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After toiling for years in the minefield of nonprofit agencies, the courts, the juvenile justice system, schools, and community mental health, I eventually forayed into the land of private practice. I had been primarily trained as an infant mental health (IMH) specialist but had done some supervised play therapy training and work earlier in my career. I knew the chances of building a practice of solely IMH work was remote, so I began seeing families with young children for parent-child play therapy as well. I had a vague awareness that I had rarely worked with families that were “good enough,” where the children were sturdy and competent, unhindered by histories of loss or trauma and where parents had the psychological and material resources to meet their children’s needs. I had worked with abused and neglected children for so long that I had forgotten, if I ever knew, what a “typically developing” child—even one who was struggling emotionally for some reason—acted like.

As I began to work with “voluntary” adoptive and foster families, often self-referred, I began to hear stories not unlike the ones I had heard in prior years. Parents came to me confused as to why, when trying to do things differently with their own child than had been done with them, or to love a child who felt himself to be unlovable, they were finding themselves exhausted, angry, overwhelmed and sometimes feeling helpless. I came to see that the issues these families faced were not so different from the issues faced by families I had worked with in the past, just buffered, more often than not, by less preoccupation with the provision of concrete needs. The differences in coping and in support was, nonetheless, profound. Whereas in the past, I had seen a predominance of families where the family had become “possessed by their ghosts,” now I was seeing more families where the ghosts were “transient…who [did] their mischief according to a historical or topical agenda.”¹ I felt a sense of relief when I encountered parents who could describe their child with some measure of depth, who could differentiate their experience of an event as distinct from their child’s, who could express ambivalence about their ideas about parenting and who could assume some measure of responsibility for the nature of the relationship with their child. Of course, I had encountered parents such as these in the child welfare system, but often, by the time families received services, they were depleted of goodwill toward their child and the stable, loving feelings that so often protect a child during times of stress was worn thin, if ever present. In this new private practice environment, even families that were referred from child welfare or their pediatrician were coming with some measure of hope and optimism. It made all the difference.

As time went on, I was referred an increasing number of intact, biological families. This was a completely new game. Without the evident history of abuse, loss, neglect or abandonment implied by involvement in the child welfare or adoption system, I was on my own, so to speak, to discern the nature of the ghost…transient or possessive? Tenacious or permeable? How I would help families identify and say goodbye to their ghosts? It was a different kind of challenge. Sometimes, I was referred an “easy” family. Clair was from such a family. Bright, vivacious and expressive at 3.5 years old, four weeks earlier Clair had been bitten in the face by the beloved family dog, Rex, who then “disappeared.” Clair’s parents, Mark and Emily, called for services after the childcare staff noted Clair had suddenly and increasingly become terrified of spiders and ants, such that she was now resisting going outside with the rest of the children during playground time. I saw the parents alone for an intake interview. Though clearly concerned about their daughter, they both presented with an air of ease, freely conversing and openly thinking about their and Clair’s experience in a rich and coherent way. Emotions evident in the intake included their concern for their daughter, the worry and guilt they were experiencing, anger at themselves for not protecting Clair and a strong sense of pleasure in being her parents. They were able to give a rich and detailed picture of Clair, of her imagination; her sense of humor, which included making up funny words and enjoying making them laugh; her sense of drama and her capacity for play. They described her as having been confident and outgoing before the dog bite, but said she had become increasingly clingy and easily frightened. The parents described their sense of guilt for not heeding the warning signs that their dog was increasingly territorial, particularly following the birth of their now 6-month-old son. Clair had accepted their explanation without question that Rex went to live on a farm where he had more room to roam. They felt slightly conflicted about not telling her the full truth—that he had been euthanized due to the aggression—but they wished to protect her from any undue feelings of guilt should she associate the bite with his death. What was striking, against the backdrop of a longer history of working with vulnerable parents who had grave difficulty apprehending or considering their child’s unspoken worries, was that Clair’s parents could do so without prompting. It was also telling that both parents spoke freely and neither seemed to dominate. Emily was emotionally more intense than Mark, but they seemed to negotiate areas of differing perspectives, which were minimal, freely. I felt confident in their capacity to build an alliance with me on behalf of their daughter.

As we planned for Clair’s first visit to see me, I let the parents know that I suspected Clair had transformed her fear of her dog, the traumatic stress of the bite and his disappearance into a smaller, more manageable fear: spiders and ants. At her age, she was grappling both with the continued need for parental protection and support as well as the need to feel a sense of mastery and competence.² Her symptoms of increased clinging, nightmares and a few toileting accidents also suggested some regression in the face of the anxiety about the sudden harm that befell her. I suggested that we use play as the medium to help her express her worries and they agreed. They did not need much convincing that young children often express their feelings, thoughts and wishes in play vs talk. Their capacity to understand their child’s developmental needs and to accept my guidance and support also marked something of a shift from working with families with less-than-secure attachment templates. These parents could be flexible in their understanding of their daughter and use me as a source of support.³ I helped them consider how they would introduce me to her and they liked the idea of telling her I was a person who would help her with her worries and fears.

In preparation for Clair’s first visit, I made sure the spider and bumble bee puppets were at the top of the puppet bin in my office. As she entered the office, she initially stayed close to her mom. I let her know my office was a place where children with worries came to play and talk, that she could “play or not play, talk or not talk.” The choice was hers. I had prepped Emily that we would let Clair take the lead in play, and that we would not provide directives or instructions. As they settled in, another clue to Emily’s capacity to support Clair would be if Emily could allow Clair to set the pace. She responded to Clair’s exploration and mirrored Clair’s interest in the toys. Though I had hoped that Clair would notice the puppets, I did nothing to draw her attention to them. Within minutes, the child who was afraid of spiders and ants found her way to the puppets and pulled them out. She squealed and tossed the spider to her mom, who asked Clair what she should do with the spider. Clair said, “Smash him!” Emily pretended to smash the spider into the ground. Over and over, Clair retrieved the puppet and re-enacted the same scene, as her tense anxiety began to dissolve into laughter. I commented how good it felt that her mom could take care of the scary spider. In that first session, Clair eventually explored the rest of the room and as the time came to end, she agreed she wanted to come play again.

In the second session, Clair went right to the puppet bin, put on the bee puppet and gave her mom the spider puppet. With a somewhat muted expression, Clair began to sting the spider puppet. In a stage whisper, I asked Clair what the spider puppet should be saying. “Owww, stop it!” Clair replied. As Emily followed Clair’s lead, Clair became increasingly animated. Intuitively, Emily comprehended what Clair was conveying and began to add emotion to her responses, saying, “Owww, that hurts! I don’t like that!” and “You are scary…go away!” I verbalized the pretend aspects of Emily’s responses so that Clair, who, at 3, could still confuse reality with fantasy, would not become overwhelmed. I was relieved to see Emily’s capacity to read Clair’s underlying emotions and to put her daughter’s experience into words, albeit displaced into play. Offering Clair a “mirror”⁴ of the fear and pain she experienced would allow her to know that her parents understood her experience and could help her make sense of it. Ultimately, this would help Clair digest and master the experience. Emily’s capacity to attune to Clair’s internal state bode well for her recovery. The ultimate aim was to reduce the feelings of helplessness and fear Clair was currently experiencing and to regain a sense of being safe and protected. What was also notable in these first two sessions was Clair’s ease in orienting to the room, not in an indiscriminate way, but in a relaxed, curious mode. Children with histories of more complex and relational trauma are often far more chaotic and unfocused in their play and exploration or inhibited and overly cautious and compliant. Another difference was the rapidity with which she was transforming her play, it was dynamic, not grim or stagnant.⁵

In the third session, Clair assigned me the spider puppet and began to sting me. In a stage whisper again, I asked Clair how the spider was supposed to feel about getting stung. She said, “Mad!” I found it interesting that as she moved into a more “negative” emotion, she drew me in to the play as opposed to her mother. I did not comment on it. As Clair kept stinging the spider, I worked to elaborate more of what I imagined her experience to have been. Even though her parents had quickly responded and taken Rex off of her, she had been bitten several times. How long it must have felt like the attack had lasted and how helpless and little she must have felt. I exaggerated my responses, and moved my body and hand trying to stay out of the bee’s way. I yelled, “Stop it, Bee! That hurts, I don’t like it!” and “No matter how much I yell or move, the bee won’t stop! I’m scared!” in various forms and words. Clair took enormous pleasure in being the powerful bee, beginning to master the littleness and helplessness she had felt. As we ended the session, I commented how good it must feel to be the powerful one and how she had helped me to understand how it felt to be little and scared.

In the next session, Clair had me adopt the spider puppet again. Wanting to weave in the theme of safety and protection, I said aloud as I was being “attacked,” “Help, somebody help me!!” with a glance and a nod toward Emily, who quickly picked up on my cue and came to my rescue, telling the bee to go away and putting her hand between the bee and the spider. Shortly after, Clair changed the game. She took the spider away from me and gave me the bee. I asked what my role was, and she told me I was supposed to chase and sting the spider. I told her I would pretend to be the scary bee, again reinforcing the fantasy vs reality aspect of our play. As the bee began to sting the spider, she ran behind her mother, who forcefully pushed my bee away saying, “You stay away from my spider! I won’t let you hurt her!” Clair giggled and came out from behind her mother to start the game again. Over and over, she declared through her play her need for her mother’s protection, and over and over again, her mother asserted her desire and capacity to protect Clair. They were working collaboratively to repair the rupture of the “protective shield” of safety that Rex had torn.⁶

That style of play continued into the next two sessions, but increasingly, Clair became interested in other aspects of the playroom. She “cooked” and fed us from the kitchen area, she tucked a baby doll into the cradle, humming it to sleep. She seemed to be reminding herself of the layers of nurturing and protection she had experienced in the past and could access now. Emily reported that Clair’s clinging and fears had diminished and that she seemed to be the confident child she had been. In one session, with her father, she asked directly where he was when “Rex bited me.” He apologized directly to her and said he would work very hard to make sure she stayed safe. She paused briefly, looking at him solemnly, as if contemplating his words, then smiled slightly and offered him a cookie.

In our last session, Clair played freely, only briefly referencing the bee and spider. She eventually settled on carefully constructing a tall house from the cardboard “bricks” in the office. Once the house was stable and sturdy, she carefully selected a number of animals and figures, surrounding the house with them. Counting in the fanciful way of 3 year olds, she announced proudly that the house had “19 protectors!” We affirmed that it was indeed a very safe, strong house.

Infants and young children who experience a trauma within the backdrop of a secure relationship may still suffer the posttraumatic stress symptoms, but their recovery is thought to be more readily accomplished. This was true of Clair. In eight sessions, she recaptured the sense of safety and protection that had shielded her in the past. The security of the relationship with her parents allowed her to experience and express her distress, not needing to defend against it too fiercely, because she “knew” her parents had comprehended and accepted her range of feelings in the past. Their sensitive response to her distress, their willingness and capacity to seek help and the ability to let her tell her story of the feelings associated with the attack all allowed for a rapid recovery. Their capacity to meet her needs in the present, and her ability to accept their efforts at soothing her and repairing the disruption to her sense of safety, was girded by a relational history of security.

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References

1. Fraiberg S, Adelson E, Shapiro V. Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. J Am Acad Child Psychiatry. 1975:14:387-421.
2. Davies D. Child Development. New York, NY: Guilford Press; 2011.
3. Wallin DJ. Attachment in Psychotherapy. New York, NY: Guilford Press; 2007.
4. Gergely G, Watson J. The social biofeedback model of parental affect-mirroring. International Journal of Psychoanalysis. 1996;77:1181-1212.
5. Gil E. Helping Abused and Traumatized Children: Integrating Directive and Nondirective Approaches. New York, NY: Guilford Press; 2006.
6. Lieberman AF, Padrón E, Van Horn P, Harris WW. Angels in the nursery: the intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 2005;26:504-520.

For many decades, the creative energy of members of the Michigan Association for Infant Mental Health (MI-AIMH) has contributed to the knowledge and understanding of infant mental health principles and practices for thousands of professionals across disciplines in the infant and family field. Beginning with the first infant mental health conference in 1977 and continuing with the publication of MI-AIMH Training Guidelines in 1986, policy papers promoting infant mental health (1985 to 1997), manuals and monographs (1989 to 2015), learning tools (2002 to 2016) and practice DVDs (2012 to 2016), MI-AIMH and its members have made their mark as national leaders, defining and supporting infant mental health.

In addition to producing materials for professionals and parents to promote relational health, MI-AIMH members developed a set of standards, the MI-AIMH Competency Guidelines^®1 (2002), as well as a systematic approach to work force development, the MI-AIMH Endorsement for Culturally Sensitive, Relationship-Focused Practice Promoting Infant Mental Health^® (2002), for the infant and family field. Linked to the MI-AIMH Training Guidelines (1986) and professional development indicators identified by the Michigan Department of Education (1996), the standards and plan provide a framework for use across systems and at multiple levels to promote infant mental health. Both provided an extraordinary focus for MI-AIMH for the last 10 years. Experts in the infant and family field recognized the standards and plan as a pathway for best practice and professional recognition in a diverse and rapidly expanding infant mental health field.^2,3

Michigan continued to lead the initiative and by 2013, 13 associations had licensed the MI-AIMH standards and work force plan to support knowledge, skills and reflective practice approaches for the development and promotion of infant mental health in their states. The oversight and quality assurance demands for a small MI-AIMH staff were considerable. The MI-AIMH leadership and leaders in other member states recognized that future strength and growth would require organizational change. The MI-AIMH Board of Directors subsequently engaged in a strategic planning process with knowledge and support from non–MI-AIMH leaders and proposed the creation of a separate organization to manage the endorsement. The organization was incorporated as the Alliance for the Advancement of Infant Mental Health, Inc.^® By June 2016, the Alliance^® shareholders approved an 11-member Board of Directors, officers, member qualifications and a set of by-laws to govern the organization. What was once a small, grass roots effort developed by MI-AIMH had grown to be a sizable national and international movement, co-lead by MI-AIMH and a new leadership structure, with over 27 infant mental health associations in the United States and one in West Australia.

Of note, MI-AIMH leaders were instrumental in partnering with non–MI-AIMH stakeholders to identify priorities for the new organization that included the following: Sustainability funding for the Alliance^®, expansion of the endorsement criteria to recognize those working with children 3 through 5, exploration and advocacy for Medicaid reimbursement of infant mental health services at the state and federal levels, development of training models and higher education programs specific to the competencies, consistent messaging and communication across state associations, building capacity for reflective supervision and consultation in each state and evaluation and research of reflective practice and the endorsement process. These priorities set an ambitious course for the new organization and led to considerable challenge and change for MI-AIMH.

 

Accomplishments in 2016

MI-AIMH and Alliance^® leaders together coordinated Alliance^® activities in 2016 and used distance technology regularly to support and strengthen a sense of community among the IMH leadership across all 27 state associations and Western Australia. Priority projects included:

• The development of an early childhood mental health endorsement (ECMH-E) specifically for those working in service settings or on behalf of children 3 to 5 years of age and their families
• The Spanish translation of the Endorsement^®, its application system (EASy) and supporting materials to extend this initiative to monolingual Spanish-speaking professionals
• The completion of the development of the RIOS (Reflective Interaction Observation Scale) to identify core elements of reflective supervision and consultation, under the committee lead of Christopher Watson, PhD, University of Minnesota and with members from Michigan, Indiana, Rhode Island, Connecticut, Texas, Colorado, Kansas and Washington
• The co-hosting of the 1^st Alliance RSC Symposium, in August 2016, at the University of Michigan, Ann Arbor, with over 115 people in attendance
• A renewed focus on competency-informed training and education that encourages relationship building and reflective practice at the 10^th Alliance Board Meeting and Leadership Retreat in Scottsdale, Arizona in October 2016
• The exploration of ways that states fund infant and early childhood mental health services, examining requirements for Medicaid funding to support and sustain infant-family interventions and treatment services and linking with Zero to Three’s Social Policy network for information exchange
• The successful funding of research faculty across Michigan universities to evaluate the efficacy of Infant Mental Health Home Visiting (IMH Home Visiting), which is vital for moving the service from a promising practice to an evidence-based practice

In summary, MI-AIMH’s creative energy and leadership for over 40 years has led to an explosion of interest and shared commitment in Michigan and across the country to the promotion of early development and relational health, as well as continuing investment in the principles and practices of infant mental health.

Looking Ahead for MI-AIMH

What next? MI-AIMH’s leadership capability and creative ingenuity, so effective in the first 40 years, will continue to characterize the organization as new leaders emerge and commit to infant mental health policies and practices in Michigan and the Alliance^® becomes a separate entity governing cross-systems and infant mental health work force development and recognition beyond Michigan. The relationship between the two organizations will remain strong. MI-AIMH and Alliance^® staff will continue to share space and tasks for the foreseeable future; MI-AIMH members will continue to share leadership responsibilities for the Alliance^®. Growth and change will require strong working relationships between the leaders of these two organizations, as well as empathy, support, honesty and flexibility. The goals of both organizations intersect…

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References

1. Michigan Association for Infant Mental Health (2002/2016). Competency Guidelines^®. Southgate, MI: Michigan Association for Infant Mental Health.
2. Annapolis Coalition, 2007
3. Weatherston D, Kaplan-Estrin M, Goldberg S. Strengthening and recognizing knowledge, skills, and reflective practice: the Michigan Association for Infant Mental Health Competency Guidelines^® and Endorsement^® Infant Mental Health Journal. 2009;30:648-663.

The first time I actually thought about resilience was while I was working as a psychologist at a Child and Adolescent Psychiatric Hospital. I was asked to test the sister of a young child who had been diagnosed with childhood schizophrenia. The family structure consisted of the oldest daughter, age 9, who had been given the diagnosis; Chloe, the middle sister, age 7, referred for testing; a younger sister, age 5, who was having behavioral difficulties; and their parents. Mother had also been diagnosed with schizophrenia and father had some symptoms that might be considered as Asperger’s Syndrome.

The child whom I was asked to test was doing well in school and at home. She was engaging, animated, emotionally warm, and related quite well. The Director of the hospital had questioned her positive adjustment given the family constellation. He felt that with the child’s genetic vulnerability and the family disturbance, this child could not possibly be as well as she appeared.

When I completed the test battery, I confirmed her positive adaptation. There was no intellectual or emotional indication of any maladjustment. The Director dismissed my findings and told me to do further testing. When I came back with the same results he shook his head, flipped the test report at me and said that it could not be so, a child with a strong biological vulnerability in an environment that was less than optimal could not be as well-adjusted as she was. In one session, I recalled asking her why she was not worried about eating food from the refrigerator that her mother said might be poisoned. She looked at me and said, “Just because my mother says it, it doesn’t mean I have to believe it! It might be bad for her, but that doesn’t mean it’s bad for me!”

Some years later, I read E.J. Anthony’s book The Invulnerable Child. He had used the term “invulnerability” rather than “resilience” to make the point of psychological invincibility.¹ Murphy and Moriarty felt that “invulnerability” was too strong a term.² They stated: “In our use of “vulnerability” there is no completely invulnerable child–we are concerned with the degree and locus of vulnerability in relation to the intensity and quality of the stress.” (p. 248)

Anthony agreed with Murphy and Moriarty and gave a wonderful example that has stayed with me over the years. He talked about a hammer that struck three objects, one at a time. The first object shattered into many pieces, the second was dented and the third, when struck with the hammer, made a beautiful, melodious sound. This was a beautiful metaphor for resilience. In a context of extreme adversity there are some who are crushed, others who are bruised and still others that weather the adversity and may even be strengthened.

The construct of resilience has remained with me as it strums the chords of my own development, spending my early years in a low-income neighborhood, living in a project, having a mentally ill mother and uninvolved father, getting less than average grades in school and getting rejected from colleges. Along the journey, I had a series of “surrogate fathers”: a basketball coach, some wonderful male professors when I finally got in to college, a mentor who took me into a graduate program because he believed in taking marginal students and a mentor, Dr. Stanley Greenspan, with whom I later wrote two books on bipolar patterns in children.

What are the factors that enable children who experience serious and chronic adversity to weather these conditions? Why are some children shattered by adversity while others experience bruises and others even thrive? Sometimes siblings living in the same family have totally different outcomes. The research on resilience has gone through four waves. The first wave was largely a descriptive wave that was focused on answering the question: “What makes a difference?” During this period, investigators were focused on developing measures and gaining an understanding of characteristics of people, environments and relationships that enabled individuals to weather adversity. During the second wave, the emphasis was on how protective processes worked. The emphasis shifted from “what” to “how”. In the third wave, there was a shift to looking at intervention, clinically and experimentally.³  In the present wave, we are looking at resilience through a multidisciplinary lens. With the use of neuroscience methods, we are now studying “the human genome, epigenetics, and the human brain in action as well as statistical strategies for analyzing complex multivariate data.”³

Masten’s research has helped to uncover some of the major factors that promote resilience. These are factors that have been found to be the primary themes that individuals who are resilient seem to share:

1. Attachment relationships and support systems: Masten states that in every review of resilience, close relationships and bonds with other people have been included as key protective factors. High-quality relationships lead to feelings of safety and security in children.⁴
2. Agency and motivation: The motivation to adapt to one’s environment and to experience mastery. This motivation for mastery and the experience of pleasurable affects was studied by Robert White (1959) in his work on “effectance motivation.”⁴
3. Learning and intelligence: Strong executive skills including problem solving, higher scores on intelligence tests and higher level thinking skills such as the ability to think abstractly are associated with resilience and adaptation.⁴
4. Self-regulation: Self-regulation is necessary for delay and inhibition that creates the opportunity to problem solve. Self-regulation is also a key component of school readiness.⁵
5. Faith, religion, and other sociocultural systems: Masten reported that in the research on resilience, individuals reported that these factors played a protective role in their abilities to weather adversity.⁴

Looking back on that initial evaluation that I described at the beginning of this article and thinking about my interviews, testing and time spent with Chloe, four of these themes were clearly evident. She was a child who excelled in school and had the strong support of her teachers and her peer group. She was a child who had strong “sending power,”⁶ which relates to the strength and clarity of a child’s social signals. Some children are weak in their ability to send social signals and their signals are hard to interpret, while others send very strong and clear signals that are easy to pick up. I had the feeling of enjoyment in her presence. Her feistiness was engaging. In addition, her test scores on the WISC were within the High Average to Superior range, indicating an evenness in her development of intellectual skills and strong verbal ability that suggested an interest in reading as well as interpersonal relating. The incident in which she described her feelings about eating despite her mother’s warnings is a clear example of her motivation for mastery and her message that she was her own person! Finally, her striking ability to be present in the moment and to demonstrate “effortful control” at a young age indicates her ability for delay, self-control and self-regulation. All of these factors were suggestive of a positive outcome under stressful conditions.

As I am writing this article I am thinking about the power of resilience even in its most severe forms. I am reminded of two present day experiences of resilience that are related to a severe form of mental illness, two adults whom I have treated and followed in psychotherapy—for twenty years in one case and just less than twenty years in the other—a boy whom I first met when he was 4 years old and a girl whom I met at 6 years old. Both of these children were evidencing signs of severe disruptive mood dysregulation that was finally diagnosed as pediatric bipolar disorder. I worked with each of them for periods of time, punctuated by periods in which I saw them and their families over the years. As they moved into adolescence and then adulthood, both shared a common denominator of tenacity, the refusal to give up and the commitment to maintaining close connections to me. Both families felt that they would be permanently disabled; however, both of them refused to agree with these conclusions. The boy, now a man, has almost completed community college—on the Honor Roll—and is determined to have a professional career. The girl, now a woman, has recently been accepted to a Master’s program in the mental health field. The tenacity to hold onto our relationships has been enormous.

The power of relationships is something we need to stress in our training and supervision of students and professionals. Often, to the outside world the child’s primary attachment figures are thought to be the child’s parents. However, a child’s primary attachment figure may be unknown to the outside world because that person may not be part of the child’s family. A child can choose an individual who has been a constant, consistent and “special” person and with whom the child has an important bond. For me, my primary attachment figure was a surrogate father figure with whom I spent a great deal of time after school throughout my elementary and junior high school years. He was the person who I trusted most, to whom I confided when I was experiencing difficulty and who I looked for first to share my successes.

Resilience is a complex relational construct. To understand it, we must look at the individual and the multiple systems that affect the child. We must understand not only the child’s primary caregivers, but also the systems outside the family, including school, neighborhood and outside community. Those individuals most affecting the child may not be immediately visible, and any valid research to understand resilience must go beyond the immediate environment.

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References

1. Anthony EJ, Cohler B, eds. The Invulnerable Child. New York, NY: Guilford Press; 1987.
2. Murphy LB, Moriarty AE. Vulnerability, Coping and Growth: From Infancy to Adolescence. New Haven, CT: Yale University Press; 1976.
3. Masten A, Cicchetti D. Resilience in Development: Progress and Transformation. In: Cicchetti D, ed. Developmental Psychopathology, Third Edition, Volume 4: Risk, Resilience, and Intervention. New York, NY: John Wiley & Sons; 2016:271-333.
4. Masten A. Risk and Resilience in Development. In: Zelazo PD, ed. The Oxford Handbook of Developmental Psychology, Vol. 2: Self and Other. Oxford, UK: Oxford University Press; 2013.
5. Blair C. Stress and the development of self-regulation in context. Child Development Perspectives. 2010;4:181-188.
6. Mahler M, Pine F, Bergman A. The Psychological Birth of the Human Infant. New York, NY: Basic Books; 1975.

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

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

What About the Baby? Where’s Eva?

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

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

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

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

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

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

Light Peeking out from the Darkness

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

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

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

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

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

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

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

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

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

Hope for the Future

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

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

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

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

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

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

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

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

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

We hope to see you there!

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References

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

Reprinted from The Infant Crier Fall 2012

For many of us, the idea of contacting our elected officials and/or key decision makers brings on a case of uneasiness; it’s a discomfort that often causes us to avoid making the contact at all!

So let’s consider the work of an advocate from another perspective. What if we remember that legislators are people just like the rest of us, people who depend on relationships to help them navigate the often troubled waters of their job.

In our daily lives, we recognize that relationships help those with whom we work — parents, children, providers — to find their footing, to help them recall their best selves and to find the strength to face the troubles of their lives with greater depth and commitment to their values and beliefs.

Now, for a moment, let’s imagine the life of a legislator — imagine the quantities of issues that cross his/her desk, imagine the information s/he is assumed to know, and imagine the decisions s/he is expected to make. When you are faced with situations in which you have to make decisions about things you know little about, what do you do? Many of us call a trusted party. We rely on one another to help us understand, to give us the critical analysis that we can’t get on our own.

You can well see the path this article is leading you toward, can’t you? You know that many people are eager to build relationships with legislators and other elected officials and key decision makers — they want to make sure that their legislator knows to call if s/he wonders about something, or at least will listen with open ears when this constituent pleads a cause. If we don’t do that same work, recognizing that our elected officials need relationships they can rely on, can we really fault them for not making the decisions we wish they would, for not understanding the issues the way we see them, for listening to the people who have fostered a relationship with them?

Hopefully, you can begin to see that making contact with your elected officials is nothing more than the beginning of a relationship. Use those fabulous relationship making skills you have honed in your practice and help these people understand the world through the eyes of a vulnerable parent and baby, help them see why investments in the first years of life have enormous fiscal and social payoffs, and let them know that you appreciate their efforts on behalf of the State of Michigan.

Think about how you like to begin relationships. Is it giving people information? Asking them about themselves? Thanking them for their work? Sharing your interests and concerns with stories? Use what you know about yourself to plan your conversation with the decision makers you intend to call.

The core message that we need to share is that Michigan is populated with an important constituent group, a group that neither votes nor can advocate for itself. This very constituent group is the future of our State — our economy, our society and our democracy. Investments in this invisible group have the capacity to dramatically improve the trajectory of our future. A few facts peppered into this core message are a great beginning for your emerging relationship with the legislators and key decision makers in your community.

We have put together some talking points and questions that may guide you as you make your advocacy approach. We urge you to do your part. Help Michigan realize the amazing returns when we do the right thing.

Brief talking points:

• High-quality investments in families with very young children have surprisingly high rates of economic and social returns.
• Toxic stress changes the very structure of the brain, decreasing the capacity of the child to learn and succeed in life.
• Supportive relationships and interventions can help parents manage the conditions that lead to toxic stress — conditions such as depression, unemployment, etc.
• The bulk of the brain is developed in the first 1,000 days of life. A healthy brain depends on high-quality relationships.
• Michigan’s future depends upon a healthy citizenry and workforce. Please make the data driven and smart investments now to realize a thriving future. Tomorrow’s workforce is being born today.
• You may not be aware, but although Michigan has been a leader in developing high-quality supports and interventions for families with young children, we have fallen behind other states that have made greater early childhood investments, allowing them to improve the lives of more children and more families. We’d like to put Michigan back in the front. I’d love to speak with you later about the work under way in Michigan and how we can give Michigan the cutting edge that will secure a thriving future.

Spread the word, build relationships and stretch your comfort zone during this important election cycle.

As you know, in our wonderful and imperfect democracy that we call the United States of America, citizens get the opportunity to vote for elected officials who will then make decisions on our behalves. Many, many decisions. And while in our imperfect democracy about half of us eligible voters filled out a ballot on Nov. 8 (and thankfully the elections are behind us now!), policymakers report hearing from only 10% to 20% of their constituents. That means that once the votes are tallied and balloons and confetti have been swept up, very few of us hold our elected officials accountable for the decisions that impact the lives of Michigan families, even though we, the people, are their bosses. And then we wonder why policymakers make choices that we don’t agree with…

This is where you come in.

I would bet that, at best, perhaps one person in the State legislature understands infant mental health.  Maybe a few understand the importance of social-emotional well-being. Maybe a few more understand the foundational importance of the first three years of life. But if the vast majority of policymakers don’t understand the importance of those first three years, the importance of safe and secure attachment of babies with caregivers, and how various programs and services throughout our state promote a strong social-emotional foundation for babies and toddlers, how can we expect them to make informed public policy decisions based on evidence and research that you know to be true?

Voting is just one step in the democratic process of an engaged electorate. Now is the time for you to make sure that those victorious candidates — as well as those who weren’t up for re-election and who will continue to serve in the next legislative session — understand that the social-emotional well-being of babies and toddlers is incredibly important. They, like all of us, need to be asking themselves, “What about the babies?” And while they certainly don’t need to become experts, policymakers should have a foundational understanding of the issues and know that they can turn to you when they have questions and need more information.

So what can you do?

Get to know your policymakers. Sign up for email bulletins from your state representative and your state senator and follow them on Facebook. Visit them during their local coffee hours or request to meet with them when they’re home in their districts (Fridays through Mondays). Invite them to visit your program, join you for a home visit, or engage them in other ways to speak to families who have been assisted by your services. Now is the time to begin educating them and building a relationship with them so they turn to you when they have questions about the needs of Michigan families with babies and toddlers and can start making informed public policy decisions.

Learn more on how to strengthen your advocacy skills by visiting the Michigan’s Children website.

Many of us have been reflecting on the current climate of our neighborhoods, our nation and our society as a whole. We feel an overwhelming need to say something, to do something, but what?  We ask ourselves how to promote peace AND speak out against discrimination, inequities, bigotry, and hatred. The current atmosphere of diversity tension, intolerance, and the avoidance of having needed intentional conversations is taking its toll on all of us.

We witness and want to support our co-workers and colleagues who have a duty to serve those who are most affected by this climate every day and who are feeling so many emotions:  sadness, frustration, anger, and confusion.  Our work requires that we offer this same mindful presence to our client families, who express these things and more.

The children all around us express fear of being hurt, bullied, or separated from parents, and their wishes are the same as those close to our hearts — for the safety to live freely, for acceptance of our unique selves, for the hope of future possibilities. They trust us to hear them.

We have so many barriers to cross, but we look for the hope in overcoming them, too, don’t we? We ask, does the recent escalation of open expression of intolerance among us (for it is not new) also offer opportunities to have important conversations? Are we more motivated now? Can we dare to acknowledge that this affects us all?

In these uncertain times we, the “helpers,” are the ones who must have the intentional conversations. We must safely and honestly talk about the injustice, hatred and intolerance in our country that too often stares in the faces of our colleagues, our clients, and our communities.  We must be willing to speak, and more important, to really listen.

To quote a wise colleague,“I feel like my silence would be worse than the wrong words.”

Let us embody the hope that compels us to work to support the health and well-being of the earliest relationships.  Let us also be caring and mindfully present in our relationships with each other.  Here is permission for us to start the conversations, the intentional conversations.

Doug Davies, M.S.W., Ph.D., was a beloved colleague, mentor and friend to many in the infant mental health community. He was a Lecturer at the School of Social Work, University of Michigan, had a private practice, and was a MI-AIMH board member for many years. After his retirement from the University of Michigan, he continued to write, provide individual and group reflective supervision, and train infant mental health and early childhood staff in Michigan, Alaska, Virginia and California. His ability to listen deeply helped each of us understand young children, their families, and ourselves better, becoming not only better therapists but better human beings. He provided listening without judgement, genuine compassion, and support that serve as a model we carry within us. We miss him dearly but he was a secure base we have internalized. His felt presence continues with us in our work and in our lives.

A Doug Davies Memorial Lecture was held at The University of Michigan School of Social Work on June 24, 2016.  The following are excerpts from speakers, Julie Ribaudo, LMSW, IMH E®, and John Bennett, LMSW,  given at that memorial. John and Julie offered personal comments about Doug, and Julie shared the beginning of a chapter written by Doug in the days preceding his death. Doug’s editors at Guilford Press had requested that he write a chapter on toxic stress and one on adolescents for a 4th edition of his text, Child Development (Davies, D. (2011). New York: The Guilford Press). Although initially not sure he wanted to commit the time to write 2 new chapters, Doug agreed, wanting to make complex scientific research easier to understand. He was excited about making information more accessible to clinicians, knowing that a better understanding of complex reactions to trauma would help make better therapists and would ultimately result in better services and outcomes for young children and families impacted by trauma.

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Comments from John Bennett, Doug’s First Clinical Supervisor

“I was Doug’s first Infant Mental Health supervisor, and he was my first supervisee. About a year later, we wrote a paper together: “Intervention and Adaptation in the Third Year: The Mother-Child Dialogue.” That was about 40 years ago. We spent those 40 years as colleagues in the Child Psychiatry Division of the University of Michigan Department of Psychiatry, as office partners in private practice, and, most importantly, as friends. We talked with each other between clients and met once a month for dinner and drinks. We traded stupid jokes, talked about our childhoods and our current lives, our children, and his grandchildren. Unfortunately both of my grandchildren were born in the year following his death, but I’m sure he would have been as happy to listen to those stories as I was his. We regaled each other about being Irish — the random, existential, metaphysical (and somewhat inebriated) views of life lived. We also talked about the new ideas we were discovering — the latest being arousal moderation, brain networks, and metabolic aspects of mental and emotional functioning in childhood, among many others. This would be serious stuff, and then we would get carried away and end up like Moose and Squirrel. It was a great friendship that covered lots of territory. When he retired from the School of Social Work, I was surprised, after hearing all the praise, and how people were not going to be able to get along without him, etc., to hear the Dean end the ceremony by announcing that Doug would continue on doing essentially what he had done prior to his “retirement.” I caught him afterwards and told him how I thought it was such a dirty little Irish trick to say he was retiring, get people to say all those nice things, then go on working just like he’d done before. Doug assured me (with his glinty little Irish wink) that he didn’t know this would happen when he announced his retirement. When he died, and we had the memorial in Kalamazoo, I was hoping he would be hiding off-stage somewhere and come laughing and popping out from behind the curtains just after all the nice things had been said… but not this time. What a nice guy to have as a friend. I still miss him.”

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Julie Ribaudo’s Lecture

“Doug approached his work with intellectual rigor, curiosity, and with a healthy respect for the magnitude of the messages he sought to convey.  Because of that, he often wrote out entire lectures.  While it could stem, on the face of it, boring to be read to (unless you are a young child with an animated parent!), listening to Doug was never boring.  I heard him enough times that he would joke with me that I should leave because I had heard his material before.  I never did and I never regretted it.  It is a great honor and with deep respect for his profound gifts that I am going to read from Doug’s last written contribution to the field of social work and to the lives of children and their families.”

This first section comes from Child Development, 3rd edition. It is included to provide a context for the new text and to show where Doug intended the new information to be placed.*

*Editor’s note

In recent years, the effects of prolonged stress on the [hypothalamus-pituitary-adrenal (HPA)] system has been re-named “toxic stress.” “Toxic stress is the extreme, frequent, or extended activation of the stress response, without the buffering presence of a supportive adult.” Created by ongoing severe environmental stressors such as chronic trauma, abuse, and neglect, “toxic stress” is an internal response to even mild stressors that has been shaped by trauma over time. It is a biological adaptation to frequent experiences of threat and high arousal. “One of the primary consequences of early life toxic stress is HPA dysregulation, as the developing neuroendocrine system is chronically pressed into action.”

The constant secretion of cortisol in response to toxic stress also weakens the immune system. Young children become more susceptible to allergens, which are move prevalent in poverty environments. Young children exposed to toxic stress are much more likely to develop asthma.

Stress Response Systems

The function of biological stress response systems is to secrete hormones and neurotransmitters that provide adaptive responses to external stressors and to modulate internal stress. The limbic system, specifically the amygdala, is responsible for recognizing threat and mobilizing reactions to it; it is the brain’s “alarm system.” When the amygdala signals a threat, the [HPA] system secretes and releases neurohormones called catecholomines, which in turn trigger increases in the amount of cortisol in the bloodstream. Catecholomine release underlies the familiar “fight-or-flight” response, in which the individual’s alertness, concentration, appraisal of the environment, and physical energy intensify in the face of danger.

“Here, I can see Doug looking up, clearing his throat, and ad-libbing just a tad to say, “Here I am thinking of…”  He was always generous in sharing his thinking process with us.”

…When faced with threat, the stress response system focuses brain activity on dealing with the threat and temporarily inhibits other functions. Animal studies have shown that the release of cortisol promotes the freeing of energy, so that the individual can take action, but at the same time suppresses the immune system, physical growth, and emotions and memory. The hippocampus, a brain area that plays a central role in learning and memory, can atrophy if it is bombarded by high concentrations of stress hormones, resulting in memory impairments.

The following section begins Doug’s work on Edition IV.

Epigenetics refers to alterations in the ways genes express themselves in response to changes in biochemical processes. These biochemical changes are in turn caused by environmental influences. The underlying structure of the genes does not change, but their “expression” — the way they regulate functioning — does change. Changes can go in the direction of a well-regulated HPA system when the child receives consistent supportive and protective care by adults; or enduring characteristics of HPA dysregulation, generally in the direction of hyper reactivity, are the likely result of ongoing, unbuffered exposure to toxic stress. When a young child is exposed to toxic stress over time, the constant secretion of the stress hormones cortisol, norepinephrine, and epinephrine leads to epigenetic changes in the HPA system. This is the process underlying over-arousal and reactivity to triggers and mild stressors we observe in chronically-traumatized children.

“Here we see Doug’s sheer brilliance in listening to and probing the meaning of aggressive behavior of young children exposed to violence.  Even before the benefit of brain science to substantiate aggression as often reactive, Doug knew to listen and observe very carefully – with the aim of understanding and helping a child gain distance, psychologically, from what they had endured, and locating the trauma in the past rather than in the present.  Profoundly empathic, he also worked compassionately with parents, teachers, and other professionals to understand the child as well.  He taught the rest of us to do the same.”

To understand  the developmental costs of toxic stress, it is useful to define allostasis, a recent concept that captures the “active process of adaptation” in response to stress.

Allostasis is defined as “maintaining stability through change.” It is “a fundamental process through which organisms actively adjust to both predictable and unpredictable events.” In animals, including humans, allostasis regulates the individual’s ongoing relationship to environmental stress through complex interactions of the nervous, endocrine, and immune systems. In the face of stress or threat — physical or psychological danger, or illness, as examples — these systems work together to promote the best possible adaptation to the environment and survival. In the face of danger, the brain and nervous system appraise the threat and prepare for action, the endocrine system secretes hormones that support action and endurance, and the immune system mobilizes an inflammation response in case of injury.

“Allostatic load,” or overload, refers to how hard these systems have to work to maintain adaptation. In conditions of chronic stress, such as child maltreatment in early childhood, the process of allostasis operates at high levels in order to protect the individual. However, these ongoing mobilizations of regulatory, internally-based protective processes become shaped, or “biologically embedded,” by constantly responding to threat: “When activated chronically and out of context, allostasis ceases to be adaptive and thus may promote disease as maltreated individuals age.” Neurobiological research has shown a number of developmental and health downsides of allostatic overload in early childhood. These include alterations in brain architecture and function. For example, maltreated children as adults show smaller prefrontal cortex volume. The prefrontal cortex houses the brain’s executive functions, including planning, attention, and impulse-control and decision-making. Neuropsychological testing of maltreated, traumatized children shows deficits in all these functions compared to normal children (Beers & De Bellis, 2002) . To the extent that these deficits become embedded, the child’s capacity for learning and flexible responses to the environment will be compromised as development proceeds. The costs of an overactive endocrine system, specifically the HPA axis, have been documented in the biology of trauma literature. Over secretion of cortisol and other stress hormones in response to chronic threat leads to an overactive and more-easily triggered stress response. Behaviorally, this translates to hyperarousal, hypervigilance, overreactions to even minor stressors, and tendencies to “act without thinking” based on fear and anxiety. When the immune system responds to threat by increasing inflammation levels, the body is preparing to fight physical injury. Children and adults with histories of maltreatment show elevated inflammation levels. Increased baseline inflammation levels disrupt the body’s ability to develop acquired immune response and lead to later vulnerability to inflammatory diseases such as rheumatoid arthritis, fibromyalgia, and chronic fatigue syndrome.

To summarize, while early allostatic adaptations to adversity by the nervous, endocrine, and immune systems promote short-term protection and survival, these same adaptations program biological responses in all three systems that are detrimental to development and physical and mental health in the long term.

“Although Doug’s last written words leave us wishing for more, they remind us how much we learned from him. His last writing is a further contribution to his enduring legacy and his capacity to help us strive for excellence and deeper understanding. He knew, and taught us to stay confident too, that through understanding, we would become more compassionate, kinder and better able to support young children and their families. Sometimes we hear sanitized versions of someone when they have died. With Doug, no sugarcoating is needed. He was simply good – through and through.”

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References

Beers, S. R. & De Bellis, M. D. (2002). Neuropsychological function in children with maltreatment-related posttraumatic stress disorder. American Journal of Psychiatry, 159, 483-486.

Danse, A. & McEwen, B. S. (2012). Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiology and Behavior, 106, 29-29.

McEwen, B. S. (2012). Brain on stress: How the social environment gets under the skin. Proceedings of the National Academies of Science of the United States of America, 109,  17180-17185.

McEwen, B. S. & Wingfield, J. C. (2003). The concept of allostasis in biology and biomedicine. Hormones and Behavior, 43, 2-15.

Steptoe, A. Hamer, M., & Chida, Y. (2007). The effects of acute psychological stress on circulating inflammatory factors in humans: A review and meta-analysis. Brain, Behavior, and Immunity, 21, 901-912.

Tarullo, A. R. & Gunnar, M. R. (2006). Childhood maltreatment and the developing HPA axis. Hormones and Behavior, 50, 632-639.

This letter, written by Debbie Weatherston and Sheryl Goldberg, was read on behalf of MI-AIMH at the Davies Memorial Lecture.

Doug served the Michigan Association for Infant Mental Health and the infant mental health community throughout his long and distinguished service to children and families. While earning his M.S.W. from the University of Michigan in 1979, Doug received clinical training in infant mental health at the Child Development Project where Selma Fraiberg was the director. That experience shaped his commitment – intellectual and heartfelt – to early experiences, the promotion of social and emotional wellbeing, and the unique developmental and relational approach to health through infant mental health. He began his clinical practice in 1980, combining skills as a gifted mental health professional, supervisor, and faculty member at the University of Michigan.
The Michigan Association for Infant Mental Health – MI-AIMH – benefited from Doug’s extraordinary professional commitments. The organization was so fortunate to have him serve in a leadership capacity for many, many years. Among his most important contributions:

• He played an important leadership role in the development of the MI-AIMH Endorsement for Culturally Sensitive, Relationship-Focused Practice Promoting Infant Mental Health, beginning in 1999. He gave generously of his time and attention to the creation of this work force system that provides a framework for the infant and family field in over 23 states and West Australia.
• He was a mainstay in the development of two Reflective Supervision DVD’s, one (2013) for the infant mental health community and a second (2016) for those working as supervisors or consultants in non-mental health infant and early childhood communities
• He was a member of the MI-AIMH Executive Board of Directors from 2012-2016 where his leadership skills were especially important for participation in the strategic planning process that led to the formal creation of the Alliance for the Advancement of Infant Mental Health, Inc.®.
• He led MI-AIMH in partnering with the Michigan Department of Human Services in 2014 to develop a Joint Policy, Attachment in Infancy and Best Practice Recommendations for Decision-Making for Infants/Toddlers in Foster Care.
• He partnered with MI-AIMH for many years in the development and delivery of training. Of note, in 2013, an important grant-funded training series in the art of Reflective Supervision, “ Building and Expanding Reflective Practice in Infant Mental Health.”

MI-AIMH honored Doug in 2007 with the distinguished Selma Fraiberg Award for his work on behalf of infants, toddlers and families and the promotion of infant mental health. Fitting for him to have been recognized with this award as that is where he began, at the table with Selma Fraiberg and her colleagues.

In sum, Doug’s presence at so many tables enriched the work of MI-AIMH for decades with his intellect, his clinical understanding, his kindness and his compassion. He was revered by all who worked with him – state policy makers, program directors, trainers, supervisors, clinical practitioners, childcare professionals, nurse family partnership professionals, head start, teachers, infant mental health specialists, members and board members, very young children and families.

He was an engaging writer, a deep clinical thinker, generous with his gifts and a beloved mentor to so many in the infant mental health community. We honor him today, with gratitude for his very significant contributions to infants, toddlers and families and each one of us.