing babbling, and visually focus on objects or interactions with increased acuity (Dave, Mastergeorge, & Olswang, 2018, citing Albrecht & Miller, 2001).

    Infants have an early ability to both pick up on and reciprocate physical and vocal cues from their mothers, and whether a mother is able to read and respond back to these signals is important for healthy language development and predictive of secure or insecure attachment. Mothers’ positive feedback to infants’ vocal sounds and expressions is largely responsible for developmentally appropriate communicative growth within secure attachments (Lavelli & Fogel, 2013). By two months, infants are less responsive to strangers’ vocalizations and smiles when they differ in affect from those of their mothers, suggesting that infants’ interactions with their mothers shape communication patterns with others (Lavelli & Fogel, 2013, citing Stern, 1974). Infants start to provide more vocal and expressive signals of their emotions at three months through smiles and coos, providing more attuned mothers with increased opportunities to mirror back their cues by smiling back or repeating their sounds. Infants whose mothers can provide this immediate vocal and facial feedback are shown to smile, gaze and coo at their mothers more than infants with less attuned mothers, who may disengage or become distressed when their communication is not reciprocated (Legerstee & Varghese, 2001). Thus, the home visitor or early interventionist is wise to carefully watch for the amount of reciprocity and vocalizations, especially in the fourth month, when we would expect to see increasing vocalizations.

    Mothers’ abilities to follow their infants’ lead and engage in these positive back and forth communicative interactions are a key indicator of maternal sensitivity and the burgeoning stability or instability of the mother-infant attachment (Beebe, et al., 2010). Maternal ability to “stimulate” infants during periods of shared gaze with touch, vocalizations, and expressions and to hold back on stimulation when their babies looked away was positively correlated with secure attachment at 12 months (Beebe & Steele, 2013, p. 590). Likewise, a mother’s tendency to increase stimulation following “negative infant cues” such as breaking eye contact or showing signs of distress, and to withhold interaction when infants gaze and vocalize to them was positively correlated with insecure attachment at 12 months (Beebe & Steele, 2013, p. 590-591). Disorganized attachment at 12 months is, in part, predicted by maternal discordant affect, seen in mothers who display surprise or a smile when their baby shows distress (Beebe & Steele, 2013).

    This reciprocity of vocal and facial expressions between mothers and infants extends beyond the ability to recognize and mirror back the infants’ communicative cues. During moments of mutual gaze, vocalizations, and play, infants and mothers derive a shared sense of each other’s emotions, mental states, and intent. Mothers with secure attachments shape their language and expectations based upon accurate understanding of infants’ abilities to comprehend their words and meaning (Dave, Mastergeorge, & Olswang, 2018). To illustrate this ability to provide responsive and appropriate communication, Dave, Mastergeorge and Olswang provide an example of a mother instructing her infant to “Give me the ball” at seven or 11 months, and the distinction in the appropriateness of this request based upon the infant’s developmental level.

    By the same token, when mothers within insecure attachments are not attuned to their infants’ behaviors and vocalizations and unable to build reciprocity within the relationship, those patterns repeat themselves and limit prelinguistic development through 12 months and beyond. In insecure attachments, inconsistencies and rigidity in exchanges reverse the pattern of communication, with mothers, rather than infants, dictating vocalizations. Again, the infant’s sense of agency and verbal exploration is limited, often leading to the infant’s withdrawal (Lavelli & Fogel, 2013). Additional strain to communicative and linguistic growth can occur when mothers are depressed. Because caregiver communication consists in part of emotional affect and expression, social-emotional engagement is critical to infant-mother interactions. Even as early as the neonatal period, infants with depressed mothers tend to be less responsive to voices and faces (Dave, Mastergeorge, & Olswang, 2018; Field, Diego, & Hernandez-Reif, 2009; Lavelli & Fogel, 2013). Further, four-month-old infants of mothers with lowered responsiveness and emotional affect showed reduced self-contingency (Beebe et al., 2007; Lavelli & Fogel, 2013). Reciprocity between infants and mothers during the first year of life is an important contributor to prelinguistic development, attachment, and emotional development.

    Do You Feel Like I Feel? Emotional Development

    Throughout all the developments in cognitive systems and language, emotions hold the self together … Trevarthen, 2001, p. 114

    How do babies experience emotions? What is present at birth and what is noticed later in infancy? How do parents observe and respond to their babies’ emotions? Does a cry represent a need for comfort or an attempt at manipulation? Is a smile perceived as an invitation to play or a smug taunt? Which emotions get attended to, elaborated, contained or rejected are influenced by parental perception and the budding attachment relationship.

    Babies are born “wired” to experience and express emotions. Recent research has worked to elaborate what is seen on the outside, i.e. expressions, and what is experienced on the inside, i.e. which emotional displays correspond with which regions of the brain (Panksepp & Watt, 2011). It is beyond the scope of this article to review the scientific debate regarding what is universal vs. culture and experience in the development and display of emotions.

    There is general consensus that newborns tend to display three discrete emotions: distress, positive/joy and interest (Rosenblum, Dayton & Muzik, 2019).

    Each of these early primary emotions then evolve into more distinct and elaborated emotions such as anger, sadness, and more robust displays of joy, including laughter. By four months, infants can show anger at having a goal blocked (Izard, 2007) and perhaps even jealousy by six months (Rosenblum, Dayton & Muzik, 2019). It is important to note that emotions connected to self-awareness, such a guilt, shame or pride, are not observed until the second year of life. Awareness of the normative onset of emotions can assist the home visitor to attend to attributions made by the parent that are more likely to be a projection of the parent’s own disavowed emotion than an actual emotion experienced by the infant.

    Rosenblum, Dayton and Muzik (2019) describe children who are well regulated in behavior and emotion as “better able to adapt to contextual and situational changes in the environment in a flexible and spontaneous manner (p. 103).” In infancy, the primary strategies available to babies include avoidance (gaze aversion, postural adjustments), displays of distress (crying), and self-comforting (touching, sucking) (Rosenblum, et al., 2019; Beebe, et al., 2010). Schore (2003) has noted that the caregiver’s capacity to modulate their own emotions, and thus more sensitively respond to their baby, influences the infant’s capacity to share pleasurable states and to find comfort and support that minimizes negative affects.

    There are many pathways by which parental reactions to infant emotions begin to shape the emotional world of the baby, as well as their relationships. One important area we can observe and support is the parental capacity to accurately appraise and mirror back, in a slightly exaggerated fashion, their infant’s emotion (Gergely & Watson, 1996). This “marking” (Gergely & Watson, 1996), even of negative emotions, helps contain the infant’s emotions and assists in the process of an infant beginning to know that their internal state can be “felt” by others. For example, the parent who responds with a “woe face” (Beebe, et al., 2010) to a baby’s distress, saying “Aww, you don’t like that; that made you sad” is communicating to the infant that their internal experience can be shared and comprehended by another, that the internal feeling “looks” like what they see on their parent’s face (i.e., they see a “mirror” of what they are feeling), and that there are words that accompany the experience. This process of marking and containing, done repeatedly in the first years of life, lays the foundation for a child to know their own internal state, find words for them, and thus be able to share them with others, as well as empathize with the internal states of others. In other words,

    a baby whose emotional world has been, for the most part, accurately interpreted and responded to through parental affect, tone of voice and words, is well on their way to being the toddler in the child care center who offers his binkie to a distressed peer or pats a crying baby.

    They are also well on their way to gleefully shouting “Me did it!” and sharing their delight at success with the caregiver, having full confidence in the admiration of the caring adult. Having been seen, known, understood, and accepted, they are on their way to doing so for others.

    The Ants Go Marching: The Journey into Toddlerhood

    By the end of the first year, the neonate has evolved into a fully-fledged human, capable of expressing strong emotions such as love, sadness, fear, jealousy, and anger, and full of their own ideas, thoughts, intentions, wishes and desires. The scientist in the crib (Gopnick, Meltzoff & Kuhl, 1999) has become the scientist in the high chair. Returning to our example, what has become of the neonate whose mother feared she has irreparably harmed him in utero? Has his robustness registered and allowed her to feel reassured? Has her partner or a family member buffered or appeased her worry or have comments only heightened her anxiety? Has she found  the words to share her worry and begun to see him in a different light? Has she developed confidence in her own capacity to help him with any struggles, real or perceived, despite her worries about the toxic exposure? Her resolution to the prenatal anxiety will have shaped his experiences in the first year. What nascent sense of self will accompany him into the journey into toddlerhood?

    References

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    Winnicott, D.W. (1960). The theory of the parent-infant relationship. International Journal of Psychoanalysis, 41, 585-595.

     

     

  • Reflected in the light of another:  Discovering parallels within infant mental health & reflective supervisory relationships

    Reflected in the light of another: Discovering parallels within infant mental health & reflective supervisory relationships

    Dearest reader,

    The following article tells the story of the relationships, discoveries, and healing processes that have unfolded within our reflective supervisory and infant mental health relationships. These examples highlight some of the reasons why Infant Mental Health (IMH) practice pays special attention to relationships and the parallel process, and why it uses reflective supervision as one of its core components. This is our story of connecting, healing and developing within and because of relationships.

    As you walk this journey with us, it is important to remember that we are embedded in relationships from the first moment of conception, and we continue to need those relationships throughout our life. The relationships we form with other humans (caregivers, family, friends, acquaintances, community) shape the ways in which we enter into all other relationships, impacting every facet of our being. While the brain and body are most impressionable to development and healing during the early years, neuroscience shows us that we have the capacity to reshape our core beliefs and deeply heal at any age under the right circumstances, with the right relationships.

    Additionally, throughout our entire life we have a deep need to be seen, to feel felt and to live interdependently with one another. It is within the seemingly unconscious, minuscule moments that we share that we can be changed forever. And it is within healthy, nurturing relationships that we have a chance to heal and truly reach our fullest potential. For this reason, we must take care of the way we see ourselves, see each other and see our collective existence. We must reflect our light (good) and discontinue projecting our darkness (bad) onto our fellow humans. It is then that we may heal, together.

    We hope you feel a sense of the ways we have challenged ourselves to see (to notice ourselves, others and the deep emotions experienced) and be seen (bringing our whole selves into each relationship, being vulnerable and sharing our presence). We embarked on this work together after deep individual healing, making this encounter, in this time, somewhat serendipitous, powerfully affirming and most imperative to our own development and the development of this family.

     We dedicate this to one of our most daring leaders — Staci (Amy’s reflective supervisor, Angela’s field supervisor and an integral partner in the parallel process that unfolds here), and to all the helpers out there — the wounded, the healed, the novice, the veteran, the believer and the skeptic. We wrote this for us, for you, for the deep work that has been done and for the family that embarked on this brave journey with us. We wrote this in honor of our own courage to trust that relationships can change the world.

    While this article and these words only capture a small piece of the work, we hope you are able to feel a sense of what it was like to share this experience, to enter into these relationships and to deeply grow personally and professionally.

    With gratitude,

    Amy and Angela

    It’s not always as it seems

    “I was ready, I had it all figured out, or so I thought. The relationships between Angela and me, between Angela and this family and the process of finding our way together has taught me how “knowing” always trips us up, and how wondering and curiosity are always there to pick us back up.” –Amy

    Angela: When I began my infant mental health field placement in the fall of 2017, I was sure I had no idea what it would be like to work in the field, but I not-so-humbly believed I knew what reflective supervision was all about. It sounded like therapy to me, and I know how to do that.

    Amy: I also not-so-humbly believed that I knew what reflective supervision was all about. I really thought I knew exactly what to do to make it a powerful space for both Angela and me. I had it all planned out; I would create a consistent, collaborative and reflective environment for us both to share. I would pay special attention to ruptures (those inevitable moments of misunderstanding in our relationship) and would excitedly embark on repairs (validating any hurt feelings and reconnecting with a new understanding between us). I would share my presence —— physically, mentally and emotionally, and I would honor the feelings that would show up for both of us if I ever misstepped, which I undoubtedly would. I would model vulnerability, transparency, and mindfulness. I would pay attention to the parallel process and notice the subtlest attachment cues, providing spaces for us to think about the families we would be helping while navigating our own internalized relationships, the labyrinths of our own core beliefs and how they show up in the work and between us. In some sense, I had it all figured out; in another, I had no clue what I was doing, and it is somewhere in between those two feelings that Angela and I existed together.

    Bringing ourselves

    “It was more than clear that Angela and I had gotten exactly who we needed in each other, and it made sense to both of us, in our own ways.” -Amy

    Amy: I was both surprised and delighted when I first met Angela. I had already developed an idea of who Angela was before she had even begun her Masters of Social Work (MSW) field placement at our agency. I had expected to see a young woman in her 20s, new to the idea of IMH and the reflective process. I felt confident that I would have something to offer. To my surprise, my bias could not have proved more wrong. Sitting in front of me was a woman with a plethora of life experiences, reflective capacities that one can only aspire to and an inherent child-like desire for discovery, exploration and secure relationships. I was unsure of my own abilities. What would Angela think of me? What use could I be to her? Could she trust someone who was younger with less life experience? There was something so familiar in her and yet I felt curiously uncertain.

    I chose to dig deep to try to find something that told me that I could do this. I needed a reminder that I did indeed have something to offer. I reflected deeply, remembering all of the previous healing I had done, all of the self-discovery that I worked so hard for in the past few years, and the courage I had mustered to be vulnerable, open and forgiving of myself and others. This deep introspection helped me open up to the idea that I could create a space for Angela and me to grow, heal and truly connect with one another and with this powerful infant mental health work. I spent many necessary and meaningful years traveling through the tough process of growing as a clinician in this work. I had been triggered and challenged personally and professionally. I spent countless moments wondering why I chose this field, only to be reminded (usually in some comical way, by the universe) that I was exactly where I was supposed to be. It was messy, it was joyful, it was uncomfortable — and I lived to tell the tale. I emerged a better me; I am a different human being than I was during my infancy as an IMH clinician. I have not only developed as a clinician in this work, but as a woman, mother and friend. It is because of everything I have experienced — the struggles, the successes and the heartache — that I am now better able to support other clinicians and professionals. I needed to remember that IMH is deeply embedded in my being; I am a true believer of the deep changes that IMH can bring to both families and professionals. I have been fortunate enough to see the process unfold, and I have been open to learning, reflecting and processing knowledge that would guide Angela and me as we embarked on this journey together. I was aware of the ways in which many of the families I once worked with were still with me (internally) and how I embodied the mentors that had believed in me through the years. I understood how these things would impact our work. I wondered how my newly developed and growing self-compassion would be helpful to us along the way. I wasn’t doing this alone; I was part of nurturing, predictable and secure relationships that I had worked hard to establish. Additionally, I had the trust and support of my own reflective supervisor holding me through this new experience. Everything I had done before this moment had equipped me to give what I needed to give to this relationship, to be open to learning, growing and continued healing as I stepped into this new role. I am grateful for the doubt that came to the surface as I thought about who I would be for Angela; it allowed me remember all of the hard stuff I had already done, and it made me thankful for all the hard stuff I was about to do.

    As I observed an internal flood of doubt about my ability to support Angela,

    it was the process of honoring my own healing journey that re-grounded me, allowing me to regain trust in myself, trust in the process and trust that I would be able to offer this relationship something wonderful.

    Recognizing each of these layers of support and healing were imperative to being able to wholeheartedly and safely step into the role of supporting this delicate work for both Angela and me.

    Angela: I began home visiting on my own about two months into my field placement; I trusted Amy and Staci to know the right time and the right client for me. During that time of waiting for my first referral, I met with Amy every week, and we began building our relationship. Just as I was a new home visitor, Amy was a new reflective supervisor, so we were both finding our way in this new relationship. I learned rather quickly that it wasn’t quite therapy, but I also learned right away that I could talk to Amy easily. I immediately felt comfortable with her because of her warmth, authenticity and kindness. As someone who’s been committed to my own healing for years — mostly through individual and group therapy — I recognized that Amy was someone who had done, and was continuing to do, this same kind of work. I shared experiences with her that brought me to the field of infant mental health and some areas I knew would be challenging for me. We talked about waiting, watching and wondering — three concepts that I was about to learn are very important in IMH work — which sounded a lot like patience to me, something that’s never been my strong suit.

    “Our” First Family

    “I see you, I’m with you, I know you as if I have met you before, and yet you are very different.” -Amy

    Angela: The first family I was assigned included Sarah, a 22-year-old mom of two, Kaleb, 2½ years, and Mariah, 4 months. Kaleb had been receiving services through Early On for a speech delay — he was mostly nonverbal, saying just “yeah” and “no” (and yelling those, at that) — and was referred to infant mental health home-based services for his behavior issues: He spit and he hit. Sarah and her children lived with her parents. The children’s father — who did not live in the home — was an active co-parent, caring for the children each day when Sarah went to work. I learned from the referral that Sarah’s parents did not support her parenting, undermining her attempts to discipline Kaleb. So before even meeting them, I already felt anger toward the grandparents for how I perceived they treated their daughter.

    Amy:  Anger. This anger that Angela described would be a bridge. It was my understanding that this anger would lead us to a place where we might find out more about ourselves and this family. I was reminded of my own experiences of being flooded by emotions in this work, of being reminded by a family of my own humanness, my own hurt, and my own early traumas. These feelings were often painful, but were also a gift for me and for them. I validated the big feelings that Angela was experiencing; they were normal, and they gave me a clue about Angela’s openness and insight into her own “stuff” (everything we carry with us that we have collected along the way from those people and experiences that have helped us, hurt us and stuck with us). I was able to share with Angela how I’ve learned my own ways of accepting the feelings that come up in the work, of noticing them, holding them and allowing them to teach me their wisdom. I could feel the power and the vulnerability that existed in these first perceptions of this family. I knew this emotion would be an important part of our work together in the reflective space and that it would be equally important within the relationship between Angela and this family.

    Angela and I often spoke about the importance of learning how to uncover, understand and reflect on our own feelings, thoughts and deep emotions so that we may begin to understand and connect with what we are seeing and feeling as we enter into relationships with young children and families. It’s a process; it requires a certain level of openness, tolerance and the ability to continually expose yourself to the uncomfortable. I felt hopeful that recognizing the anger she felt was a wonderful sign that Angela and I could gain wisdom from exploring her anger when we were ready for it.

    I was excited for Angela, for us, for this family and this new experience. I believed that this uncharted piece of our work together could bring hope and new discoveries that would allow us to develop in ways we had not yet experienced together. I wondered how this piece of the work might stir up doubt and other difficult emotions for me, for her and for this family. I understood that it was important in our reflective supervision to authentically bring all that a family represents and stirs up in us into the reflective space so that we may feel and understand it. This both excited and scared me as I wondered what tough discoveries we might be challenged by. I noticed the doubt bubble in myself again, remembering some of the times as a supervisee when bringing a family into my own reflective supervisory relationships caused tension, or disorganization, and the difficult emotions I experienced as a result. I paid attention to this. I wanted to grow in my own capacity to work through the feelings that would undoubtedly come up for me and for Angela. I thought of my current reflective supervisor, the ways she was able to stay attuned with me even in the difficult times; this gave me hope. I wanted to be able to regain a calm state if Angela and I were ever to feel too overwhelmed by the work. I wanted to trust that all the healing I had done would allow me to be a safe haven (stable, attuned, protective, predictable), especially in the difficult moments, which meant I would have to continue to do my own tough work outside of our meetings to remain grounded, calm and safe for Angela as she experienced the big feelings that might come up in our space. I remained unsure, sitting with the thought that when these moments come, they will be ones of learning and practicing — for both of us.

    Simultaneously, I felt confident that Angela and I had built a strong beginning together, a foundation stable enough to weather a storm, and I believed that our relationship was ready to be challenged by the unknowns of a new family. Mostly, I knew Angela had a lot to offer and that she was ready to discover “the field.”

    Angela: I met Kaleb at my agency when he and his parents, Sarah and Shawn, whose relationship status was unclear to me, came for an intake. I saw a beautiful boy, with dimples and twinkling brown eyes and A LOT of energy. He went from toy to toy in the intake room while his mom and dad answered my questions. My first impression was of two parents who were looking for help in dealing with their son’s behavior. They seemed patient with him, and Sarah seemed to work hard to understand her son’s nonverbal communication.

    Amy:

    The hope that exists after a first encounter with a family — that’s what I remember feeling after reflecting on this visit with Angela. The feeling is unique, it is energizing, and it’s what I have come to find as one of the most beautiful parts of this work.

    It was even more fascinating to be able to experience this through Angela’s lens. I deeply listened as she described what she had seen, heard and felt. I watched as the wonderings began to take shape, as the optimism and excitement about who this family was, who they might be and what she could be for them took form.

    Angela: Amy accompanied me on my first home visit with the family to help me complete paperwork, and I was so grateful for her support. It was at that visit that I met Grandpa, Sarah’s dad. Grandpa asked questions about ways to improve Kaleb’s behavior, and I immediately thought he saw Kaleb as a problem to be fixed. But I had already formed an opinion about him, so I’m not sure he had a chance of making a good impression on me.

    Amy: I experienced some feelings of relief that this was the first family that Angela was able to work with. Having been in this field for some time, I understand that there is a wide range of young children, families and environments that a practitioner may encounter. This home appeared to be safe and clean, with plenty of room to sit and play; this would be the space where Angela and this family would embark on the (sometimes difficult) work of Infant Mental Health therapy.

    During this visit I was in an important role; I was the observer, the supporter, the holder for Angela; I was there for her. I stepped lightly in supporting Angela; I sat close, and allowed her to lead. I remember mentally attending to the parallel process, trying to support her in the ways that she could begin to support this mother. Angela amazed me. She was gentle and curious, and she balanced the unknowns of paperwork and attending to the new relationship like a skilled juggler. Angela and I spoke on the car ride home. I shared my delight with her, my feelings of pride and amazement around the ways she was able to be with this family. I held her experience through deeply listening while she reflected on her own feelings about her first home visit. I made mental notes of how she described Grandpa, wondering how these feelings might connect with things we had already begun to explore about her own relationship histories, feeling certain (based on my own previous experiences) that if this connection was important it would visit us again.

    I also experienced feelings of pride for myself. I was able to show myself a sense of compassion for accomplishing my first home visit in the role of reflective supervisor, for remaining intentional and aware during the visit and for vulnerably expressing my thoughts and feelings to Angela after the visit. I was proud of myself for showing her that I truly see her and truly support her. I remember also bravely asking for feedback, if there was anything I could have done differently. I was modeling transparency and openness in this moment, something I believe is imperative for a truly collaborative relationship like the one I was working to establish. This was a growing moment for both of us, and we got through it together. I feel proud of that.

    Angela: On my first solo home visit, I was sitting in the living room with Sarah and the children. Grandpa came home from work, said hello (he and his wife were always very hospitable, saying hello and offering me something to drink or eat), and then asked me something to the effect of “what’s wrong with him?” about his grandson. Inwardly I was angry at the way he talked about his grandson and felt very protective of Kaleb. I kept calm and responded that, after one visit, I didn’t feel comfortable giving any kind of evaluation. I also added that what I saw so far was a very spirited little boy.

    Amy: I can recall Angela describing this visit; the feelings that arose for her were brought to life in the space we shared. I remember my own internal struggle of not wanting to push too hard or too soon, but also needing to acknowledge that there was more to be discovered than what met the eye, not only for this family, but also for Angela’s healing. This balance was difficult, and it was hard for me to hold what I was thinking, feeling, wondering. When I did express thoughts or feelings too soon, just as in past home visits with a caregiver, all of the signs were there that I’d gotten it “wrong” (averted gaze, tension, dismissiveness), that what I was saying was being offered “too soon” or that what I really needed to be doing was listening, deeply. My own eagerness, and dare I say ego, got in the way in these moments. I prematurely “knew” things that weren’t yet mine to know. I had to re-learn how to watch, wait and wonder in this new role. Fortunately, I understood that rupture and repair are the very essence of what strong relationships are built on, and so I excitedly and cautiously gave words to these mis-attunements. I noticed and narrated these missteps and allowed Angela the space to be open with me about how I may have gotten it wrong, and how it made her feel. I invited her to clarify how she saw or felt things.

    I also often shared with Angela some of my journeys of healing alongside a family, and I cautiously wondered if the entanglement with this family would uncover a similar parallel. We processed a bit of this session, and came to realize that not only were Angela’s feelings and responses important for herself and for Kaleb, but that it could in fact be Sarah who was most protected by Angela’s thoughtful comment about Kaleb being a spirited little boy rather than a child with a problem.  This mom needed a supporter, someone who could see her and her son in a positive light and someone who could protect them from the judgment and criticism they so often encountered. Angela deeply nurtured this relationship and established her role with this family in this brief and intentional response.

    Angela: For the next several weeks, I would visit with Sarah and her children for 5 to 10 minutes before Grandpa got home from work. We met in the living room and, once he arrived, he repeatedly would enter the room to ask me questions, scold Kaleb for some behavior, or scold Sarah for not controlling Kaleb. I found myself tensing up whenever I saw his car pull in the driveway and felt angry when he would interrupt our visits. I imagined myself as a cartoon character with steam shooting out of my ears. Outwardly I kept my calm and often bit my tongue. I felt very protective and defensive of Sarah and her children. I saw so many strengths in her as a mom. Once, when Kaleb acted out in a way that could have hurt his sister, Sarah moved the baby out of harm’s way and then started to say something negative about Kaleb. She stopped, took a breath, and said quietly to herself, “Don’t be mean, don’t be mean.” I commended her for doing this. Not because I thought it was what she should do, but because I could tell she was very conscious of the type of parent she wanted to be.

    It was then I found myself wondering who the angel in her life was who showed her a different way to talk to her children.

    Clearly she was trying to be a different parent than the ones she had. (Grandma was rarely home during visits, but when she was, she often yelled at Sarah and Kaleb from the other room.)

    Amy: Angela and I often spoke about angels and ghosts; the people, relationships and experiences of our past and present that are nurturing and safe (angels) and those that represent hurt and loss (ghosts). These angels and ghosts can show up in the most unlikely places — we can be reminded of them by sight, touch, smell, noises and feelings. This is especially true in the infant and early childhood field where we are immersed in relationships that often represent our own early relationship histories in some way or another. Angela and I explored the idea that as early interventionists and reflective supervisors we have the unique role of being able to become angels for those we work with. Angela often found it hard to feel and see her potency in this work with this family, a theme I find most apparent in developing clinicians, myself included. I would gently nudge here and there, hoping that Angela could catch a glimpse of how she had become an angel for this mother that allowed her to treat her son differently.

    When we are with a family who is ready for an angel, those integrations can happen more quickly.  A family’s response to the feelings of being felt, of being seen and of being reflected in the positive light of another comes with no certain timeframe. With some families we will not be around to see the signs that show us where our work has made an impact, while others may show us right away. The qualities of this particular relationship with this family had all the makings of a safe, healing relationship. Angela and I used our space to go deep into our own internal worlds, emerging to bring our attention back to the family, reflecting on the space we all shared and around again, over and over. There was something oddly organic about our work together, about our meeting at this time in each of our lives and about our ability to truly be there with one another.

    Trusting the process

    “How is it that we may trust that which we have not felt? How is it that we can trust change, interconnectedness, fluidity, and truly see things for what they are? Let’s not go at it alone, let’s do this together.” -Amy

    Angela: My sessions with Amy consisted of me venting the anger I contained during the home visits and exploring why I was so triggered. He was Kaleb’s grandpa; it was his house and his family, and yet I could not see him as anything other than someone from whom Sarah and Kaleb needed to be protected. I seemed unable to let go of that idea. Amy asked me questions about Grandpa. We talked about what it must be like for him, and she tried to help me imagine his experience as Sarah’s dad and Kaleb’s grandpa. We also thought about what it must be like for Sarah and Kaleb. If I felt stifled and emotionally unsafe there, how must Sarah and Kaleb feel?

    Because Grandpa was usually there, I was not comfortable asking Sarah much about her relationship with her parents or with the children’s father. I didn’t think it was a safe space for her to share on those topics. After many weeks of sharing with Amy how intrusive Grandpa was, and how I believed Sarah couldn’t share openly while he was in earshot, Amy suggested I ask Sarah if she wanted to meet at the agency or somewhere in the community. I had not known this was even an option. Sarah agreed, and we had a couple of uninterrupted sessions at the agency. She talked to me about her parents’ lack of support — she was planning to move out soon, and they repeatedly told her she couldn’t do it on her own — and I reminded her of all she was already doing as a mom. I didn’t know if anyone in her life acknowledged how hard she was working to be a good mother. As good as it felt to not have to deal with Grandpa, I knew that just avoiding him wasn’t a good solution since Sarah and Kaleb lived with him and he was an important part of the family. And avoiding Grandpa wasn’t good for my growth as an IMH therapist either, as much as I hated to admit it. So we began alternating home and agency visits. The space from Grandpa allowed me to be a little more relaxed and open the next time I saw him. I don’t know if his behavior was any different, but I knew my attitude was. I wondered if Sarah and Kaleb felt any difference after having some visits away from him.

    Amy: It’s funny how at times a word can be so fitting and at other times be completely unable to carry the weight of that which it is describing. From my lens, the word “venting” only scratches the surface of what Angela was doing. It does not adequately capture the deep and healing processing that went on in our reflective spaces. Angela and I revisited her feelings, observations and relationship with the family almost every meeting. I saw pure delight when Angela spoke of Kaleb and of his mother. She was amazed by mom’s resilience and was absolutely adoring of Kaleb. I remember feeling warmth toward Angela in these moments, as well as in the moments that she chose to be open and vulnerable about all the emotion that this grandpa stirred up in her. I knew one of my most important roles was going to be holding Angela’s experience and helping her begin to peel back the layers that would allow her to see Grandpa separate from the internalized version she held of him. I had to be there with her, to hold her — this holding is not physical, rather I was deeply listening in a nonjudgmental and accepting way, leaving room for the emotions and thoughts that she experienced. I used this type of holding as a way to co-regulate, or to help calm, which allowed us to better understand what was going on with both Angela and this family, and partner with her as we regained internal safety. I supported her in regaining external safety by exploring alternative options for the home visit environment. It was clear that by over-exposure to this very triggering figure, for Angela, and for this family, the work was being done in the context of what felt like a ghost. We spoke about boundaries, and about how sometimes we need to create distance from that which is getting us “stuck” — a word we often used to describe the almost tangible feelings that came up when talking about this family and our own relationship histories — as a way to open to new perspectives, and so we experimented.

    Angela: Despite that small shift, I still felt triggered by Grandpa, and  my sessions with Amy continued to include lots of venting about him, exploring my strong reactions to  him and, of course, how Sarah and Kaleb might also be triggered by him. With Amy’s help, I was able to see that Grandpa’s words triggered shame in me, reminding me of some critical people in my life. While I’m sure my instinct to protect my clients was largely due to my commitment to them, I can acknowledge that my need to protect my inner child also was being triggered. Without Amy’s supervision, I think my work with the family would have been impeded by that. She held the space for me to explore my personal relationships and how my feelings about those relationships were impacting the way I saw and interacted with Grandpa. And she continued to reframe things for me to help me do that. I’m not sure I had the faith she did that it would happen.

    Amy: These shifts, these discoveries and the fact that Angela was able to come to them in the space we shared was powerful. Her ability to acknowledge her own inner child’s need for protection was imperative to deeper knowing here, and that she allowed me to protect with her enabled us to move through this together. Much like this mom was open to talking and exploring with Angela, Angela too was open to our relationship, her door was open and I was careful and intentional about how I would walk in, how I would be with her, be there for her, and honor the gems, the darkness and the light that she so generously shared with me. This was not just “this family” or just “this grandpa” or just “this thing we get to do.” This was transformative.

    Opening to New Experiences

    “It is only within the integration of new experiences that our core beliefs can grow, change and shift. We must seek out the uncomfortable new experiences that conflict with our maladaptive beliefs; it is then that we can feel the change.” -Amy

    Angela: One day I showed up for my session and Sarah was backing out of the driveway while Kaleb and Grandpa looked on. She told me she had to hurry to get a low tire repaired before the shop closed and asked if it was OK if I had a session just with Kaleb and her dad that day. I immediately panicked at the thought of spending 60 to 90 minutes with Grandpa but decided to stay after briefly checking in with my field supervisor. I’d been looking for an opportunity to reframe Kaleb’s behavior for Grandpa but had never felt comfortable doing that. And I don’t think I previously was able to hold space for him to hear me.

    During this visit, he commented about Kaleb’s speech delay, and I felt comfortable enough to say, “I know it’s frustrating. Imagine how frustrating it must be for him not to be able to express himself.” He listened attentively and didn’t say anything critical or dismissive. That was a breakthrough for both of us in my book. As I was preparing to leave, Kaleb needed his diaper changed, but was hiding under the table. I was going to wait for Grandpa to change him before I said goodbye, but Grandpa informed me he had quite a mess and it was going to be a while. So I left the two in the bathroom, with Kaleb standing in the shower as Grandpa cleaned him up. As I was walking away, I overheard Grandpa say — in a caring tone I had never heard from him before — “That’s OK, Kaleb. Everyone has accidents.” I got into my car and immediately called Amy to share that with her. I was emotional and teary, sharing what felt like a huge breakthrough for me and Grandpa. That was the first time I had witnessed him being tender with Kaleb, and I finally saw him as a grandfather worried about his grandson. Several months later it still brings tears to my eyes.

    Amy: I can still remember this phone call; the happiness and transformed perspective that Angela shared was beautiful. I wondered how this would shift her work with this family, how she, Sarah, and Grandpa included, may have a new way together to support Kaleb. It was clear to me that Kaleb was being honored in Angela’s new perspective allowing her to truly see parts of his grandpa that Angela’s lens, and grandpa’s defenses, did not allow her to see before. Grandpa existed in a new light, which meant Kaleb also existed in a new light and within a new relationship. I was curious about how the inner child in Angela may have had some healing and relief in this moment and through this new experience. I remained curious about how Sarah and Angela might be able to share a new experience together, one where Grandpa was neither the villain nor the hero. I believed this unexpected meeting between Angela, Grandpa and Kaleb all happened for a reason. I believe we get what we need when we are ready for it, and Angela, and Grandpa for that matter, were ready for this growth, ready to see things differently. It was in Angela and Grandpa’s shifting relationship that Kaleb and mom were truly seen. Two of their primary supports were finally in some sense of attunement, both with the intention of protecting this dyad, both with very different ways of showing their care and love, and now, both able to see one another.

    This different lens also offered Angela and me a new way to be together. I remember vividly the ways in which certain caregivers or families I worked with as an IMH clinician triggered something in my inner child that caused me to need protection of my own,  and what a relief it was when I was able to work through, separate and see things more clearly. I think a deeper part of me was validated and able to heal through experiencing and supporting this healing in Angela and in this family. We all had something to offer and something to gain through this difficult work. We are all connected in this way.

    Holding the Chaos

    “When we are safe enough to release our need to control both the internal and external worlds, something beautiful happens. We shift from needing to be in control to being able to gently hold what comes up. Let us build relationships of acceptance with the chaos so that we and those we have connected with can move through it more gracefully.” -Amy

    Angela: Just as before, this breakthrough with Grandpa — though more significant than the earlier shift I had toward him — doesn’t mean I was never triggered by him again, but I think it let me relax a bit in my urge to protect Sarah and focus more on supporting her. I continued to ask her about her progress toward moving out. She had looked into apartments and said the children’s dad was most likely moving in with them, but I didn’t get a strong sense of urgency from her. Widening my view of Grandpa a bit helped me hold space for the possible reasons Sarah might be dragging her feet, because I wasn’t as convinced that she needed to get out of the house as soon as possible. She was talkative and receptive, but she did not share deep feelings easily, so I just continued to support her and ask questions. Throughout our work together, I had struggled with my role with her. I wasn’t sure if I was having an impact and couldn’t shake my fear that Sarah didn’t think I was doing anything. One of the ways this fear came up in our work was that I hesitated to talk to her about terminating our relationship and the possibility of her transferring to another IMH therapist. Part of me feared if she said no, that would be confirmation of my fear that I wasn’t effective. We touched on the topic more than once but she never shared a concrete answer with me about continuing services. My self-doubt told me that if she did not continue with services, it was because she did not value our work together.

    Amy: This breakthrough and the work that followed were big. We laughed, cried and laughed again. How could it be that this grandpa was anything other than an awful ghost here to haunt us in the most unnerving of ways? How was it that he was able to be both a ghost and an angel? Sigh. This was quite a shift, one that I must admit I needed. I needed to know that the ways that I was holding Angela, the gentle seeds I was planting, and watering, and nurturing, would flower. I needed to know that the inner child in me, in Angela and in each member of this family would have some relief, some healing. I know we don’t always get so lucky. I know the work isn’t always so clear in the reflective room, or in the home, but I believe we get what we get when we are ready for it or, maybe in this case, when we need it. It was from this point that the murky waters settled, and that we could have more cohesive and clear conversations and reflections about this family. Angela was insightful in her reflections, and we built a narrative around the process that brought us to this clearer space. We did not abandon our earlier “knowings” of this family or of ourselves, but we did gain some balance, which meant everyone gained some balance, Kaleb included.

    Angela struggled with her own feelings of worthiness and of potency in her work with Sarah and Kaleb. In parallel, this mom often questioned herself and her abilities to support and nurture Kaleb, and I too observed as my own feelings of doubt once again bubbled to the surface. Angela often questioned how she was being helpful, or shared thoughts that if the family did not continue with IMH it would be a direct result of her “faulty skills.” I watched, I held, I prematurely offered my own thoughts that were sometimes missed or quickly replaced by Angela for far more appealing evidence that she was “doing nothing.” I had to step back, I had to be there with her, I needed to hear her worries and to help her explore them rather than to replace them with my perspective. We needed to feel this together, the doubt, the guilt, and the stuck-ness. Another bridge. This bridge was sometimes painful, but most meaningful to Angela’s development in this work and my development as a reflective supervisor. So we sat with her self-doubt as I indulged and I held the “what ifs.” “What if she doesn’t continue with IMH work?” “What if you aren’t doing anything?” “What if…” We stayed here for a while, until those words no longer held so much power, until they were just words, until we connected with the feeling that we cannot infer anything from the answers we were finding. We stayed just until we could walk a bit more confidently into the space where we could deeply believe that both this family and we were positively changed just from having been held by us. Angela “visited” this more confident space with me from time to time. She also, often and most purposefully, stepped out of this confident space and back into the very meaningful space of doubt. And I did my best to hold it.

    The Good-goodbyes

    “If we can stick around for them and truly bring ourselves, we might catch a glimpse of what we really meant to one another when we say “goodbye.”” -Amy

    Angela: Sarah had always been very conscientious about our appointments. It took a lot of effort for her to show up — physically, mentally and emotionally — each week. She would pick up the children after a full day of work, getting home right before I arrived — sometimes at the same time — and then spend one to two hours with me. I knew she was committed. So I was surprised when, in the last six weeks of my semester, she canceled two appointments in a row and `didn’t return my phone call. I thought she had decided to end services without telling me. I had been dreading having to say goodbye to this family I had grown to care about,  this little boy I adored, and had been talking to Amy about it for a while (my strongest comfort about leaving them was that Amy and Staci had decided Amy would take over the case if the family decided to continue services). The idea that I might not be able to say goodbye was hard for me to accept. It turns out that car issues and changes in her work schedule had made it difficult for Sarah to keep our appointments, so I did have my chance to say goodbye. But it wasn’t until our final session that she told me she wasn’t going to continue services. She hoped to get Kaleb into Early Head Start and thought it would be too much to do both. I reminded her that she could call the agency if she ever wanted to start services again and gave her a card thanking her for allowing me to work with her family. I told her she had so many strengths as a mom and that the children were lucky to have her on their side. She and Kaleb gave me a thank you card, and Sarah and her mom both hugged me goodbye. I drove away with tears in my eyes, grateful to know this family.

    Amy: Behavior really does say what can’t be said. Goodbyes are hard, you meant something, I’m going to miss you. My own journey through life and in this work has taught me that goodbyes represent vulnerability. They trigger us to become avoidant, doubtful and sometimes dismissive around ourselves and those we have grown to love. Goodbyes teach us, they challenge us, and they call us to action. It has been healing for me to learn my goodbye language. It was a tough process; it took messing up, fumbling and learning how to truly and deeply share my feelings with others, regardless of what they are able to give back. I talked with Angela about the difficulty of goodbyes, and we shared stories about what the world has taught us about leaving and being left, about how we have healed from goodbyes that weren’t spoken, that were left un-honored, that weren’t respectful and that were traumatic for us. This helped us think about what type of goodbye we wanted to share with this family and with each other, I scaffolded with Angela as she formed ideas about how she would facilitate a good-goodbye with this family if she got the chance. What would she like to say? How would she say it? How would it feel to share in this way? I also shared some of my own failures and successes in separating from families or people in my life. And, whether this family allowed us to have a good goodbye or not was up to them. How we worked through the feelings that were triggered by this and how we made meaning of the time we shared was up to us. We were in this together, and I felt that Angela truly trusted that.

    Angela had been quite convinced that these missed appointments meant she would not hear from Sarah and Kaleb before her semester was over; I wasn’t so sure. I remained skeptical, I believed these missed appointments were a way for Sarah to express herself around the looming separation in the coming weeks, one in which Sarah had to make a big decision, to continue or to be done for now. I remember throughout our work together that I often encouraged Angela to use her own feelings to clue her into how the family felt or to help give words to something, and this was one of those times. And while it was difficult for Angela to imagine that Sarah and Kaleb could have such strong and positive feelings about her, the behaviors really showed us otherwise. Sure enough, Sarah, Kaleb and Angela got their good-goodbye where they bravely faced one another and said the things that seemed impossible to say.

    Angela: In the following session with Amy, I think I was still stuck on this idea that I hadn’t been effective with this family. I had been told that sometimes we don’t get to see the results of our work while we’re actually working with the family, but part of me was hoping for a clear message saying “THIS is how you helped this family!” The only thing I saw very clearly was that I was triggered by Grandpa and that my reactions to his behavior had nothing to do with Sarah and Kaleb. There were so many sessions in which I found myself talking about people in my life whom I have felt triggered by in similar ways. I remember stopping to ask Amy if it was OK to talk about them, thinking it wasn’t related in any way to my work with this family. I know now that Amy knew it WAS related, and that talking about it in our sessions was an important part of the process. My work with the family ended in the spring, and I still wonder, “Who was I for this family?” I know part of this work is being OK with not knowing the answer.

    Amy: I continued to be amazed by Angela — and by myself for that matter. Her work with this family, my work with her and the ways in which we both braved our own internal darkness, light, ghosts and angels, all in an attempt to get “unstuck” so that she could help this mom and this baby and so that I could support her — it was all profound. I saw Angela, and I believe that allowed Angela to see this mom, I mean truly see her and truly delight in her. That, in turn, allowed Kaleb to be seen, to be held and to be delighted in in ways that he needed so that he could heal, develop and thrive with those who loved him, for him. I have a deep sense of warmth when I think about who I was able to be for Angela as she embraced this new experience. It moves me to think about the gift that Angela was for this mom and this baby. And, it’s OK that, sometimes, Angela didn’t know who she was for this family. It’s OK that sometimes she felt that the answer was clear while at other times she felt that she had no clue. That’s just what it is.

    Who we are to each other

    “No one can take away that which has become integrated, the space we shared, and what we are to one another, thanks for being an angel.” -Amy

    Angela: Saying goodbye to Amy wasn’t as difficult. I knew I would miss my sessions with her but I had no doubts about who we were to each other. Having our first reflective supervision experience together felt so significant to me. Having known nothing about my field agency when I was placed there, I left believing that the universe had brought me to the agency for the purpose of working, healing and growing with Amy. I knew I had a rich, beautiful, authentic experience that would be a strong base for my work in the field

    Amy: It’s almost unreal to think of the time that we shared. We both moved through our “first first” together. We discovered so many parallels in the work, in the reflective space and in life. We were raw, transparent, forgiving and open. We were brave and willing enough to trust each other, to mess up, to repair and to bare ourselves. We took our shoes off, we got comfortable, and we challenged ourselves to be seen and to see.

    We didn’t do it alone, we were surrounded by support and love, intertwined in many other healthy, interdependent relationships within our team, and each of those pieces was meaningful, they each played a role that enabled us to support the family and to see Kaleb. I can visualize it, and it’s wonderful — in the center there is the family (Grandpa and Mom and her children), with Angela holding them, with me holding her holding them, with Staci holding me, holding Angela, holding the family, with our team holding us all — the parallel process was palpable. We were living it.  It was cohesive, predictable and stable. We each took care of our parts and of one another. I feel honored to have had this experience, to have connected with Angela in this way, and to have had the large amount of unconditional love and support surrounding us.

    Angela and I knew our “goodbye” was only for now, and not really a goodbye at all, for you never really say “goodbye” to someone and something that has become a part of you.

  • Keeping It Simple

    Keeping It Simple

    Starting at the Beginning – Ula Rutan

    The families I work with continue to remind me to remember the foundation of my training and the fundamentals of helping. When I interviewed at Integro, a private behavioral health agency that provides mental health services to children and families in Jackson and Hillsdale counties, I was fresh out of graduate school and had just received my license as a professional counselor.  I wanted to be supportive of others and I was ready to help families in a deeper way. I also wanted to work on a team and be mentored in the mental health field. Infant Mental Health was a perfect fit for me and my passion.

    But, when I first began, I was overwhelmed learning new working relationships, program processes, expectations, resources, and the IMH approach to working with families who have babies and young children.  I had meeting after meeting with colleagues and supervisors who talked about handouts, activities, resources, and ideas for families. I was conflicted because I believed in my innate traits as my tools and the guidance I received in grad school to use them, but I also wanted to take the advice of others who have been working in the field. The training provided by the Michigan Association for Infant Mental Health (MI-AIMH) was helpful, and Reflective Supervision (RS) was a lifeline during a particularly tough case. But it was also this family who supported me in remembering how important the therapeutic relationship is and how powerful empathy, unconditional positive regard, and self-awareness are in my work.

    “Begin with the end in mind”

    “Begin with the end in mind” is one of the habits that author Stephen Covey identifies in “The 7 Habits of Highly Effective People” (1989). His book encourages me to make time to reflect on what is at the center of my work with families and, more important, challenges me to reflect on the values that drive me and to reflect on what I say to myself. This reminds me of the value of self-awareness as well as my own core values in my everyday life.

    This becomes incredibly challenging when facing the complexity and pain experienced in the homes of families that I work with as an Infant Mental Health Specialist. Reflective Supervision provides an opportunity for me to think about my feelings and values in this very formidable work. As I explore my relationships with families, I have an opportunity to learn and grow.  Every family that allows me to walk beside them in life for a period of time becomes part of my own personal journey, and I carry them all with me. Each child touches my heart, serving as a continual reminder of my core beliefs. Because of my background as a day care provider, I understand the value of providing high-quality care to infants, toddlers, and young children through safe, nurturing relationships. This is what I want for all young children. Early in my infant mental health work, I found myself wanting to protect one young child and his younger sibling in particular. At times, I wanted to tell his mother what she should do.  Despite this desire to react, I remembered to slow down. It was then that I was really able to see that the mom in front of me wanted to be the one protecting her sons and truly wanted to be accepted, be understood, and to experience love.

    Remembering the Basics

    Jeffery, Ashland, and Samantha allowed me to walk beside them for over a year providing Infant Mental Health services. As they faced painful situations and barriers, Samantha, the mother, allowed me work with her to understand Jeffery, age 2, and his newborn brother Ashland, and to be there to support her as an individual and mother. Often when I arrived for home visits, she would be babysitting other people’s children and her apartment would be filled with the disharmony of crying, arguing children, and chaos. The stench of the kitchen garbage or a dirty diaper being changed filled the small space. More times than once I stepped onto a soggy carpet, wet with drool or urine. These things and the occasional random dog snarling at me from a cage or a toy being thrown and hitting me in the head were examples of some of the sensory overload I needed to bring to Reflective Supervision.

    Samantha was overwhelmed, trying to make a little money and struggling to keep up. I was overwhelmed as well.  As complex as the situations she faced and the challenges that surrounded the family, pacing and basics were essential in my work with them. Infant mental health and my counseling education fundamentals allowed me to become more grounded when I found myself in sensory overload.  My father once told me that “keep it simple, stupid” (Krause, 2017) is one of the sayings he uses at work when facing difficult situations and the tendency to make the situation even worse by trying fancy techniques, tools, or steps to fix things.

    He taught me the importance of stepping back, taking in the whole picture and remembering the basics.

    I met Jeffery and his family when he was referred by Protective Services for assessment and ongoing support from our agency.  Samantha had an open CPS case because of multiple domestic violence situations that Jeffery and Ashland witnessed in their early development. Jeffery was experiencing prolonged tantrums with intense screaming, aggressive behaviors, nightmares and sleep disturbances, and Samantha shared that she was worried because Jeffery would not listen to her.

    A History of Loss and Violence

    Samantha and her family needed emotional support, developmental guidance, help meeting material needs and addressing safety, and more, yet it was important for me to take time to understand Jeffery and what it was like for him in his relationship with his mother. As I learned more about the family, I understood further what Samantha was experiencing as a mother and how infant-parent psychotherapy would benefit them. Samantha, who was 22 years old when I met her, started having children when she was still a child in her parent’s home. Her first pregnancy, as well as several others, ended in a miscarriage that she continues to grieve to this day.  She had Jeffery’s older brother, Robert, who is now 6, as a teenager, and her older sister takes care of him in an arranged guardianship. Often she would describe how Jeffery’s birth went well but she laughed and smiled as she told me how she was mean and swore a lot during his birth. When she was pregnant for Ashland, his father physically assaulted her while Jeffery watched. Afterward, Samantha had to be hospitalized.

    Ashland was born only one month before I started working with the family. I quickly noticed developmental concerns and placed a referral to Early On services. On several occasions Samantha mentioned that she was concerned that Ashland might have Down syndrome or that he was affected by the physical harm she experienced during the domestic violence. Samantha and Ashland wait for further testing through his medical services.

    Samantha often repeated stories of how each of the children’s fathers was not safe in one way or another, yet expressed a desire for each of the children to know their father. As I worked with this family, Samantha experienced another miscarriage and is currently pregnant by a man she hoped to marry.  It was a new beginning and another chance at her dreams for a family that she had shared many times. But the relationship deteriorated and Samantha ended her relationship because of continuous arguments. She told me she has talked with her OB/GYN and plans to have a tubal ligation. She stated that she is not going to have any more babies, that she “is done; no more.”

    During the time I worked with the family, Samantha was able to complete her high school special education classes and has had some limited employment. She has several medical conditions which, at times, limit her ability to maintain work. She dreams of having a home with space for all of her children and desires a safe relationship with a man who will father her children and support her. But each relationship with a man has ended.  She says that reading challenges her and that she sometimes has to have people – especially doctors — repeat information in different ways when they are talking. She is able to use community supports as needed and has family that continues to help her regularly.  Samantha will continue to need this support.

    Our Relationship

    I really needed to keep myself from trying to be Samantha’s mother and taking care of the problems the family faced. I did not want to start giving answers to her situations and working harder than she was in our time together.

    But having a relationship that she could trust and consistently rely on gave her a safe space to share. (Weatherston & Tableman).

    She could then sense that I cared “so intently and (was) not afraid to get involved with her emotionally” (Small, 1990). Providing a secure base and creating space for her to experience safety supported Samantha to share her worries and wonder, and to express herself. At one point, she was able to say in raw fashion that because she suffers from depression and consequently sleeps a lot, she was sometimes afraid to be alone and run the risk that she would not wake up to Jeffery and Ashland. This had happened in the past and had resulted in flour and laundry soap being poured all over the floor.

    Carl Rogers’ core conditions of counseling —  accurate empathy, unconditional positive regard, and congruence — are essential in supporting clients and their families (Capuzzi & Gross, 2009) and are “both necessary and often sufficient for therapeutic progress” (Egan, 2010).    I had to remember to pace myself in my clinical work with Samantha, to take my emotional responses back to my supervisor in Reflective Supervision, and to continue to see the potentials and strengths in Samantha, Jeffery, and Ashland.

    Samantha’s sense of humor is one strength I noticed right away, and her children are learning daily from this humor. Laughter was very important during our appointments together. Even though we did not laugh at every session, I was reminded that having a sense of humor helps support children and their parents. At our last session, we all found ourselves singing and dancing and laughing together even though the apartment was a complete mess because they were being evicted and their belongings were piled everywhere. The belief that positive interactions with each other would get them through yet another tough situation, building resiliency through shared joy and love, was my guide.

    We All Continue to Grow

    Jeffery and Samantha allowed me to continue to grow in my experiences of providing infant-parent psychotherapy. Samantha would open her home to various relationships with people who would give her time, physical help, and a partner in parenting, at least until it grew too unsafe. She continued to have relationships that would have a negative impact on Jeffery and Ashland as well as herself. She needed to be able to learn ways to guide Jeffery to not use aggression in his relationship with her and with his brother. She wanted to have her voice heard as a mother, have rights to safety, and to guide Jeffery in the development of love; to “grow his capacity to love” and to “mature in love” (1959, Fraiberg). Samantha was challenged in providing appropriate limits for Jeffery and had difficulty at times responding to Ashland and Jeffery’s bids for care and attention. With Samantha’s permission for additional support, I quickly placed a referral when our agency hired a Family Advocate to offer an additional layer of support to the families we serve. Our Family Advocate worked with this family for about six months, helping Samantha address basic needs and use community resources as required. I was able to focus more of my energy clinically. I learned of the various methods this family used to share important information, such as pictures, stories, and themes, and Reflective Supervision allowed me to slow down and notice more connections and understanding. I grew further in noticing patterns of behaviors within interactions and how Samantha experienced Jeffery and Ashland at times.  Sometimes I felt stuck in the process of infant-parent psychotherapy and needed to remind myself of how Jeffery and Samantha were the ones who set the pace and that change comes from the inside out as I provided a safe and secure relationship to explore, grow, learn, and develop (Weatherston & Tableman).

    Jeffery, Ashland, and Samantha taught me far more than what I have conveyed in this writing. I wanted to highlight some of the various lessons I carry with me from my time with this family. It can be easy to become wrapped up in chaos and all of the ever-changing techniques, models, and approaches. Keeping it simple, showing up with empathy and genuineness, and really getting to know the family has been vital in my work.

    Self-awareness and self-care are important as well. Samantha needed self-care and so did I.  Reflective Supervision was vital in supporting me to continue to go back into Samantha’s home and be the care she needed. I was able to use Reflective Supervision to discuss how my own historical trauma was reactivated and how this could impact my work. I discussed my values and how they may have been different or similar to that of Samantha and her family. Reflective Supervision allowed for a space that I needed to explore emotions, hopes, pains, values, beliefs, and my work with this family. Mirroring what I provide to families, Reflective Supervision benefits me when it is non-judgmental, collaborative, consistent, and a relationship where I am known. I have learned how thankful I am for it.

    Reflective Supervision with Ula: A Parallel Process — Andrea Bricker

    Relationships are the foundation of Reflective  Supervision (RS). This sacred relationship begins with safety, respect, dependability and consistency. From this foundation a supervisee begins to feel acceptance and empathy. Only when these things are present can trust develop and the opportunity for genuine sharing and exploration of self and others occur.

    Zero to Three states that there are three building blocks of reflective supervision — Reflection, Collaboration and Regularity.

    Reflection means stepping back, slowing down and taking time to wonder about what the experience that you have with an infant/toddler and their family really means.

    Ula and I have been able to set aside time weekly to establish a trusting relationship and have grown in our ability to be reflective. I have had the privilege and honor of supervising Ula for the past four years at Integro. Integro is a behavioral health private agency that provides an array of mental health services to children and families in Jackson and Hillsdale counties.  Integro has cultivated an environment for learning and growing.  Reflective Supervision gave Ula a safe place to explore the meaning of her work and her relationship with this family and her impact.

    Reflective Supervision is the regular collaborative reflection between the worker and the supervisor that provides space to scaffold the worker’s use of thoughts, feelings, and values within her work with families. Collaboration emphasizes sharing accountability of control and power. Power comes from many sources, including the “knowledge of oneself and the knowledge of children and families” (2001, Parlakian). Power within collaboration also allows for conversations to occur. This type of open communication allows for the partnership to see the best about each other, builds trust, creates safety, and is non-judgmental. In the first few minutes of our Reflective Supervision, I focus on Ula and how she is doing in life and really seeing her and not necessarily starting with the work. This demonstrates the important concept that she felt cared about outside her work. Significantly, she was able to carry that to the family and connect with them in the same way. Each meeting of reflective supervision was grounded in creating a safe place for Ula to share and learn, and to express and manage all the strong emotions she carried by being with this particular family. Naming and claiming her thoughts, feelings and experiences were connected to her growing knowledge of this child and his mother.

    The reflective supervision that Ula received gave her the opportunity to examine her own thoughts, feelings and reactions as she worked closely with Jeffery and Samantha. Research demonstrates the importance of providing high-quality services and its connection to reflective supervision. In Infant Mental Health work there is value in holding space for another. When workers are held by supervisors they are better able to hold the parent so the parent can hold or contain themselves. Then they gain capacity to hold their baby and then the baby takes in the holding.

    In the course of her clinical interventions, Ula was able to build an alliance with this mother and provide regular and predictable visits.  She offered spaces to feel, be held, and be known through her relationships with this child, mother, family members, and other agencies. As part of this ongoing therapeutic support, she listened carefully to learn the stories from the past and how they were connected to her present day.

    Ula used Reflective Supervision with a readiness to be vulnerable, to stay curious, and to lean into those uncomfortable difficult places with this family. She attended weekly team meetings for case review and group support to seek different perspectives and to explore more of her thoughts and feelings.  On those days where she just needed a little more intentional breath in the moment, she would call upon her team members to help put into words what she saw, heard, and felt to move forward in her work and into the next day.  Ula knew that Integro and her supervisor had her back.  She was never alone in the work.

    The power of the reflective questions that were raised set the stage for Ula to explore her struggles with the family, with me, and this mother. How Ula and I interacted was critical to the work with this family.  Ula and I were able to wonder, reflect and notice in ourselves, in each other and then Ula with this child and family. Judgment drops as wonder grows within the Reflective Supervision. The power of wondering allowed us to explore our observations; noticing, listening, and wondering provided space for discoveries in the patterns Samantha continued and the impact on her family.

    Ula was able to notice strengths and build relationships with this family to learn, wonder, and partner with them rather than giving them advice and answers.  As Integro grew its programs, a shift occurred in the way we delivered our services.  The company as whole began to value building relationships and developing strengths.  There was a parallel process within the Reflective Supervision where I did not give the answers, nor did Ula give the mother advice or answers.  There was an invitation from Integro as a company, within the Reflective Supervision relationship, and within the work with this family to wonder and partner, which allowed for discovery and authentic support. This really has helped support Ula’s own personal style, giving her space to continue to build her competencies and effectiveness. Reflective Supervision and reflective practice allows for continuous learning, professional development, and skill building, which keeps us engaged in the process and deepens our understandings in the field.

    Ula and I have a very strong working relationship based on safety and understanding. Ula and I are committed to each other and the Infant Mental Health model of care. The relationships we hold and have are the most powerful tools in our tool box. Ula was able to form a therapeutic working relationship with this child and his mother, which allowed this family to really feel seen, heard, and known.  Keep it simple, remember. You are the intervention.

    Sources:

    Capuzzi, D. & Gross, D. (2009). Introduction to the counseling profession. Pearson Education Inc., 59.

    Covey, S. (1989). The seven habits of highly effective people. Simon and Schuster, 96-144.

    Egan, G. (2010). The skilled helper; a problem-management and opportunity development approach to helping. Brooks/Col, Cengage Learning, 9th ed., 36-39.

    Fraiberg, S. (1959). The magic years; understanding and handling the problems of early childhood. Charles Scribner’s Sons, 281-282.

    Krause, U. (2017). Conversation between each other by phone.

    Parlakian, R. (2001). Look, Listen, Lean. Reflective Supervision & Relationship-based Work. Zero to Three.

    Small, J. (1990). Becoming naturally therapeutic; a return to the true essence of helping. Bantam Books, 30.

    Weatherston, D. & Tableman, B. (no date). Infant mental health home visiting; supporting competencies/reducing risks. Michigan Association for Infant Mental Health, 175-190.