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  • 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.

  • What’s Going On In There?  The Developmental Work of Pregnancy

    What’s Going On In There? The Developmental Work of Pregnancy

    “The connection between the pregnant woman and her developing fetus is perhaps the most profound but enigmatic of all the human relationships.”  (DiPietro, 2010, p. 28).

    INTRODUCTION: It’s a story we sometimes overlook entirely. Even when we do ask parents about it, sometimes we don’t catch the drama, the power, and the meaning of it.  The story is about the beginning of life, and what is happening inside the three people who are having this most profound and unsettling experience.Of course, we’ve long known that pregnancy is anything but innocuous for the one most visibly affected — the mother — but even then, we can fall short in our wondering.We know how to look backward (“What happened in there?”) when there is, later, a problem with the baby, or with one or more of the relationships.What if we had a chance to back up (long before there are symptoms of a problem), slow down, and just wonder what sort of mental activity is brewing in there, and why? What’s the point of it all? Is it really a developmental progression?  What variables impinge on the progression?  How do the parts — mom’s state of mind, dad’s dreams, baby’s sense of self, mom’s imagination about who this baby is, and the everyday things going on around this trio — all fit together, while influencing each other?That’s the sort of wondering we get to do, in this article, the first in a series on the developmental paths of early life.I wish we had room to ponder dad’s inner work.  We know it’s happening, and we know it’s important.  We’ll have to consider it another time. To be clear:  It is wondering that we’re doing herein.  We’re not establishing rules for pregnancy, or even proposing an orderly set of stages.  We’re just proposing a way to think about it all, and to imagine some implications.

    EXAMPLE #1   A crisis in a little northern Michigan town is featured in the national news.  A Farm Bureau employee in the southern part of the state inadvertently mixes a fire-retardant chemical into cattle feed. The feed is shipped north and fed to unsuspecting cattle. Soon, I pass stacks of dead cows beside barns as I pull in for home visits.  Polybrominated biphenyls are discovered in the food chain.  Word in the nearby farming communities is that this little-understood chemical might wreak havoc in the brains of humans, including babies.  Soon it will appear in breast milk.  Mothers hear about it, although they are mostly terrified to talk about it.

    If Reva Rubin was right, in an article published about this time (Rubin, 1975), that one of the key developmental/psychological tasks of the pregnant woman is her seeking safe passage for her unborn child, then what does the PBB crisis mean to a pregnant mom in rural northern Michigan?  Has she — irrationally, perhaps, but no less profoundly — come to believe she is failing to protect her baby?  Will this unspoken belief influence her capacity to move forward into other developmental tasks of pregnancy, including those needed to promote a profound sense of maternal self-confidence and authority?  Will she be able to attach to a child she fears she has harmed? When father asks her why she seems so blue, so detached, will she be able to put any of it into words?

    EXAMPLE #2   A baby is born to a mom still silently grieving the death of a previous child. The second baby was conceived just days after the death of the first one. Neither mother nor father has ever spoken of their shared loss; as a result, it seems to not actually be shared by the two of them at all.  They press forward, in silence, as if nothing has happened. Can parents attach to an unborn baby when their hearts are broken — especially when they deny it is so?

    In her brilliant description of the maturational crises of pregnancy, Grete Bibring drew our attention to the “…intense object relationship to the sexual partner [which] leads to the event of impregnation, by which a significant representation of the love object becomes part of the self” (Bibring, 1961, p. 15).  The above mom now has two pieces of unconscious psychological/developmental work to accomplish: In a state of estrangement from her husband, she must still manage to internalize the impregnation, in which the “love object becomes part of the self” (Bibring, 1961, p. 15); and she must achieve sufficient resolution of her grief over the child who has just died, in order to access needed libidinal energy for her connection to the next pregnancy, the next baby.

    Perhaps it’s too much.  Perhaps something will stand in the way of mom connecting to the new baby — or even accepting that she’s pregnant. The mother to whom this happened fell mysteriously ill immediately after the birth of the second child. She moved far away for a “recuperation period,” leaving her new son in the care of a stranger. Mom seemed unfazed by the separation. She had, indeed, come to the end of the pregnancy without finishing essential internal work.  She could — quite literally — not “face” her newborn, who would live the rest of his life with the psychological residue of his mother’s detachment.

    After several weeks, a friend — horrified to discover that mother was making no moves to see her little boy — brought them together for a visit. Decades after that brief visit, in response to a request by this newborn as an adult and father-to-be, mother wrote to him of her memories of those moments of greeting: “I felt no inclination to sweep you into the embrace I’m sure all expected.  You looked very much as I expected you to look … and we examined one another with what I fancy was a quite neutral expression.”

    Such breakdowns in the developmental work of pregnancy are often reparable. Parents play catch-up, and something allows many to “fix” the detachment or the depression that threaten life with baby. This particular mom never found her way back to her boy.  He stumbled into my office three decades later while awaiting the birth of his own firstborn son.

    EXAMPLE #3  It’s not news when a mid-adolescent becomes pregnant.  We know something of the obvious risks — that she may go through the pregnancy alone and poor, that the normal narcissism of her own developmental status might deter her efforts to invest fully in the Other inside her — but what do we know about how this will all play out developmentally?

    Pregnancy is never an “accident.”  Despite the pretense of many parents that they were uninvolved in the timing, it’s never true.  When and why it happens always has meaning.

    For Becky, it was right after a family trip to see her grandmother in North Carolina. The trip immediately preceded not only the pregnancy, but a significant change in Becky’s school performance and mood.

    Becky barely knew the boy-father, who was disinterested in her, and went on to impregnate another girl. While he evidently had no special meaning to her, the child growing inside her did. Sent to a home for unwed mothers, it was assumed Becky would give up her baby.  But she didn’t, even after discovering he was a boy. Her distance from him, throughout the pregnancy, was evident. At the delivery, one of the nurses took note of Becky sucking in her breath and mumbling, “Oh, no…” when she saw her newborn’s penis, even before she noticed his face. Nobody seemed to understand why she wanted to keep him when she felt so distanced from him.

    I met her when she returned to our little town with her son in tow. She spoke often of her expectation that her son would leave her someday.  Males always did, or so her narrative maintained. Her father, I learned, had been a military man on the base near her grandmother’s house.  Becky’s mother had been a “townie.”  He showed little interest in the pregnancy for little Becky, and appeared to be relieved when he was shipped overseas right after Becky was born. Becky grew up in her grandmother’s house with her mom, but with no dad anywhere.It looked as if Becky might be repeating the pattern; another child would be born without a daddy nearby.

    While I could not see it at the time, Becky began her interruption of the pattern by relinquishing custody of her son to her mother and stepfather before Jeremy was a year old. Her next step was to get pregnant again, this time with a military man. He was ordered to basic training at the base where her father had been 18 years earlier, so she moved back into grandma’s house.  She wrote me that her boyfriend had received orders to ship out, coincidentally to the same European country where her dad had been sent so long before.  She had pleaded with the base commander to change his orders. The father of her baby would stay.  They would marry.

    In her very last letter, Becky said she had learned that her new baby would be a girl, and that it would “…all work out, this time.  I think you know what I mean.”

    Sometimes the dynamics of pregnancy are awfully complicated, with the developmental work of pregnancy not completed for some years.

    THE DEVELOPMENTAL WORK OF PREGNANCY

    It would be unreasonable to assume that a living being as sophisticated and complex as an adult woman would treat the entrance of a human body into the insides of her innocuously, without noticing and responding.  “Noticing” and “responding” then become the work of pregnancy. In a flash, an expectant mother’s attention is riveted.  She is shaken. She does not just sit there.  She has work to do.  It will be sequential — developmental — but not perfectly so.

    THE BEGINNING:  ACCEPTANCE OF THE FOREIGN BODY

    A key element of this early work is simply acceptance of the pregnancy.  This sounds easy enough, but it’s not automatic. It involves a developmental step.  It implies traversing a threshold into motherhood, which may be rife with worrisome meaning for some moms.  It implies an unfamiliar responsibility, the need to conserve emotional energy, and the acceptance of certain limits.

    Something has come into mother’s body that did not use  to be there.  A certain resistance (not altogether unlike the natural rejection response of one’s body to a newly transplanted organ) must be overcome.  Mom must take note, her body must take note, and she must give permission.

    For a young woman of rape, this may be a huge step. Already there was an intrusion of another kind.  Now she must somehow separate that intrusion (of the rapist’s body) from the part of himself he left behind.  She must find a way to reject the first while accepting the second.  This is a tall order.

    Even without the violent or controlling intrusion of rape, merely the intrusion of the foreign body of the baby may be enormous for a woman who has never felt much control over her own body.

    For a mom living in a war-torn part of the world, even allowing herself to consider that life is beginning inside may bring on anticipatory grief, as the likelihood is high that this new life will have a very short term indeed.

    Under circumstances in which the safety of the fetus is more-or-less assured, however, mom will move forward (albeit unconsciously) toward acceptance of the intrusion of this “foreign body” (Bibring, 1961, p. 15), and incorporate it into her own. Mom and baby become one. (For this reason, death of the unborn baby in this early part of pregnancy may feel to mom like the death of part of herself.)

    She will eventually reach through this haze of lack-of-identity and confusion and say, essentially, “Yes.” It’s an unconscious act, of course, this affirmation, this acceptance.  It’s not necessarily an act of acceptance of a person, yet, since little in the way of an identity is yet available.

    This mostly-unconscious act of saying “Yes” may not be a one-time thing; the unconscious “decision” may be revisited several times.  As Lederman’s research showed us, acceptance of the pregnancy is not the same as acceptance of the baby, or of motherhood (Lederman, 1984, p. 17).  But accomplishing this first, delicate, unconscious act means her body can go on (instead of working to eliminate the intruder), and her mind can go on (tucking the fetus within so there is really no difference between that-which-is-mother, and that-which-is-baby — the safest possible place for baby to be, unless it isn’t).

    A NOTE ON THE DIFFERENCE BETWEEN ACCEPTING THE FOREIGN BODY AND WANTING TO BE PREGNANT

    [box style=”rounded” border=”full”]We’ve always been eager to understand how a mother’s attitude toward her prenate affected his later development, and many of us entertained private theories, based on our clinical work, about such connections. But wantedness, per se, is not really the point of this description of mother’s developmental work of acceptance.  We’re not suggesting that the developmental work of pregnancy requires that all mothers reach a certain plateau of acceptance of the pregnancy, of the baby, and of motherhood.  There is reason to believe that these are separate kinds of acceptance, perhaps reached at different times, perhaps never equivalently in all mothers. Mothers are fully entitled to tons of ambivalence, mountains of giddiness and terror, and various acts of reliving the past and predicting the future through dreams and strange — but perfectly normal — flights of ideas.  Our purpose here is not to take the mystery out and find categories (much less diagnoses) for the normal work of getting ready.  Our purpose is to come to an appreciation of the nuance and complexity of what goes on inside. We’re not looking for pathology; we’re looking for an understanding of what this marvelous inner work usually is.[/box]

    THE MIDDLE: IMAGINING AND THE EMERGENCE OF IDENTITY

    Having moved through acceptance of the intrusion of the foreign body, mom is now free to picture her baby; such imagining will constitute much of the work of the next developmental stage. Romantic notions aside, creating an identity for the being(s) growing inside may be tough, confusing, dismaying, complicated … and magical.

    In this second developmental stage, the outlines of an identity begin to be formed in mother’s imagination. This may be an exhilarating time, as mother’s imagination infuses baby with the best-of-all-possible-characteristics from her own and her partner’s histories. For some moms, however, the door opens to worrisome thoughts:

    • “My mom demeaned me during my whole childhood for being fat. I think my baby is fat.  What will mom say when she looks at my baby?”
    • “I feel mad at him sometimes, even now. What if I just don’t like him?”
    • “What if he’s weird, like Uncle Joey?”

    On and on it goes, this powerful developmental dance.  Thoughts are inconsistent and sometimes illogical.  Dreams are all over the place.  Ever so slowly, however, the notion of a person emerges.  It used to be that this developmental step — this emergence of an otherness —began sometime after quickening, after the baby announced herself suddenly and profoundly with a kick. But the near-universal use of routine ultrasound now pushes this second developmental step earlier in the pregnancy.  It can be joyful and affirming and real. Whatever else it is, it’s certainly far from innocuous.

    THE END:  DIFFERENTIATION

    Could it possibly be that mothers are obligated to say “good-bye” before they have fully said “hello”? In a sense, the answer is yes.

    As moms traverse the winding and complicated road from being alone in their bodies to becoming mothers, it appears there are two acts of differentiation that — while usually accomplished with little effort or even conscious attention — seem, nonetheless, developmentally important:

    • The “…growth of the pregnant woman from the role of the ‘daughter of the mother’ to the ‘mother of her baby’” (Schroth, 2010, p. 4). In other words, mother separates herself from her own mother as part of her preparation to become the mother of her baby. It seems a significant and meaningful step. In order to feel her power as a woman and to create a new view of herself as an efficacious, capable, intentional mom in her own right, she must assert that she is no longer merely her mother’s child. She is a mother, herself, perhaps resembling her mom in some ways, but wholly distinct in others.
    • The shift from the unconscious perception of the baby as part of the Self to the perception of the baby as an Other. In other words, mother separates herself from the baby who was fused with her as part of her preparation to encounter him as a unique and distinct human being.  Attachment, by definition, relies on accomplishment of this developmental task; otherwise, we’re left with mother everlastingly confusing the baby with herself, while the baby remains confused about the boundaries between self and other.

    Psychoanalysts Jenoe Raffai in Hungary and Gerhard Schroth in Germany developed a systematic facilitation for this final developmental work (Raffai, 1995 and Schroth, 2010).  Offered during the last weeks of pregnancy, the facilitation supports moms conversing with their unborns in ways that acknowledge the differentiation while opening up lines of communication that may be helpful during delivery, and may feel familiar to both mom and baby as they later begin to attach during the first postpartum days.  Schroth suggests that a kind of empathic “mirroring” (Schroth, personal communication) by the mother may support the unborn baby’s sense of being seen and known before birth.

    Practical results of this facilitation showed up in outcome studies on deliveries in Hungary and Germany. In the first Hungarian cohort of 1,200 mothers who participated in such facilitations, the rate of premature birth dropped to 0.1% (compared to the average of 8%); the cesarean section rate dropped to 6% (compared to the average of 30%); and the rate of postpartum depression dropped to nearly zero (from the average of 15%) (Raffai, 1995 and Schroth, 2010).

    French child psychiatrist Miriam Szejer suggested, “By the end of the pregnancy… the fetus and the mother no longer live by the same rhythms” (Szejer, 2005, p. 69).  I’ve come to believe that this is as it should be.

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

    BARRIERS TO ACCOMPLISHMENT OF THE DEVELOPMENTAL WORK

    No one would be surprised if a mom whose last baby died might delay the very first developmental step (acceptance of the intrusion of the foreign object), when such acceptance —or even acknowledgment — might cause so much pain.  She may barely have begun the
    “…reorganization of the survivor’s sense of self to find a new normal” (O’Leary and Warland, 2016, p. 3). A strong sense of her capacity to protect her unborn may now elude mom (as well as dad, in ways often invisible to most observers), which may lead to a disinclination to imagine that they are pregnant again. One researcher, with decades of experience interviewing and supporting families after prenatal or infant loss, reports that “…most parents entering a new pregnancy believe … that grief for the deceased child will diminish” (O’Leary and Warland, 2016, p. 6), only to discover that grief is actually resurrected by the new pregnancy. Understand that we’re not implying that a baby conceived after loss cannot be accepted, but only that the developmental work of acceptance may, quite naturally, encounter a bit of resistance.

    The developmental work of which we speak may be complicated by the loss of one baby — a “vanquished twin” — while the other one remains, lying inside.  Mom now has the work of grief and the work of acceptance all at the same time. Sometimes a mom simply cannot simultaneously do both.  So she may, without ever noticing what she is doing, turn over the work of grieving the lost twin to her partner, or delay it entirely. (The remaining/surviving baby is, of course, witness to it all.)

    Sometimes interference comes from the outside world. What if mom is preoccupied with a sense that she is physically at risk (due to domestic violence, for example)?  She needs emotional energy to do the developmental work of pregnancy, but that energy is being drained away.  She cannot revel in a focus on self (already — and normally — a bit muddled, with unclear boundaries between that-which-is-fetus and that-which-is-mother), because the context of ease and safety is missing. Essential self-indulgence feels absurdly inaccessible in this state of uncertainty and unease.

    And on it goes, through the entire pregnancy.  To notice these challenges is not to suggest psychopathology.  It is to acknowledge how complicated the work is, which makes it more than a little awe-inspiring that moms somehow navigate these unconscious waters so well.  The aim of such understanding need not be the elimination of all challenges.  Rather, the aim might be to support more of it becoming conscious, which then gives the family access to the narratives that naturally arise.  For example, dad might later be able to say to his son: “Your grandma got very sick while mom was carrying you inside.  Mom was sad about it.  She didn’t get to just think about herself, and about you. That’s why we’re making cupcakes for her, and for you, today.  Today is about nothing except the two of you being together, with no worries.”

    Or mom might explain this narrative to her pre-teen daughter: “You’ve always had to work extra hard to get me to let you go.  I know.  I’m sorry.  Believe it or not, we’ve been fussing about this since you were inside me.  You were ready to separate from me before I was ready to let you be your own little person. I heard you, but I couldn’t get myself ready to let you go. That’s probably why you were several days late in being born, and why I sometimes act goofy and scared when you want to try something on your own.  I get it. Sorry.”

    SUPPORTS IN THE ACCOMPLISHMENT OF THE DEVELOPMENTAL WORK

    Recent research teaches us that the growth of maternal self-efficacy (MSE) during pregnancy is an important inoculant against perinatal depression, and is a predictor of satisfaction with both the childbirth experience and with later parenting (Fulton, et al, 2012). Achievement of high levels of MSE does not result merely from being surrounded by cheerleaders, of course.* The formula for one’s perception of self-efficacy may include self-evaluation of one’s abilities in specific domains, but it may also include a range of internal perceptions, including long-standing self-narratives about one’s personal power and agency, and one’s “remembered care from their own parents” (Fulton, et al, 2012, p. 331). One of the joys of the developmental work that rests on delicious and healthy self-absorption is that these perceptions can be made conscious, can be mused upon, and can even be revised.  During some parts of pregnancy, some moms find themselves dreaming about events that haven’t been thought of in many years; calling family members from whom they have been estranged; asking their own parents surprising questions; looking at yearbooks and photo albums and otherwise digging into old memories and narratives — all part of a noble effort to pull together an efficacious sense of self.

    * It doesn’t hurt, of course, to have one’s attributes and capabilities highlighted during and after pregnancy. But one study of the relationship between social support and MSE turned up an interesting finding: “…partner support was unrelated to both maternal self-efficacy and depressive symptomatology” (Haslam, et al, 2006, p. 286), whereas higher levels of parental support were related to higher levels of MSE.

    Perhaps planning for the delivery, itself, can constitute a piece of developmental work.  We have seen mothers wrap themselves protectively around their bellies as they declare how they want the upcoming process to unfold.  Does maternal self-efficacy increase when a mother asserts herself in ways not previously associated with her personality?  Must we take note of the potential loss of self-efficacy when it does not go according to plan? French obstetrician Michel Odent affirms a truth felt by many women: “In the age of industrialized childbirth, the mother has nothing to do.  She is a ‘patient’” (Odent, 2002, p. 29).  Perhaps less scoffing at assertive women who are looking not only for a better start for their babies but for a greater sense of their own authority in the world might be in order.  As a mother prepares the way for birthing her unborn, maybe she’s also doing yet more developmental work.

    CONCLUSION

    It can be seen that the developmental work of pregnancy is not a one-off and may not be tidily sequential.  It builds on itself (thus the descriptor we’ve been using: developmental).  It may be messy and clumsy, moving in fits and starts, and it may be unnerving to partners, employers and extended family members (if not the mother herself).  But it has purpose and meaning. Decks are cleared, issues revisited (if not resolved), hopes investigated, fears aroused anew (perhaps so they can be put to rest — or, at least, put into storage for a bit). Mom gets a chance to greet herself, to re-invent herself, to meet parts of herself she had forgotten.  She gets a chance to feel integrated, even as she may worry that she’s falling apart.  She gets a chance to feel powerful, even in the face of so much inner challenge, with more to come.

    Guess who benefits from all of this?

    One final reminder: This clumsy, dramatic, mostly unconscious work is not being done in private. There is a witness.  Certainly it’s clever for evolution to work this way, with baby and mom communicating throughout the pregnancy about who she is, about life outside, about what the baby can expect. It means that — irrespective of her conscious intentions — mom “talks” to baby; if it’s not her words, it’s her endocrine system, giving information about her heart, her state of being, her reactions to things she’s seeing or thinking about or feeling.  The baby, of course, is a perceptive listener, retaining the messages (while undoubtedly getting the meaning of some of them all wrong).

    In the end, we see that there’s meaning in every last bit of this powerful, mostly unconscious developmental work of pregnancy.

    List of References, Suggested Reading and Study Questions:

    What’s Going On In There? The Developmental Work of Pregnancy – References and Study Questions

  • Pathways to Parenting:  Prenatal Bonding in Mothers and Fathers

    Pathways to Parenting: Prenatal Bonding in Mothers and Fathers

    “In giving birth to our babies, we may find that we give birth to new possibilities within ourselves.”
    – Myla and Jon Kabat-Zinn, Everyday Blessings: The Inner Work of Mindful Parenting, 2014

    For many parents, pregnancy represents a time of reorganization that leads to psychosocial growth and the hope of new possibilities.  The coming of a new baby inspires shifts within the psychological worlds of the parents as their emotional ties to the infant begin to take shape. The development of these ties is critical because they are related to parents’ postnatal feelings about the baby (Vreeswijk, Maas, Rijk, & van Bakel, 2014), and they provide psychological fuel for the demanding work of postnatal infant care (Rapael-Leff, 2005).  Importantly, a parent’s prenatal thoughts and feelings about his or her infant are also associated with postnatal parenting behaviors (Dayton, Levendosky, Davidson & Bogat, 2010; Dubber, Reck, Muller & Gawlik, 2015; Hjelmstedt & Collins, 2008).  Just as the infant will ultimately develop an attachment to the parent, the parent develops a complementary caregiving system that provides motivation to protect and nurture the infant (Solomon & George, 1996), and this system comes online during pregnancy.

    To date, the majority of the research informing our understanding of prenatal parent-infant relationship development has been with mothers (Slade, Cohen, Sadler & Miller, 2009).  More recently, prenatal bonding in fathers has also been the subject of research. Across studies, accumulating evidence suggests that: one, pregnancy represents the beginning of the parent-infant relationship for both women and men (Vreeswijk et al., 2014), and two, the quality of this relationship is related to postnatal parenting for both mothers and fathers (Dubber et al., 2015; Hjelmstedt & Collins, 2008). Focusing exclusively on mothers, D.W. Winnicott put it this way:

    I suggest, as you know I do, and I suppose everyone agrees, that ordinarily the woman enters into a phase, a phase from which she ordinarily recovers in the weeks and months after the baby’s birth, in which to a large extent she is the baby and the baby is her. There is nothing mystical about this. After all, she was a baby once, and she has in her the memories of being a baby; she also has memories of being cared for, and these memories either help or hinder her in her own experiences as a mother.

    — Winnicott, 1966 (as cited in Winnicott, 1987)

    In the IMH field we take Winnicott’s words to heart every day in our work with parents and infants; we talk to parents explicitly about their own child rearing histories, and we help them make conceptual links between past and present.  Indeed, attachment theory argues that a parent’s own relational history, described as “memories” by Winnicott and as “Ghosts” or “Angels” by more contemporary authors (Fraiberg, Adelson, & Shapiro, 1975; Lieberman, Padron, Van Horn, & Harris, 2005), is influential in the formation of the parent-infant relationship. Extensive research in the attachment field supports this link (Mayseless, 2006), and our clinical work with families reinforces its importance.

    Pregnancy represents the first point in development when we have clinical access to the parent-infant relationship.  Therefore, whether we are working with expectant parents or helping parents reflect on their prior pregnancy and birth experiences, understanding the role of risk and resilience factors in pregnancy can extend the clinical window backward to the place where the parent-infant relationship first took shape.

    Risk and Resilience in the Lives of Expectant Mothers

    For women, pregnancy involves both physical and psychological processes that contribute to the deepening of the maternal-fetal bond over time (Yarcheski, Mahon, Yarcheski, Hanks, & Cannella, 2009; Slade, et al., 2009; Zeanah, Carr, & Wolk, 1990).  The quality of the mother’s physical health and psychological well-being during pregnancy is fundamentally tied to that of the fetus.  Prenatal risk factors that the mother is exposed to, therefore, have the potential to influence her own health, the health of the fetus and her psychological connection to her unborn baby.  Exposure to intimate partner violence (IPV), for example, increases the risk for infant mortality and morbidity (Sharps, Laughon, & Giangrande, 2007).  It also affects the mother’s psychological tie to the fetus.  IPV exposure during pregnancy is associated with less positive internal working models of the infant for mothers (Huth-Bocks, Levendosky, Theran, & Bogat, 2004), and is ultimately related to less sensitive early parenting behaviors (Dayton, Levendosky, Davidson & Bogat, 2010; Dayton, Huth-Bocks & Busuito, 2016).

    Symptoms of psychological distress including depression, anxiety and post-traumatic stress disorder (PTSD) can also influence the maternal-fetal bond (Dayton, Hicks, Goletz, Brown, 2017; Luz, George, Vieux & Spitz, 2017).  Estimated rates of clinical depression during pregnancy range from 10% to 30% for mothers (Ashley, Harper, Arms-Chavez, & LoBello, 2016), and untreated depression is associated with less optimal maternal-fetal bonding (Yarcheski, et al., 2009; Alhusen, Gross, Hayat, Rose, & Sharps, 2012). It is important to note, however, that much of this work has been conducted with married or cohabitating Caucasian parents from middle-income socioeconomic groups (Yarcheski, et al., 2009). In light of the economic and racial health disparities in pregnancy and birth outcomes (Lu & Halfon, 2003), more research that extends this work to economically and racially diverse samples of parents is needed.

    Protective factors for healthy and adaptive maternal-fetal bonding have also been identified. For instance, Yarcheski and colleagues (2009) conducted a meta-analytic review and found that, across many independent studies, increased levels of social support were associated with increases in the strength of the maternal-fetal bond.  From biological and psychological perspectives, this finding makes a lot of sense.  In relation to contextual stressors such as violence exposure, social connection has a countervailing influence on the human bio-behavioral regulatory system. Connection with trusted others is physically and psychologically calming and has important biological correlates such as lowering cortisol levels and initiating the release of oxytocin. These biological responses to social connection calm the nervous system and may thereby support the development of the maternal-fetal bond via increases in a mother’s sense of psychological and physical safety.

    Findings from this body of literature have important translational implications for the early parenting field.  IMH interventions during pregnancy that help women free themselves from violent relationships, process and heal from the violence they have been exposed to, and decrease their symptoms of psychological distress are clearly indicated.  Further, and consistent with the central aims of many IMH programs, increasing a mother’s social support network may help promote a positive bond with her unborn baby, ultimately leading to more positive birth outcomes and a healthier postnatal mother-infant relationship.

    The Father’s Prenatal Journey

    The meaning of fatherhood in the United States has changed in important ways over the past few decades (Lamb, 2010).  Men are now more actively involved in the daily lives of their children (Bianchi, 2011), and the importance of fathering to the social-emotional development of children is more frequently acknowledged (Lamb, 2010).  When fathers are involved very early in the lives of their children, they have the opportunity to form foundational and enduring relationships with them, and outcomes for mothers and babies are improved. The positive health effects associated with father involvement begin in pregnancy with improved prenatal, birth, and neonatal health outcomes and significantly lower per-infant healthcare costs (Alio, Salihu, Kornosky, Richman, & Marty, 2010; Salihu, Salemi, Nash, Chandler, Mbah, & Alio, 2013). In contrast, a lack of father involvement in pregnancy is associated with significantly higher infant mortality rates (Alio, Mbah, Kornosky, Wathington, Marty & Salihu, 2011).  Given these compelling findings, supporting the prenatal father-infant bond is an important target of intervention that has the potential to improve birth and relationship outcomes for fathers, mothers and infants.

    Though less is known about the factors that affect the development of the prenatal father-infant bond, preliminary research suggests that psychological distress in fathers, including depression and anxiety, may be one risk factor for lower levels of prenatal bonding (Luz, George, Vieux & Spitz, 2017; Dayton, et al., 2016). Preliminary work also suggests that, on average, fathers may experience higher levels of emotional distance from their unborn babies, relative to mothers (Vreeswijk et al., 2014).  Much of this research has involved samples of middle-class, Caucasian fathers, however. As a result, less is known about how risk factors such as violence and poverty exposure may affect the developing father-infant relationship in pregnancy.

    To address the relative paucity of prenatal studies of fathering in contexts of risk, ongoing research at the Motown Family Relationships laboratory located at Wayne State University’s Merrill Palmer Skillman Institute, is currently investigating prenatal relationship development in urban-dwelling fathers, with the goal of informing early interventions with fathers.  A central finding of this work is that a father’s belief in the importance of early fathering to the health and well-being of the infant is robustly associated with stronger prenatal bonding: Fathers who believe that early fathering is important tend to report experiencing stronger bonds with their unborn infants (Dayton, Hicks, Goletz, Brown, 2017). This is an important finding because fathers in low-income groups are exposed to social narratives that describe fathering primarily in economic terms, and poverty-exposed fathers are clearly disadvantaged in this respect. Furthermore, qualitative data from this study suggest that many fathers have a difficult time grasping their importance during infancy and tend to view their parenting role as more influential when their children are older (i.e., preschool aged and above) (Dayton, et al., 2016). Helping fathers understand the importance of their early relationship with their infant beginning in pregnancy can help shift the narrative from fathering as a mainly financial role to the importance of the early father-infant relationship in promoting the healthy development of the infant.

    These cumulative findings have significant implications for IMH work with fathers and their families.  Most important, there is a need for early intervention protocols that communicate to fathers the centrality of the early father-infant relationship as a foundation on which the long-term parent-child relationship is built.  IMH practitioners are ideally positioned to engage fathers in clinical work and to help fathers negotiate the barriers that may prevent them from full involvement with their infants.  However, it is important to acknowledge that the vast majority of IMH workers are women. As women, our own histories have likely resulted in feelings and beliefs about the relative importance of fathers in the lives of infants and young children.  To authentically engage with fathers, therefore, we must examine our own feelings and challenge our own biases.  A mother-centric approach has dominated the IMH field since its inception.  Shifting our individual and collective views about early fathering will help move the field toward a more balanced family-centric approach and, ultimately, improve the lives of the families we care so deeply about.

    References

    Alhusen, J. L., Gross, D., Hayat, M. J., Rose, L., & Sharps, P. (2012). The role of mental health on maternal‐fetal attachment in low‐income women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41(6), E71-E81.

    Alio, A. P., Salihu, H. M., Kornosky, J. L. , Richman, A. M., & Marty, P. J. Feto-infant health and survival: Does paternal involvement matter? (2010).  Maternal and Child Health Journal, 14(6), 931-937.

    Alio, A. P., Mbah, A. K., Kornosky, J. L., Wathington, D., Marty, P. J, & Salihu, H. M. (2011).  Assessing the impact of paternal involvement on racial/ethnic disparities in infant mortality rates. Journal of Community Health: The Publication for Health Promotion and Disease Prevention, 36(1), 63-68.

    Ashley, J. M., Harper, B. D., Arms-Chavez, C. J., & LoBello, S. G. (2016). Estimated prevalence of antenatal depression in the US population. Archive of Women’s Mental Health, 19(2), 395-400.

    Bianchi, S, M. (2011). Family change and time allocation in American families. The ANNALS of the American Academy of Political and Social Science, 638, 21-44.

    Dayton, C. J., Levendosky, A. A., Davidson, W. S., & Bogat, G. A. (2010). The child as held in the mind of the mother: The influence of prenatal maternal representations on parenting behaviors. Infant Mental Health Journal, 31(2), 220-241.

    Dayton, C. J., Buczkowski, R. S., Muzik, M., Goletz, J., Hicks, L., Walsh, T., & Bocknek, E. L. (2016). Expectant fathers’ beliefs and expectations about fathering as they prepare to parent a new infant. Social Work Research: Special Issue on Social Work with Men and Fathers, 40(4), 225-236.

    Dayton, C. J., Huth-Bocks, A. C., & Busuito, A.  (2016). The influence of interpersonal aggression on maternal perceptions of infant emotions:  Associations with early parenting quality.  Emotion, 16(4), 436-448.

    Dayton, C. J., Hicks, L., Goletz, J., & Brown, S. (2017). Prenatal bonding and child abuse potential: Risk and resilience in vulnerable, pregnant mothers and fathers.  Oral presentation at the annual meeting of the Society for Social Work and Research. New Orleans, Louisiana.

    Dubber, S., Reck, C., Müller, M., & Gawlik, S. (2015). Postpartum bonding: the role of perinatal depression, anxiety and maternal–fetal bonding during pregnancy. Archives of Women’s Mental Health, 18(2), 187-195.

    Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry, 14, 387–422.

    Hjelmstedt, A., & Collins, A. (2008). Psychological functioning and predictors of father–infant relationship in IVF fathers and controls. Scandinavian Journal of Caring Sciences, 22(1), 72-78.

    Huth‐Bocks, A. C., Levendosky, A. A., Theran, S. A., & Bogat, G. A. (2004). The impact of domestic violence on mothers’ prenatal representations of their infants. Infant Mental Health Journal, 25(2), 79-98.

    Kabat-Zinn & Kabat-Zinn, (2014).  Everyday Blessings:  The Inner Work of Mindful Parenting. New York: Hachette Books.

    Lamb, M. E. (Ed.) (2010). The Role of the Father in Child Development (5th ed.). Hoboken, NJ: Wiley.

    Lieberman, A., Padrón, E., Van Horn, P., & Harris, W.W. (2005). Angels in the nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 26, 504–520.

    Lu, M. C., & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A life-course perspective. Maternal and Child Health Journal, 7(1), 13-30.

    Luz, R., George, A., Vieux, R., & Spitz, E. (2017). Antenatal determinants of parental attachment and parenting alliance: How do mothers and fathers differ? Infant Mental Health Journal, 38(2), 183-197.

    Mayseless, O. (Ed.). (2006).  Parenting representations: Theory, research, and clinical implications.  New York:  Cambridge University Press.

    Raphael-Leff, J. (2005). Psychological Processes of Childbearing. London: The Anna Freud Centre.

    Salihu, H. M., Salemi, J. L., Nash, M.C., Chandler, K., Mbah, A. K., & Alio, A.P. (2014). Assessing the economic impact of paternal involvement: A comparison of the generalized linear model versus decision analysis trees. Maternal and Child Health Journal, 18(6), 1380-1390.

    Sharps, P. W.,  Laughon, K.,  & Giangrande, S. K.  (2007).  Intimate partner violence and the childbearing year: Maternal and Infant Health Consequences.  Trauma, Violence & Abuse, 8(2), 105-116.

    Slade, A., Cohen, L. J., Sadler, L. S., & Miller, M. (2009). The psychology and psychopathology of pregnancy: Reorganization and transformation. In C. H. Zeanah, Jr. (Ed.), Handbook of Infant Mental Health (pp. 22-39). New York: Guilford Press.

    Solomon, J., & George, C. (1996). Defining the caregiving system: Toward a theory of caregiving. Infant Mental Health Journal, 17(3), 183-197.

    Vreeswijk, C. M. J. M.; Maas, A. J. B. M.; Rijk, C. H. A. M.; Braeken, J.; van Bakel, H. J. A. (2014).  Stability of fathers’ representations of their infants during the transition to parenthood.  Attachment & Human Development, 16(3), 292-306.

    Winnicott, D.W. (1987). Babies and their Mothers. New York: Addison-Wesley.

    Yarcheski, A., Mahon, N. E., Yarcheski, T. J., Hanks, M. M., & Cannella, B. L. (2009). A meta-analytic study of predictors of maternal-fetal attachment. International Journal of Nursing Studies, 46(5), 708-715.

    Zeanah, C.H., Carr, S., & Wolk, S. (1990). Foetal movements and the imagined baby of pregnancy: Ar

  • Integrated Health Care – Starfish’s Integrated Pediatric Approach

    Integrated Health Care – Starfish’s Integrated Pediatric Approach

    Jung Nichols, LLPC, Integrated Health Supervisor

    A great need for mental health services is recognized

    Many years ago, Starfish Family Services’ late CEO, Ouida Cash, and Oakwood Health Care (now Beaumont Health) submitted an application to the Health Resources & Services Administration (HRSA) to start a local Federally Qualified Health Center (FQHC) in Inkster, Michigan, which became Western Wayne Family Health Center.  Years after the clinic was established, the clinic staff realized there also was a great need for mental health resources, and the FQHC partnered with Starfish.  Initially, it began with a part-time therapist who worked in an office in the building.  They quickly learned that the outcomes they had hoped for were not being achieved. Transformation to a more integrated approach (as opposed to co-located model) began when Michelle Duprey from Starfish Family Services came on board around 2010 and worked closely with staff and with the support of the management.  They learned the valuable lesson that you can’t place a mental health professional into a medical clinic and think that integration will just happen because true integration requires change and transformation of culture, workflow, relationships and attitude.

    A unique and creative approach to meeting mental health needs

    About two years later, the Ethel and James Flinn Foundation granted funding, which was subcontracted to the Detroit Wayne Mental Health Authority, for Starfish to begin the Screening Kids in Primary Care Plus program.  This program was specifically designed to partner with pediatricians to embed a Pediatric Behavioral Health Consultant into their practice to provide screening, brief intervention, action plans, resources, referrals and consultation on children’s mental health issues. Although the grant ended years ago, the Detroit Wayne Mental Health Authority continues to support this important Wayne County initiative. During this time, the Authority also initiated the Pediatric Integrated Health Care Workgroup to ensure that work being done for the adult population was also being addressed for the pediatric population.  One result was the Wayne County Pediatric Integrated Health Care Concept Paper with Duprey as the lead author.  Starfish was awarded additional grants to continue integrated health care work and expanded to Integrated Infant Mental Health (I-IMH) with the help of a Flinn Foundation grant around 2013.

    A Comprehensive Team Approach

    Currently, the Starfish Integrated Health Care team has one director — Michelle Duprey, and two supervisors — Chy Johnson and Jung Nichols.  There are nine IMH therapists who provide specialized home-based Infant Mental Health therapy and are also embedded in OB/GYN settings (outpatient clinics and hospitals). This allows them to combine their specialized training with the OB/GYN team for optimal women’s health care.  The four full-time Behavioral Health Consultants and one Medical Care Coordinator, who are embedded in various medical settings including pediatrics, family medicine, and oncology, work alongside medical staff to provide behavioral health and community resource expertise.  Our staff are physically located right inside the medical setting.  This is the One Location, One Visit philosophy.

    This philosophy is described in the Pediatric Integrated Health Care Manual developed by Duprey, who is a national subject-matter expert on PIHC https://www.integration.samhsa.gov/integrated-care-models/children-and-youth

    One Location, One Visit

    One Location, One Visit ensures that the medical team has behavioral health expertise available on-site when patients come to see their doctor.  The goal is to treat the whole person, which means mind and body.  As behavioral health professionals, we know that social/emotional well-being impacts physical health and that physical well-being in return  impacts social emotional health.  Having a behavioral health professional on the medical care team allows the team to address the many concerns that may arise in various ways, including care coordination, referrals to specialty mental health treatment, and information about how to access community resources.  Families can also receive education and support about anything normative that comes up in primary care visits, such as child development, parenting/discipline, and educational needs.  This normalizes discussion about and awareness of behavioral health needs of their children, as well as knowing where to go for questions/concerns if they arise in the future.  We know that addressing emotional needs of families as early as possible can help with early detection and allows us to provide intervention before things develop into more serious conditions.  An added benefit is that the medical staff also receive education that allows them to become more aware of behavioral health and the impact on health behaviors and outcomes.

    Example #1: Intervention on behalf of a 5-year-old

    Cash, a 5-year-old boy, came to the primary care clinic for a Child Protective Services (CPS) physical following a referral from the school after Cash came to class with a gash on his head. When prompted, Cash told his teacher, “My mom gave me a whoopin’ with a belt.” The forehead mark was found to be from his 3-year-old brother, who threw a hammer at his head after Cash hit him with a broom. When Cash’s mom, Cheyanne, was interviewed by CPS, she admitted hitting him with a belt and leaving physical marks.

    Cash is in the Detroit Public Schools Head Start program. He has been suspended five times. He can no longer ride the bus because he jumped on a boy on the bus and started hitting him with his fist. He also tried to kick a female classmate down a flight of stairs. He is disruptive in class and frequently throws temper tantrums.

    Cheyanne is fed up, easily aggravated and worried. Cash’s little brother is reported to be “absolutely terrified of him.” His 7-year-old brother teases Cash and Cash reportedly gets easily angry and punches and spits on him. His biological father is only intermittently available to the family and Cheyanne worries because he has been diagnosed with bipolar disorder. Cash has an involved stepfather but he is not comfortable with discipline.

    An internal referral was made to Starfish and the family successfully enrolled in services.  For the past five months, they have been getting home-based services, which emphasize parenting/discipline and family relationships.  Cash is making progress and is no longer violently aggressive toward his brothers.

    Kelly Mainville, MS, LLPC

    Building relationships promotes health and wellness from the start

    A major component of Infant Mental Health Therapy (IMH) is to promote the health and wellness of a child through close, secure relationships and attachments with their caregivers. As an Integrated Infant Mental Health Therapist/Behavioral Health Consultant working in an OB/GYN clinic, I strive to promote and model close, secure relationships and attachments with patients so they can go on to promote that same relationship with their loved ones. I help the patient understand the importance of forming a secure relationship with their doctor to further promote health and wellness throughout their pregnancy and early post-partum period and get them in the good practice of relationship building. And while my role is most certainly to promote healthy mental well-being in patients, more than anything it is to help them feel supported and held during their visits to the clinic. My IMH training and expertise is the foundation of my work; I apply it to my interactions with the patients I see — pregnant or not. My focus is to build relationships, to promote health and wellness at any stage of reproductive health, and to support patients. I also do a lot of advocating for baby — before baby is even here — and educating the patient on the importance of forming a close, secure relationship with their unborn child.

    My work is slow but deliberate

    Like much of the work we do in Infant Mental Health Therapy, my work with patients is often slow, but deliberate, difficult at times, but so rewarding. To see a patient’s face light up because this is the first time someone has really asked “How are you doing?” and is willing to listen to her concerns and to support her, validates that this work is important. To have patients say “hello” or “I was hoping you would come see me today” means that the relationships I am building means something to them. A few weeks ago, I encountered a patient for the first time and when I described my role in the clinic, she started crying. Of course, I asked her if something was wrong and her response was “I’m just really happy that someone cares about us.” She stated that her hormones caused her to be overly emotional but she kept repeating how happy she was that someone was going to check in at each appointment and support her. Other patients have shared similar sentiments, shaking my hand or giving me a hug and telling me how grateful they are to feel supported during a mostly happy, incredibly transformational time in their lives.

    Example #2: Infant Mental Health Intervention with a Depressed Mom

    Recently, Rosa, a woman in her late 20s, came into the clinic for her 6-week post-partum checkup. It was apparent that she was exhausted — mentally, physically, and emotionally. She had made a few concerning comments to the medical assistant (MA) during her vitals check and the resident doctor about not being able to cope with the baby’s crying, feeling very sad, and feeling very isolated. Both the MA and the resident doctor conferred with me and together we decided that it would be beneficial if I could speak with her. I entered the room and immediately saw a woman who was struggling. She had showered, gotten dressed, and looked physically presentable, but I could see worry, fear, and trepidation in her eyes. Instead of my more formal introduction of what my role is in the clinic, I simply said “I’m Kelly and I’m here to see how you are doing.” The minute I said that I could see a shift; mom became tearful, but I saw relief wash over her, too. She began to tell me her story. She and her husband had decided that because of some health issues, they would have children soon after they married. Mom said,  “I’ve nannied before, but never for kids under 2. I didn’t realize how much babies cry and I can’t take the crying.” She also reported feeling alone and like a bad mom because she couldn’t figure out what was making her baby cry and because she couldn’t handle the crying. I spent about 20 minutes with her, reassuring her that what she was feeling was a feeling shared by many new moms, that she was doing her very best to meet her baby’s needs and keep him comfortable, and that while this seemed overwhelming right now, it would not last forever.  It was at this time that I realized what an amazing candidate this mom would be for Infant Mental Health Therapy. I explained the program to her and I could see even more relief wash over her. Unfortunately, I was unable to add her to my caseload, but I was able to place her with a teammate who is also a mom and someone I felt would be a great fit. I will now follow up with Rosa in the clinic at her next post-partum appointment (the resident and attending doctors both agreed she should come to at least one more to monitor her mental health) and check in with how IMH is working out for her. I have a lot of hope that this program will benefit her greatly and I am so happy that I could play such an integral role in getting her the support she needed. This family makes me further believe in the importance of having a trained infant mental health clinician working as a Behavioral Health Clinician in OB/GYN offices. I was able to provide immediate support, which facilitated her acceptance of a long-term intervention to ensure optimal mental well-being and a positive outcome for her and baby.

    Expanding the Model: Partnering with the University of Michigan

    Of course, I value and believe in my work within the OB/GYN clinic, as do many of the patients and clinic staff, but it’s about more than just one clinic believing in the Integrated Infant Mental Healthcare model. It’s about the importance of integrated health becoming a regular practice in all OB/GYN clinics state and nationwide. This is why we have partnered with the University of Michigan to conduct an Integrated Infant Mental Health study that will evaluate the effectiveness of the Integrated Infant Mental Health Model (I-IMH) on maternal and child outcomes, as well as estimating the cost for implementing and delivering the I-IMH intervention in OB/GYN clinics. The hope is to show that the Integrated Infant Mental Health Model is a worthwhile investment in OB/GYN clinics and that through its emphasis on relationship building and support, it can promote healthier maternal and child outcomes in the process. We are in the beginning stages of this study; recruiting patients and getting other clinics we are embedded in on board with participating is proving to be a challenge, but we are working hard to show that the Integrated Infant Mental Health Model works.

  • Enforcing Immigration Policies Frightens and Negatively Affects Children and Their Families

    Enforcing Immigration Policies Frightens and Negatively Affects Children and Their Families

    Parents do not uproot their children to make a long and dangerous journey to an unknown future in the U.S. unless situations in their home country are so threatening that the risks of migration pale in comparison to more certain risks at home. Parents do it because they feel they must!

    Zero To Three is one of many organizations feeling compelled to respond to young children being separated from their parents at the U.S. Border.  In a recent statement:

    “The secure attachments young children form to their caregivers are the bedrock of healthy development and emotional stability, providing a sense of security and a buffer from the toxic effects of stress and trauma. Migrating to a new country is already stressful. 

    Separating children and caregivers destroys the relationships that foster resilience.  Make no mistake: separation at this point is a trauma that can have long-term impacts on an infant’s well-being. 

    Post-traumatic stress disorder, anxiety, depression, and sleep disorders can follow.

    The practice of having border agents remove children from caregivers suddenly and place them institutional care, especially without any policy for visitation, or reunification, amounts to maltreatment.

    Anyone with infant/early childhood mental health expertise – and anyone with a heart for children – will tell you that separating young children from caregivers at the U.S. border is appalling and must be stopped”

     – Myra Jones Taylor, chief policy officer
    ZERO to THREE

    As immigration enforcement ramps up, so increases the fear of undocumented parents about the fate of their children.  There are about 6 million U.S. citizen children with at least one parent who is in the country illegally.  Research shows that harsh immigration enforcement policies have consistently undermined the health, economic security, and overall wellbeing of children of immigrant families.

    Specifically, the current administration’s immigration enforcement orders:

    • Tear families apart
    • Harm children’s short- and long-term mental health
    • Undermine children’s economic security
    • Threaten children’s access to education and basic needs
    • Endanger the lives of asylum-seeking children and families

    Last year, the current administration issued two executive orders that powerfully expanded the intensity and scope of federal immigration enforcement activities in the United States.  These orders have included policy changes that have negative consequences for children living in mixed-status immigrant families. Many of these children are U.S. citizens.  This policy enforcement has dire consequences for unaccompanied children seeking protection here.

    The current administration’s orders call for:

    • An increase in immigration enforcement activities for deportation, triples the number of immigration agents,
    • Increased collaboration between federal Immigration and Customs Enforcement (ICE) and local law enforcement agencies to detain undocumented immigrants,
    • Focus on immigration enforcement along the U.S. southern border,
    • Significant expansion of immigration detention capacity.

    Additionally, the current orders have resulted in the separation of at least 2300 undocumented children from their parents who are placed in governmental care in shelters and foster homes across the United States. At the time of this writing, few have been reunited despite judicial mandates.

    Parents who come to the U.S. have to make very difficult decisions about whether or not to bring their children with them to a new country that is unknown to them.

    There are policy changes that would return more migrants, including women and children seeking asylum, back into harm’s way and strip children of critical protections.  These orders and policies undermine the wellbeing and development of millions of children and are directly linked to the parent-child relationship, external stress factors, and family economic security.

    Parts of these orders may face legal challenges and other parts require additional funding to be fully implemented making these policies not final.

    Significant effects of current immigration enforcement orders:

    1st – Immigration enforcement orders tear families apart and mixed-status families are now more likely to be separated by deportation because every undocumented immigrant is being seen as a priority for removal and quickly processed with deportation orders. The “official guidelines for implementing the orders” rolls back previous Department of Homeland Security (DHS) policy that gave immigration officials discretion in deciding whether to detain certain immigrants, including parents and legal guardians of minor children.

    More than 5 million children in the United States live with at least one undocumented parent and 4.1 million of them are U.S. born citizens.

    As a result of these official guidelines, children are at risk for having a parent or guardian deported.

    The current administration has called for national raids which have captured hundreds of people (parents and young people) previously covered by the Deferred Action for Childhood Arrivals (DACA) program which was established in 2012 giving relief from deportation for undocumented youth who came to the U.S. as children.

    Family separation is one of the most harmful effects of the current administration policies.  As we know, parents are extremely important to the wellbeing of their children and the sudden loss of a parent can have long-term consequences.

    2nd – Immigration enforcement orders harm children’s short and long term mental health by increasing children’s anxiety about their undocumented parents. At very young ages, children are impacted significantly by parent stress, according to many studies.  High levels of parental stress can result in poor cognitive development in children as young as two years of age.  Persistent stress, also known as “toxic stress”, can have harmful effects on brain development in very young children affected by fear and worries of their family and community, and the trauma of watching a parent be arrested can result in behavioral changes.  Very young children are particularly vulnerable to the impact of toxic stress due to the rapid brain development taking place, as well as their dependence upon familiar, caring adults to assist in regulation of their state of arousal.  The social and emotional development that takes place during the earliest years will impact later functioning for years to come.

    Children of all ages are affected by fear and worries of their family and community, and the trauma of watching a parent be arrested can result in behavioral changes. Children’s sleeping habits often suffer and increased anger or withdrawal is common.  Schoolwork can suffer.  Additionally, the remaining parent may experience depression and withdrawal.  Mixed-status families involved in immigration enforcement often lack access to mental health services that are affordable and culturally and linguistically appropriate.

    3rd – Immigration enforcement orders can undermine children’s economic security. Parental deportation or risk of parental deportation can push children in low-income immigrant families further into poverty.   One study estimates that the sudden loss of a deported parent’s salary can reduce a family’s household income by 73 percent.  Poverty faced by children in mixed-status families results in barriers to basic health and nutrition supports available to non-mixed status families. We know that children living in low-income households when compared to same age peers often experience more hunger, decreased health outcomes, and increased learning disabilities and developmental delays. Poverty faced by children in mixed-status families results in barriers to basic health and nutrition supports. Additionally, poverty causes extreme stress on parents, affecting their ability to recognize cues and attend to their children.

    4th – Immigration enforcement orders threaten children’s access to education and basic needs. The fear of deportation can cause parents to be reluctant to send their children to child care, school or after school activities.  Every day parental responsibilities – transporting children to and from school or childcare – become too risky for undocumented parents.  A routine traffic stop could result in deportation.  Anti-immigrant rhetoric increases parent fears to reach out for a variety of supports for themselves and their young children.  There are also concerns for schools, early childhood education and care programs, health clinics and other programs that serve immigrant children and their families regarding confidentiality.  Current ICE policy restricts immigration enforcements from occurring in “sensitive locations” like schools, child care centers, bus stops, hospitals, and places of worship.  Yet, we know of incidents where parents have been taken into custody at these locations.  There is a need to review policies and to provide protocols to ensure the safety of all children and families.

    5th – Immigration enforcement orders endanger the lives of asylum-seeking children and families.

    These are the children and families that have experienced significant trauma in their migration from their home countries: families primarily from Central America trying to escape violence and instability in their home countries because of drug trafficking, gangs, and organized crime.

    When border patrol agents turn away migrants at the border, forcing them to wait for outcomes outside the United States, their children are exposed and vulnerable to trafficking, and young children are being recruited for gangs.  Policy guidelines need to define who qualifies as an “unaccompanied child” and to provide protections for these children.  The Federal government requires women and children to be placed in detention centers – a controversial practice that has been shown to be detrimental to children’s healthy development. This is being challenged in court.

    These are not the values of America.  This policy enforcement is dangerous to the health of our most vulnerable children.  Separating families sends children deeper into poverty and jeopardizes their rights to basic human protection. Current immigration policies and practice go against MI-AIMH’s mission to promote safe lives and healthy social emotional development for all very young children.

    “MI-AIMH believes that each infant needs to be nurtured and protected by one or more consistent and stimulating caregivers who enjoy a permanent and special relationship with the baby.  This relationship is essential for optimal social, emotional and cognitive growth. MI-AIMH also believes that the failure to provide and maintain nurturing relationships, at least one, during infancy may result in significant damage to the individual and to society.”

    Infant and early childhood mental health specialists understand what is at stake and it is critical that we advocate for practices that protect and support the healthy development of every young child.

    References:

    Cervantes, Wendy, & Walker, Christine (2017) Five Reasons Trump’s Immigration Orders Harm Children. Center for Law And Social Policy, April 2017 1-8. mi.aimh.org

    Njoroge, Wanjiku F. M. (2015) Complex Intervention: A Family’s Story of Loss, Struggle, and Perseverance. Zero To Three Journal, March 53-56.

    Paris, Ruth, & Bronson, Marybeth. (2006) A Home-Based Intervention for Immigrant and Refugee Trauma Survivors: Paraprofessionals Working With High-Risk Mothers and Infants. Zero To Three Journal, November 37-45.

    Prieto, H. Victoria. (2017) Considerations for Serving Immigrant Families With Young Children. Zero To Three Resource for Professionals.

    Zayas, Luis H. (2018) Immigration Enforcement Practices Harm Refugee Children and Citizen-Children.  Zero To Three Journal, 38(3) 20-25.

  • Early Identification of Autism Spectrum Disorder (ASD) and Parent-Child Group Intervention Based on the Early Start Denver Model (ESDM)

    Early Identification of Autism Spectrum Disorder (ASD) and Parent-Child Group Intervention Based on the Early Start Denver Model (ESDM)

    Increasing access to early intervention for ASD, a national and international health priority

    Autism Spectrum Disorder (ASD) now affects approximately 1 in 59 children in the United States.

    Based on the knowledge of developmental science and rigorous intervention studies, we know that early intervention leads to better outcomes when started as early as possible in development. Unfortunately, on average in the United States children with ASD are diagnosed at 4 years of age and start intervention even later, despite the fact that they can be identified as young as 12 months. Usually, children and their families experience long waits before accessing a diagnostic evaluation and after this, they need to wait even longer to start services. The gaps between parents’ concerns and the beginning of services are due to the increase in the number of children with a diagnosis of ASD combined with a scarcity of specialized providers. The National Research Council has recommended a minimum of 25 hours per week of intervention. However, it is nearly impossible to provide such intensity by relying uniquely on professional delivery to all children immediately following diagnosis. One way of increasing access to intervention is to teach intervention strategies to parents. Parent-based interventions have shown positive outcomes in children, as well as in parents. Research has shown that by learning intervention strategies with the help of professionals, parents naturally implement intervention throughout the day during activities such as play, mealtime, and grooming. By including the parents in the intervention, the time spent with a professional will have cascading effects in terms of increasing therapeutically productive time for the child.

    Julie’s story, the importance of paying attention to early signs of ASD

    Julie is a child who was lucky enough to receive an early diagnosis of ASD at 23 months of age, after which she was quickly enrolled in our Parent-Child Group intervention, described below. Julie was born full-term after an uncomplicated pregnancy and was a happy, easy-going baby. She started babbling around 6 months of age and met motor milestones on time. However, her parents became concerned about her development around 18 months of age, because her language was not progressing, she regularly flapped her arms and she did not consistently alert her parents to her needs, despite their sensitive caregiving and responsiveness towards her. Rather, they had to predict when she might be hungry or thirsty or need a diaper change. Furthermore, she has a cousin with a diagnosis of ASD, and her parents noticed similarities between the children. For instance, Julie preferred playing by herself to playing with others, especially other children. She often engaged in repetitive play with a shape sorter or putting toys in a toy box. However, she did engage with peek-a-boo and pat-a-cake appropriately with her mother and enjoyed clapping when excited. She transitioned easily between activities, however she did engage in some repetitive behaviors, especially during bedtime.

    She preferred doors to be closed and also engaged in some repetitive sensory seeking behavior, such as running her hands on walls and placing her fingers in the door latch. Julie also had tactile aversion to messy play and significant temper tantrums if expected to ride an elevator.

    Obtaining a multidisciplinary evaluation for ASD

    Her parents sought out an evaluation based on their concerns and brought her to the University of Michigan Department of Psychiatry when she was 23 months old. Julie and her parents engaged in several interviews and tasks during the assessment. Her parents responded very warmly to her and attempted to engage her in many tasks. At times, she appeared to enjoy back and forth interactions, such as when being tickled. However, more frequently, she did not respond to her parents’ and examiners’ attempts to engage her in developmentally appropriate play. She also tended to run away, rather than toward her parents, when distressed. However, when her parents picked her up to comfort her, she was very quickly soothed.

    Overall, Julie demonstrated strengths in imitation and emerging eye contact. However, she was delayed in the areas of language and communication and reciprocal social interaction and had several restricted and repetitive behaviors. For instance, although she babbled regularly, these vocalizations were not typically directed towards others. She did not point, nor use other gestures. She gave items to her father, but did not show items, and only rarely initiated joint attention, despite enjoying several tasks. Although her eye contact was emerging, it was not regularly used to initiate, regulate, or terminate social interactions. She was able to play appropriately with several toys, including those present in a bath time play activity shared with the examiner However, At other times she engaged in more repetitive play, that was difficult to interrupt, such as repeatedly putting items in and out of bins. She engaged in brief finger posturing and had some sensory interests, often examining items close to her face or sniffing them.

    Julie was also evaluated just prior to 24 months by Occupational Therapy and at 25 months by Speech-Language Pathology. The Occupational Therapy evaluation noted weaknesses in self-care skills and fine and gross motor as well as sensory aversions. For instance, her motor weaknesses led to difficulty assisting in dressing routines and holding crayons, and she was very averse to engaging in messy play. The Speech-Language Pathologist felt that Julie had moderate Receptive and Expressive Language Delay. All of the combined information from parent report of her development and examiners’ observations led to a diagnosis of ASD. Although Julie’s parents were sad that the diagnosis they feared was confirmed, they were receptive to the feedback and excited to engage in treatment to assist Julie, as soon as possible.

    Parent-Child Intervention Begins-a low intensity group adaptation

    Parent-Child Group Intervention Begins – a low intensity adaptation of the ESDM within a parent-child group setting

    Julie enrolled in our group intervention at 24 months of age. This intervention is based on the Early Start Denver Model (Dawson and Rogers, 2010), an evidence-based intervention that fuses developmental science, relational approaches, and the principles of Applied Behavior Analysis. The Early Start Denver Model (ESDM) has been implemented in many different settings including the more traditional therapist-child delivery, parent coaching, school-based groups, as well as telehealth therapy. In our Department, Dr. Colombi, through internal and federal funds, has developed a Parent-Child Group intervention based on ESDM principles to offer intervention to all families who receive a diagnosis at the University of Michigan and want to start intervention immediately.

    The Early Start Denver Model uses a child-centered, responsive interactive style and 10 foundational intervention themes, including (1) social attention and motivation for learning, (2) sensory social routines, (3) dyadic engagement, (4) non-verbal communication, (5) imitation, (6) antecedent-behavior-consequences relationships, (7) joint attention, (8) functional play, (9) symbolic play, and (10) speech development. From session 2 to session 10, each strategy is the focus of one session in which the parent is taught to deliver the lesson in the context of a shared activity using age appropriate play materials. In session 1, we introduce the structure of the group to the participants. In session 12, we review all strategies.  During the first 45 minutes of the session the interventionist meets with the parents and covers one of the above themes while children play with the supervision of student research assistants. During the last 45 minutes of the sessions, the parents join the children. During this second phase the parents are encouraged to implement the strategies learned during the first phase with the coaching of the interventionist.

    In comparison to the original evidence based Parent – ESDM intervention delivered by the therapist to a single parent-child dyad, some adaptions had to take place for the group delivery. While the topics of each session are the same across Parent-ESDM (single dyad delivery) and Parent-Group delivery, the format of the sessions are slightly different. In Parent-ESDM delivery, therapist, parent, and child are in the same room for the entire session and there is a continuous alternation between verbal discussion and direct practice of the specific intervention strategies. During the Parent-Group delivery, verbal discussion and direct practice are more clearly separated. During the first part of the session (first 45 minutes) therapists and parents discuss the topic while the children play in a different room. Usually, 3-5 children with ASD play with developmentally appropriate toys with the help of 3-4 students. The direct practice of the strategies, with therapist’s coaching and feedback, occurs during the second part of the session, when parents and children reunite. In general, the families who participated in our groups, expressed satisfaction. Moreover, children demonstrated improvement in social communication as measured by the Behavior Observation of Social Communication Change (Lord et al., 2013).

    Julie and her mother participated in our group Parent-ESDM intervention, as described above, and made significant progress. ASD symptoms were evaluated through the Brief Observation of Social Communication Change (BOSCC) (Grzadzinski et al., 2016). The BOSCC was developed as an outcome measure of symptoms associated with an Autism Spectrum Disorder (ASD) for young children. It is responsive to change in core ASD symptoms. Julie and her mother were administered the BOSCC at three time points, during the diagnostic evaluation, just prior to starting the intervention (almost 2 months after initial evaluation), and at the end of the intervention. Higher scores in the BOSCC are associated with higher ASD symptom severity. Julie’s scores were 38 at the time of diagnosis, 44 before starting the intervention, and 17 at the end of the intervention. Thus, Julie’s ASD symptoms worsened from diagnosis to the beginning of the intervention and improved drastically after receiving the intervention. Additionally, Julie ’s mother learned the intervention strategies. At the time of diagnosis and prior to starting the intervention, Julie’s mother worked hard to present many opportunities for Julie to interact with her and with toys, but Julie frequently did not respond to this more directive approach and rather tended to engage repetitively with toys on her own.

    Through the group intervention, Julie’s mother became more adept at following Julie’s lead and imitating Julie’s behavior with toys, vocalizations, and actions.

    This captured Julie’s attention more readily and Julie was subsequently better able to imitate her mother’s actions, vocalizations, and play. This led to an increase in Julie’s expressive language and more creative uses of toys and other objects. Perhaps most importantly, Julie and her mother appeared to enjoy their interactions more and had much more shared positive affect by the end of the intervention. In general, both mother and daughter smiled and appeared to have more energy post-intervention. Julie’s mother learned the ESDM strategies, as demonstrated by reaching fidelity in the implementation of the intervention. Moreover, in a satisfaction survey, Julie’s mother indicated that she found the program very helpful.

    Julie’s story reminds us of the importance of early identification and early intervention with the inclusion of parents

    The case study here reported suggests that parents can learn helpful intervention strategies through a low intensity parent-child group program. Moreover, the child described seemed to show a dramatic improvement in her ASD symptoms after participating in the intervention. By learning the intervention strategies, Julie’s mother was able to implement treatment throughout the day. While intensive intervention is still to be considered the gold standard for young children with ASD, it is not realistic at present to administer intensive services to all children immediately after diagnosis. Our case study demonstrated how more children can receive effective intervention in low resource communities or in families without sufficient ASD service benefits.

  • Balancing This Wonderful Work During These Trying Times

    Balancing This Wonderful Work During These Trying Times

    Sharing Our Perspective

    It is our hope to share our perspective and acknowledge the feelings and interactions that come with home visiting during this time of uncertainty regarding today’s social and moral climate in 2018.  Our hearts and our heads literally hurt for all that is happening in society now. It is a difficult task to write about real issues and difficult feelings in a meaningful way. How does one hold and make sense of all of this at one time? In the infant and early childhood field we have the wonderful opportunity to deeply experience and explore feelings.  Yet, right now some of us really don’t want to feel this level of discomfort.  Each day we read the news and there are more challenges: very young children being separated at the border from their traumatized parents, murders that are racially or politically motivated, sexism and a multitude of other injustices. I wonder how anyone holds all of this – work, family, health, political climate, etc.- and then supports the families that we serve. And how can supervisors support supervisees to the extent needed and, in turn, how can supervisors get the support they need? We offer two perspectives in reflection on many of the current happenings in 2018.

    Kristina’s perspective 

    As a home visitor over the last 18 years and specifically as an IMH therapist for the last 10 years, there are many experiences and stories from which I can choose to share.  It is my hope to share my reflections in a way that helps acknowledge the experiences of home visitors and how this work continues to be done with very young children and their families.  In today’s political and social climate so many situations that encompass tragedies, separations and racial inequalities are being played out in the media every day.  Each of us is impacted in some form or fashion whether personally or professionally and for some of us it is both personal and professional. The profound impact of daily inequalities we experience directly and indirectly as clinicians require a safe place to discuss and process our own feelings and experiences as well as the feelings and experiences of the families we serve.

    A privilege to do this work

    It is a privilege to work with each family we encounter.  Often the families we interact with have little trust for people, especially people they may view as in authority.

    The reality is that each of us has initial thoughts, biases and judgements upon our first meeting; assumptions are made by both the clinician and the family.

    The clinician may be wondering: ‘Will I be able to relate to this family?” ‘Can I help this family?’ and possibly, ‘Will this family overwhelm me?’  The client may be wondering: ‘Can this therapist help us?’ ‘Will she take my children from me?’ ‘Will she understand my hurt and pain and that I want better for my children?’ With all of these thoughts, how does a clinician unpack her own experiences and start fresh with each family? Often clinicians have the opportunity to utilize reflective supervision but what about the experiences that are too hard or too charged to talk about?  I have left home visits feeling completely dysregulated because of thoughts, feelings and experiences that have occurred during a two – hour session.

    My own cultural background

    I remember home visits when race was discussed and feelings of prejudice were vocalized by family members without the other person having any recognition of my own cultural background and with no regard as to how these thoughts and feelings might impact me. As an African American clinician with very fair skin, I recognize that some families may be unsure of my race and be surprised to learn that I am not biracial or Latino. I have coined the term, “when I announce my blackness” to describe these conversations with families in an attempt to understand their point of view.  At times I have asked myself if I feel safe and if will I be able to go back and do meaningful work with a family after these conversations have taken place.

    These questions are critical to each unique working relationship and are issues that need to be explored.

    Great support is needed not only by supervisors, but also from peers and the agencies where we work.  Without exploring these very deep issues, our relationships become compromised and we are unable to be our best and do justice to our work.

    I can also reflect on experiences when families were facing separation from their children due to child protective services involvement, incarceration of a parent, non-involvement of a parent, immigration laws or homelessness. The very idea that a family cannot be together due to challenging circumstances or past mistakes can be too much to bear at times and heartbreaking for all involved. I cannot help but think about innocent children being affected by the new immigration laws that are separating them from their parents without any warning or plan of reunification. My feelings about issues impact me deeply and affect my ability to effectively do my job. I need supportive supervision to discuss these as well.

    My own experience with immigration

    I am the wife of a legal immigrant who came to this country for a better opportunity. My husband came to the United States at the age of 19 to live the American Dream that is so proudly talked about and held in such high regard. He obtained his citizenship in 2012 which was a very happy day for him and our family. As an American citizen I felt proud to witness so many people actualizing their dreams and pursuit of happiness that day.

    I held my oldest son high off the ground, so he could see his father presented with his citizenship and shake the judge’s hand after they all took their oath to be upstanding citizens here in America.

    I remember saying to our son, “We are so proud of Daddy.  This is such a great day.”

    However, with that vivid memory of joy I also have a vivid memory of uncertainty and fear. Thirteen years ago, my husband and I were planning to travel out of the country for vacation and my husband realized his green card had expired. In that moment, sheer panic set in and we were terrified as to what this would mean not only for my husband but for me as well. We quickly went to immigration services and had our lives in the hands of someone who knew nothing about us, who we were as individuals or as a couple. I remember my husband pleading his case to have his green card extended for an additional thirty days so he could properly renew his status. In that moment, our entire lives were hanging in the balance and we were at the mercy of a stranger. I prayed silently that she would help but feared she would make a judgement or have a bias and say” sorry, I can’t help you.” She decided to help us and gave my husband an extension, but this is not always the reality for the families we serve and the countless families here in the United Sates that are undocumented immigrants who just want a better life for their children.

    As clinicians how do we hold these stories, advocate on families’ behalf and witness these realities without being impacted? It’s impossible and this is worthy to be discussed.

    Andrea’s Perspective

    We are in a unique place and time in history. While very cognizant of issues of racism, sexism and overall hatred and injustice, these last few years have been a harsh wake up call. Our nation is not new to consistent calamity. We have seen and experienced a great deal in the past 100 years, from WWII, to the Civil Rights Movement, Vietnam, the War on Poverty and new age terrorism to name a few.  I not only see a nation divided but a nation of overwhelmed, frustrated and overall hurting people. What is the answer? I even googled that question to come up with something.  I know some of you have watched the news, read your social media feeds, talked with loved ones and then also pondered that same question. In the infant and early childhood mental health field, we are the helpers. What is it that we as the helpers can offer as a salve on this gaping wound of intolerance? We the helpers must first do what we do best, start with self-reflection. We look within and become aware of our own inner workings to find common ground with our neighbor, our co-worker, and our clients.  We start within and go beyond, moving to society as a whole. Our country needs an IMH worker!

    What I have held on to in these uncertain times is not just believing but knowing that what separates is so much less than what brings us together. While I have seen racism, sexism and many other intolerances, I have also see those who demonstrate unity and healing in word, action and deed. I know individuals in this wonderful profession who advocate for those who look nothing like them. We make assumptions all the time, and privilege allows us to do so. However, if you are like me, you, too, are wondering ‘what can I really do to make a difference?’ We must be intentional about responding when issues of diversity, equity and inclusion come to our attention. It is difficult to be the person to speak up but if we don’t, who will? No one can afford to turn a blind eye to injustice and inequity.

    We cannot do this work alone

    We cannot do this work alone. We need each other: home visitors, clinicians, educators, advocates, policy makers-all are essential to this great work. We will voice the interests of infants, toddlers and families, and we will do this FOREVER!

    Both supervisors and supervisees need support and supervision.  Recognize when your cup is empty and identify for yourself who to turn to when it needs to be filled.   You can’t pour out of an empty cup.

    Together we can make a meaningful difference

    In the end you don’t have to be Latino to care about immigration, you don’t have to be African-American to care about black lives matter. You don’t have to be Native American to care about sacred grounds; You don’t have to be in poverty to care about the poor and you don’t have to be female to care about women’s rights. We are all connected and that’s what matters and together we all can make a meaningful impact!

    “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” Margaret Mead

  • Elephant? What Elephant?

    Elephant? What Elephant?

    The American Heritage Dictionary of Idioms tells us that “to sweep under the rug” dates from the mid-1900s and refers to that which we wish to hide, such as floor dust that has been gathered with a broom, and then — the doorbell rings announcing guests. I think the reasons for sweeping dust under a conveniently placed rug are fairly clear: I don’t want people to see this dirt, but…  Oh, what to do? I know, I’ll just sweep it under this rug and attend to it later. I’m sure I won’t forget it.  There. The room looks very nice now. I want people to see me as a responsible homeowner. I sure don’t want any doubts to arise about my good character!

    Over time, the phrase has come to refer to much more than the risk of embarrassment, now including anything we wish to avoid thinking about, discussing, or dealing with. But today, with vacuums and robotic floor-cleaners in our homes, we need something more obvious to carry the moral message. So, we now have the unmistakable metaphor of the elephant in the room, plus one that blends the old and new: the elephant under the rug.

    Of course, hiding an elephant is quite different than a bit of dust, which suggests that the more uncomfortable our darker thoughts, the more room they threaten to take up in our consciousness. The image of an out-sized elephant standing in even the largest of living rooms offers a rather compelling way for us to regard and reflect on the realities of troubling thoughts and the costs of ignoring them, particularly to our social selves, members not only of families and communities but also the societies in which we live. It is people who are the fabric of society: The more uneasy the people, the greater the number of uneasy people, the more wear and tear on the fabric. Considering the rug as a symbol of society itself, i.e., individuals who are all gathered and held by an intricately woven tapestry, it would stand to reason that the more unsettled the people, the greater the risk of thin spots and holes that will weaken and even threaten to destroy even the strongest fabric.

    Let’s get back to the elephant. Sometimes the elephant is small enough that, over time, it gets moved to the recesses — the dimmest corners of our minds and generally ignored. We might know it’s there, but we have ways to get around it, or we may just avoid that room in the house of our self. As long as nothing in our lives reminds us of the elephant’s presence, it can just stay where it is — hidden well enough from our everyday lives that its existence can be, at least for a time, denied.  OR, sometimes we actually know where the elephant is, its size, shape, which room it’s in, and the particulars of the rug that covers it. We may even acknowledge its being with us, but it’s just not worth bothering about because, well, we may not be totally comfortable with what that elephant represents, but, hey, can’t we just let some things be? We can have different beliefs, different opinions, but do we have to talk about the differences? After all, aren’t we really more similar than different? Some things are better left unexamined. Life is just … smoother that way.

    Well, maybe. But doesn’t that depend on who or what the elephant is representing? Sometimes we come to depend on the presence of a particular representational elephant. We don’t want to talk about its existence in our lives; we just don’t want anything to change. In fact, when threatened with the possibility of the rug being lifted up and ‘exposing’ our elephant, an attitude of quiet acceptance can turn rather quickly toward strongly voiced convictions, as in: “I think the elephant can stay right where it is. My rug still looks nice. I haven’t really noticed it bothering anybody. If there really are people who would object to a little bump in my rug, well, maybe it would be better if they just didn’t come to my house.”

    Hmmm.

    These scenarios are, at the least, somewhat discomforting. Lots to think about, to reflect on, but … some other time?

    Sure, that’s OK. The elephant will still be there, waiting.

    Because what I really want to consider is: What does it mean to totally ignore an elephant?

    Since I’ve never heard it suggested that the elephant under the rug is dead, I’m wondering what it’s like to be that elephant. What might the elephant think and feel about being so ignored? What might we learn if we could hear the elephant’s communication with itself about an hour after arriving at an open house hosted by the leaders of a special interest organization in your community?

    “How come I’m here? I thought I was invited, but everything tells me I wasn’t really welcome. Yes, that’s it, invited but not welcome. I was the first guest to arrive, so I found a rather nice spot at one end of the main gathering room in the house so that I could watch others arrive. Well, it sure didn’t take me very long to discover that I’m the only elephant here! The more I tried to meet the others, the more ignored I felt. I know now I don’t belong here. What do I do? I can’t just tiptoe out. It’s gotten pretty crowded in here. I’ll knock everything over. I might even step on somebody’s feet! I wish that I had just stayed home with my elephant friends, but I was really interested in this organization and wanted to meet some of its members. Silly me.”

    A few minutes go (slowly) by before the elephant continues:

    “I don’t really want to cause a scene. I’ll just have to wait until no one’s around. Oh, look! The edge of this nice rug is a bit puckered up. Let me just slip myself under the rug and wait till they all leave.”

    What happens next is quite challenging for the elephant. Best not to watch, though it seems quite odd that no one else seems to be watching either. Finally:

    “Phew. That was hard. I wonder if I’m well enough hidden. Well, at least they’re not staring at me now, so maybe if I just stay real still, I’ll be OK until they leave the room. Oh, I’m being ridiculous. Of course they can all see me here! I’m sure they’re all talking about me. I’m so big — and feeling bigger by the minute! Why did I think I could hide? This feels awful! I wish I could just disappear!”

    A seemingly looong time passes, with lots of guests coming and going. The elephant tries to remain very – um – inconspicuous:

    “Wow! It’s been hours, and still no one’s paying me any attention! Wait a minute, why aren’t they paying me any attention? Why aren’t they even acknowledging my presence, my realness? What do I do now???? How long am I going to have to hide like this????”

    More time passes. Then, the big bump in the rug appears to move a bit, as new feelings well up in our elephant:

    “Wait a minute here.  What if I don’t want to hide? What if I threw the rug off, got up, looked people in the eye and tried to get them to respond to me? Wait, what if their responses are horrible, hurtful? Can I stand that? Yeah, I guess I can. Then I could just leave, and go back to being me, the me I feel I really am. OK, I’ll just take a chance and try to remember that my embarrassment won’t last forever. Or will it?? What if I have to always be looking over my shoulder, always trying to make sure that I never again find myself in this position, always hoping that I don’t see these people again? What will I do then? Humph! Talk about hiding!!

    “So, what should I do? Protest or stay silent? How did my life suddenly get this hard? I could tell myself to mind my own business, stick to my own kind, but right this minute, I don’t really know what my “business” is!!

    “So, which one is most tolerable to me? Is there one where I don’t lose myself? That’s what I can’t let happen. I can’t leave here feeling that somehow this was my fault.

    Depending on which I choose, the results will be different, and either way I’m not going to be comfortable. What happens is going to leave with me. What happens is going to affect how I think and feel — about them, about the situation, about me.”

    After more than a few deep breaths:

    “Well, whatever I choose to do is going to be OK. It’s going to be me, my best next steps for right now. Yes, I’ll be OK.  I’m so glad I know that. Even if what’s happening right now feels horribly scary, I’ll still be me. I didn’t always know that, but I’m sure glad I know ME better now. I will still have my ME to be with ME. Period.

    “And, know what? Because I can understand and accept my ME, I can — maybe not right this minute, but later, when I’m not here in this predicament — I can try to understand how all these people felt when they saw me. Why? Because if I can do that, I can let go of how close I am to being really, really angry at what “they” are putting me through right now. I can do this.”

    As we continue to observe the bump, it stops moving. We wonder what will happen next; we look at our watches and see that we must leave. So we don’t know what’s going to happen next, but we can hope. And we can challenge ourselves and others with some questions and reflections:

    First, how did the elephant come to be there?! It’s probably safe to assume that whoever sent the invitations didn’t know it had been delivered to an elephant! The awkward reality of that would have been made quite clear to each and every person as soon as they saw the elephant in the room!

    Second, assuming at least an initial reaction of awkwardness, what would people do with those reactions? Did they turn to each other, wonder together, even if just with their eyes or tense bodies? If so, did they find others who had the same reactions, and did those even brief feelings of connection feel reassuringly safe? Is that why they could decide to ignore the elephant, and avoid the lump?

    Third, might there have been people who actually felt concern for the elephant, felt uncomfortable about the silent treatment, wished they could approach the elephant, but just couldn’t take whatever risks they thought were at stake? After all, some risks can have very grave consequences. We all have very unique comfort zones. They serve an important purpose for us, so important that it takes a lot to step (or even think about stepping) out of them. So, while we’d best not judge others’ actions or inactions, we can — and perhaps should — take time to wonder about the costs of anyone, including ourselves, being as frozen in time as the elephant.

    And last, for now, since all of us have at some point had “elephant in the room moments,” what is it that makes us desperately wish for a handy hiding rug? Ahh, that may take careful observation over time to consider and learn! And let’s not overlook the fact that every elephant is unique in every way imaginable. My elephant will never be identical to your elephant, whether a result of a societal, community or personal discomfort. No one-size applications here! However reluctantly, we must each start by acknowledging the presence of an elephant, and then by exploring its significance in this situation from this elephant’s perspective. Whether the elephant is within me or near me, if I can be brave enough to look, I always find it eventually — hiding in plain sight! Then I am able to wonder what it’s like to actually be either the elephant hiding under a rug in a room full of people, or a person in the room who is feeling elephant-like in an emotional freeze. The elephant in isolation has no one to look or turn to, and the elephant-like folks are feeling too isolated to reach out to the elephant. Neither are feeling the comforting or encouraging relationships needed to get that rug off and deal with the exposed ‘dust’ that society has found ways to hide and keep hidden!

    There will always be dust, but we are ever-evolving. So I need to periodically challenge myself by actually noticing when I’m feeling elephant-like, looking into my emotional mirror, and asking:

    Who am I right now? Am I hiding? Am I avoiding?

    What next steps should I consider?

    What courage do I need?

    What relationships do I need? Do I have them? Do I need to strengthen them?

    I have confidence that the answers to these hard questions will support and guide me to the relationships that will make next steps — growth steps — possible and steady.

  • Diversity-Informed Tenets For Work with Infants, Children and Families

    Diversity-Informed Tenets For Work with Infants, Children and Families

    The Diversity-Informed Tenets for Work with Infants, Children, and Families (Tenets) are guiding principles created to encourage the infant mental health (IMH) field to intentionally and mindfully engage in standards of practice that promote and strive for a just and equitable society.  The Tenets present a call to action to intentionally address some of the racial, ethnic, socioeconomic, and other inequities embedded in society.1

    The Irving Harris Foundation Professional Development Network Tenets Working Group released the 1st edition of the Tenets in 2012.  Integrating this 2nd edition of the Diversity-Informed IMH Tenets into our personal and professional work is essential to shaping our personal understanding about the inequities and injustices within our systems, as well as contributing significantly to the relationships developed with infants, young children and their families.2

    Working group members:  Victor Bernstein, PhD; Karen Frankel, PhD; Chandra Ghosh Ippen, PhD; Linda Gilkerson, PhD; Mary Claire Heffron, PhD; Anne Hogan, PhD; Carmen Rosa Noroña, MSW, MSEd, CEIS; Joy D. Osofsky, PhD; Rebecca Shahmoon Shanok, PhD; Maria Seymour St. John, PhD, MFT; Alison Steier, PhD; Kandace Thomas, MPP.

    1-www.imhdivtenets.org
    2-Holmberg, Margaret, Alliance for the Advancement of Infant Mental Health DRAFT document, April 2018


    DIVERSITY-INFORMED TENETS
    FOR WORK WITH INFANTS, CHILDREN, AND FAMILIES
    Irving Harris Foundation Professional Development Network Tenets Working Group

    Tenents are listed below in both english and spanish – you can also download here: TenetsSpanishEnglish2ndedition2018 copy

    CENTRAL PRINCIPLE FOR DIVERSITY-INFORMED PRACTICE

    1. Self-Awareness Leads to Better Services for Families:

    Working with infants, children, and families requires all individuals, organizations, and systems of care to reflect on our own culture, values and beliefs, and on the impact that racism, classism, sexism, able-ism, homophobia, xenophobia, and other systems of oppression have had on our lives in order to provide diversity-informed, culturally attuned services.

    STANCE TOWARD INFANTS, CHILDREN, AND FAMILIES FOR DIVERSITY-INFORMED PRACTICE

    2. Champion Children’s Rights Globally: Infants and children are citizens of the world. The global community is responsible for supporting parents/caregivers, families, and local communities in welcoming, protecting, and nurturing them.

    3. Work to Acknowledge Privilege and Combat Discrimination: Discriminatory policies and practices that harm adults harm the infants and children in their care. Privilege constitutes injustice. Diversity-informed practitioners acknowledge privilege where we hold it, and use it strategically and responsibly. We combat racism, classism, sexism, able-ism, homophobia, xenophobia, and other systems of oppression within ourselves, our practices, and our fields.

    4. Recognize and Respect Non-Dominant Bodies of Knowledge: Diversity-informed practice recognizes non- dominant ways of knowing, bodies of knowledge, sources of strength, and routes to healing within all families and communities.

    5. Honor Diverse Family Structures: Families decide who is included and how they are structured; no particular family constellation or organization is inherently optimal compared to any other. Diversity-informed practice recognizes and strives to counter the historical bias toward idealizing (and conversely blaming) biological mothers while overlooking the critical child-rearing contributions of other parents and caregivers including second mothers, fathers, kin and felt family, adoptive parents, foster parents, and early care and educational providers.

    PRINCIPLES FOR DIVERSITY-INFORMED RESOURCE ALLOCATION

    6. Understand That Language Can Hurt or Heal:

    Diversity-informed practice recognizes the power of language to divide or connect, denigrate or celebrate, hurt or heal. We strive to use language (including body language, imagery, and other modes of nonverbal communication) in ways that most inclusively support all children and their families, caregivers, and communities.

    7. Support Families in Their Preferred Language:

    Families are best supported in facilitating infants’ and children’s development and mental health when services are available in their native languages.

    8. Allocate Resources to Systems Change: Diversity and inclusion must be proactively considered when doing any work with or on behalf of infants, children, and families. Resource allocation includes time, money, additional/alternative practices, and other supports and accommodations, otherwise systems of oppression may be inadvertently reproduced. Individuals, organizations, and systems of care need ongoing opportunities for reflection in order to identify implicit bias, remove barriers, and work to dismantle the root causes of disparity and inequity.

    9. Make Space and Open Pathways: Infant, child, and family serving workforces are most dynamic and effective when historically and currently marginalized individuals and groups have equitable access to a wide range of roles, disciplines, and modes of practice and influence.

    ADVOCACY TOWARDS DIVERSITY, INCLUSION, AND EQUITY IN INSTITUTIONS

    10. Advance Policy That Supports All Families:

    Diversity-informed practitioners consider the impact of policy and legislation on all people and advance a just and equitable policy agenda for and with families.


    Diversity is used in the most inclusive sense possible, signaling race and ethnicity, as well as other identity markers, and referring to groups and individuals on both the “up and down side of power” along all axes.

    Diversity-informed practice is a dynamic system of beliefs and values that strives for the highest levels of diversity, inclusion and equity. Diversity-informed practice recognizes the historic and contemporary systems of oppression that shape interactions between individuals, organizations and systems of care. Diversity-informed practice seeks the highest possible standard of equity, inclusivity and justice in all spheres of practice: teaching and training, research and writing, public policy and advocacy and direct service.

    This is an update to the 2012 Diversity-Informed Infant Mental Health Tenets ©2018 by Irving Harris Foundation. All rights reserved www.imhdivtenets.org


    SPANISH Version  – PRINCIPIOS INFORMADOS EN LA DIVERSIDAD

    PARA TRA A AR CON E S, NI OS, NI AS Y FAMILIAS

    Grupo de Trabajo sobre Principios Informados en la Diversidad de la Red de Desarrollo Profesional de la Fundación Irving Harris

    PRINCIPIO CENTRAL PARA LA PRÁCTICA INFORMADA EN LA DIVERSIDAD

    1. La Constante Toma de Consciencia Sobre Sí Mismo (a), a Tra s de un Proceso Re e o, Conduce a Me ores Ser c os para las Familias: Trabajar con bebés, niños(as) y familias requiere que todas las personas, organizaciones y sistemas

    de atención re exionemos sobre nuestra cultura, valores y creencias, y sobre el impacto que el racismo, clasismo, sexismo, capacitismo (discriminación hacia la discapacidad), homofobia, xenofobia y otros sistemas de opresión han tenido en nuestras vidas, de manera que proporcionemos servicios informados en la diversidad y en sintonía con la cultura de aquellos a quienes servimos.

    POSTURA HACIA LOS E S, NI OS AS Y SUS FAMILIAS PARA UNA PRÁCTICA INFORMADA EN LA DIVERSIDAD

    2. Defender los Derechos de los Niños(as) Globalmente: Los bebés y niños(as) son ciudadanos del mundo. Es responsabilidad de la comunidad global el apoyar a los padres/adultos responsables/cuidadores, a las familias y a las comunidades para que puedan acoger, proteger y cuidar de los niños(as).

    3. Tra a ar para Reconocer el Pr leg o y Luchar Contra la Discriminación: Las políticas y prácticas discriminatorias que les hacen daño a los adultos, también dañan a los bebés y niño(as) bajo su cuidado. El privilegio constituye en sí una injusticia. La práctica informada en la diversidad signi ca reconocer nuestra posición de privilegio, en todos ámbitos donde nos otorga ventaja, y usarla de manera estratégica y responsable. También signi ca luchar contra el racismo, clasismo, sexismo, capacitismo (discriminación hacia la discapacidad), homofobia, xenofobia y otros sistemas de opresión presentes en nosotros mismos, nuestras prácticas y nuestro campo profesional.

    4. Reconocer y Respetar los Ca pos No Do nantes de Conocimiento: Las prácticas informadas en la diversidad reconocen formas no dominantes del saber, áreas de conocimiento, fuentes de fortaleza, y métodos de sanación/ curación dentro de familias y comunidades diversas.

    5. Honrar las Estructuras Familiares Diversas: Las familias de nen quiénes las componen y cómo están estructuradas; ninguna constelación u organización familiar en particular,
    es inherentemente óptima en comparación a otras. La práctica informada en la diversidad reconoce y se esfuerza por contrarrestar la tendencia histórica a idealizar (o en contraste, a culpabilizar) a las madres biológicas como guras de cuidado primario. Esta tendencia pasa por alto las contribuciones cruciales en la crianza de los niños(as) de otros padres y cuidadores primarios; incluyendo otras guras maternas, al padre, los padres sustitutos y adoptivos, parientes y familia extendida, los educadores de niños(as) pequeños(as), además de otras personas.

    PRINCIPIOS PARA LA ASIGNACIÓN DE RECURSOS INFORMADOS POR LA DIVERSIDAD

    6. Co prender ue el Lengua e puede Ser Usado para Her r o Curar/Sanar: La práctica informada en la diversidad reconoce el poder del lenguaje para dividir o unir, denigrar o celebrar, herir o curar/sanar. Nos esforzamos por utilizar el lenguaje (incluido el lenguaje corporal, imágenes y otros modos de comunicación no verbal) de la manera más inclusiva posible para todos los bebés, niños(as), sus familias, adultos responsables/cuidadores y comunidades.

    7. Apoyar a las Fa l as en Su Id o a de Pre erenc a: Las familias son ayudadas de manera más efectiva a fomentar el desarrollo y salud mental de los bebés y niños(as), cuando los servicios destinados para ellos(as) están disponibles en sus idiomas de preferencia.

    8. Destinar Recursos para Cambiar los Sistemas: La diversidad e inclusión deben ser consideradas de manera proactiva al realizar cualquier trabajo con o para bebés, niños(as) y familias. Esta consideración requiere que se destinen recursos tales como: tiempo, dinero, prácticas adicionales/alternativas u otros apoyos y adaptaciones adicionales para este propósito; de lo contrario los sistemas de opresión pueden reproducirse inadvertidamente. Las personas, las organizaciones y los sistemas de atención necesitan oportunidades continuas de re exión para identi car sesgos implícitos, eliminar barreras y trabajar para desmantelar las raíces de la disparidad y la inequidad.

    9. Hacer Espac o y A r r Ca nos: La fuerza laboral al servicio de bebés niños(as) y familias, será más dinámica y e caz cuando las personas y grupos histórica y actualmente marginados tengan acceso equitativo a una amplia gama de roles, disciplinas y modos de práctica e in uencia.

    A OGAR POR LA DIVERSIDAD, INCLUSI N Y EQUIDAD EN LAS INSTITUCIONES
    10. Pro o er una Pol t ca ue Apoye a Todas las Fa l as: Los(as) profesionales, que están informados en la diversidad, consideran el impacto de las políticas y la legislación en todas las personas y fomentan una agenda justa y equitativa para y con las familias.

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