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.