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Infant Mental Health Treatment
Angela M. Tomlin, Ph.D., HSPPStacey Ryan, LCSW
IAITMH2007
Objectives
Participants will be able to• Describe what basic principles of IMH
intervention • Discuss treatment techniques• Explain the importance of reflective practice and
supervision in IMH
IMH Interventions
• Core Concepts
• Contributions
• Strategies
• Approaches
Core Concepts Regarding Interventions
• Since all areas of development take place within the framework of interaction between the infant and caregivers the treatment relationship needs to always include parents/caregivers (including foster parents)
Core Concepts for Intervention
• The parent’s capacity to nurture an infant is dependent to a great degree on the support that is available as well as the ability to use the support available.
Core Concepts Regarding Interventions
• Interventions are based on:– The Contribution of the Infant– The Contribution of the Caregiver– The Contribution of the “Fit”– The Contribution of Stress and Cultural
Factors
Infant Factors
• Individuality of each Infant
• Temperament Characteristics
• Sensory Functioning
Contribution of Caregiver
• Desire for a Child
• Timing of arrival of Child
• Expectations regarding baby
• Perception of child
• The real infant vs. the imagined infant
Contribution of the Relationship
• Fit between expectations and reality
• Flexibility in the parent and the infant
• Degree of conflict or disappointment
Contribution of Stress Factors
• What is the role of stress within the family
• Understanding cumulative effects of stress
• Dealing with stress may be the first point of entry
Cultural Factors
• Understanding context so that stereotypes or assumptions aren’t made
• Differences in dealing with feeding, sleeping, crying and conflicts.
Common Interventions
Fraiberg Model Levels of Intervention:
• Building an Alliance or Trust• Meeting Material Needs• Supportive Counseling• Development of Life Skills and Social Support• Developmental Guidance• Infant Parent Psychotherapy
Building Trust
• Consistency• Providing Telephone Support• Observes, Listens, Accepts, Nurtures• Visits Regularly• Identifies and Meets Material Needs Infant Mental Health Services: Supporting
Competencies Reducing Risks
Providing for Material Needs
• Facilitates access to community agencies
• Assists with transportation
• Forms alliances with other professionals on behalf of family
Supportive Counseling
• Observing
• Listening
• Feeling
• Responding
Development of Skills and Support
• Develops Social Supports
• Models Problem Solving Skills
• Models Decision Making Skills
• Teaches Problem Solving Processes
Developmental Guidance
• Provides Information• Speaks for Infant• Encourages Observation and Interaction• Models Appropriate Interaction• Encourages Developmentally Appropriate
Activities
Determining Types of Interventions
• Determining Needs and Strengths of Child and Parents from Assessment
• Determining Willingness and Ability of Family and Child to Address Issues
• Availability of Services
The Process of Change
• The Therapeutic Relationship strongly influences the Success of Intervention
• Change can Occur in a Variety of Ways: Crisis, Natural Environment
• Building on Strengths is Crucial
• Ongoing Assessment and Review of Strategies is Important
Landy and Menna
Stages of Treatment: Initial
• Trust Develops • Collaboration Occurs• Allow Family to Take the Lead• Crisis Plans Developed• Family’s Needs Met• Develop Understanding of Treatment
Experience• Invest in Change
Working Phase
• Assessment is Ongoing• Acknowledge Ups and Downs• Allow Family to Pace Treatment• Set Reachable Goals and Re-
evaluate Interventions• Review Progress• Encourage Expression of Feelings
Regarding Therapy Experience
Transition/Preparing for Closure
• Hold ongoing Discussions Regarding Plan for Closure
• Transfer Skills to Parents• Support Parents Guiding the
Work• Develop Wellness Plan• Develop Community Supports
Intervention Methods
• Infant-Parent Psychotherapy
• Interaction Guidance
• Play approaches
Infant Parent Psychotherapy
• Assists the Parents to: Develop new and healthier patterns of Interaction
• Identify feelings and put them into words• Understand reactions, defenses and coping
strategies• Form Corrective Attachment Relationship• Recommended Resource: Don’t Hit My Mommy
by Alicia Lieberman
Corrective Attachment Relationships
• Internal Working Models
• Parent IWM and child outcomes
• Function of therapist to making change in the parent-child relationship
Internal Working Model
• What relationships are like
• What I am like in a relationship
• Related to attachment security
Parent Attachment Status and Child Attachment Status
• The parent’s attachment status is related to their child’s attachment status
• Parent status during pregnancy predicts the child’s status
• Change in parent IWM is more important in changing the parent-child relationship than parenting behaviors
Reflective functioning
• The ability to envision mental states in oneself and others
• To understand self-experience in terms of mental processes
• The ability to think about one’s own and other’s behavior in terms of mental states (reflection)
Reflective functioning
• Develops through early experiences with social relationships
• Is essential for social relationships
• Is regulating
• Is protective in cases of trauma
Therapist’s role
• Provide the secure base and safe haven functions for the parent
• Parent experiences a secure relationship and a model of how to be in relationships
• Parent gains emotional fuel to provide secure base and safe haven functions for their child
• Parent’s capacity for RF is enhanced
Goals for Intervention (Lieberman & Van Horn, 2005)
• Return to Normal Development• Increase Capacity to Respond to Trauma.• Maintain Regular Levels of Arousal• Re establish Trust in Bodily Sensations• Restore Reciprocity in Close Relationships• Normalize Reactions to Trauma• Encourage a Differentiation Between Reliving
and Remembering• Place the Traumatic Experience in Perspective
Results of Interventions Assist Child in Understanding…
• Stressful body experiences can be alleviated with help of others and coping strategies
• Adults can support and protect child• Child is not to blame• Can talk about emotions rather than only
acting them out • Life can contain elements of mastery, fun
and hope
Methods for Intervening
• Using Play, Physical Contact and Language to Promote Developmental Progress
• Offering Unstructured Reflective Developmental Guidance
• Modeling Appropriate Protective Behavior• Interpreting Feelings and Actions• Providing Emotional Support/Empathetic
Communication• Offering Crisis Intervention and Concrete
Assistance
Areas of Clinical Concern include…
• Play• Sensorimotor Disorganization• Fearful Behavior• Self Endangering Behavior• Aggression Toward Parent• Aggression Toward Peers• Parental Use of Physical Discipline• Parental Use of Threats, Criticisms of Child• Relationship with Perpetrator
Play
• Encouragement of Play with Dyad
• Help the Parent Understand and Support Use of Play
• Allow the Parent to Be Main Supporter to Child
Child Fears
• Support Parent Understanding of Fears
• Bring Attention to Cues Child Gives Regarding Fears
• Develop with Parents Strategies for Containing Fears
Video Example
• Review video
• Discussion
Interaction Guidance
Susan McDonough, Ph.D. MSW
• Incorporates systems theory
• Designed for high risk families; especially those who have not been successful in treatment before
• Use of video tape to help parent observe child and self with child
Interaction Guidance
Therapeutic stance
• Ask if family thinks you will help
• Culturally sensitive, non-judgmental approach
• Identifying problems with family
• Emphasize strengths; recognize vulnerability
Interaction Guidance
Therapeutic practice
• Work hard, quick on therapeutic alliance
• Address what parent sees as problem
• Attend to all concerns, but address only critical concerns
• Answer questions directly
Interaction Guidance
Phases of treatment
• Assess family situation and caregiving environment
• Decide who comes to treatment
• Family sessions
• Reviewing videotape
• Discussion and conclusion of session
Interaction Guidance
• One hour weekly sessions
• Review of past week, questions, concerns
• Play session (5 minutes)
• Family view tape (therapist takes notes)
• Review of tape with therapist– Systematic probes/family comments– Highlight strengths
• Concluding discussion
Interaction Guidance
Techniques• Provide perspective, clarify distortions• Provide instrumental help when asked• Share information about child
development• Develop behavior plan• Elaborate and extend positive interactions• Model supportive, nurturing style
Interaction Guidance
Evaluation:
• Family defines problem and success
• Therapist is positive
• Therapist focuses on dyad
• Videotape is used to provide feedback and increase awareness of family interactions
Play Approaches
• Theraplay
• DIR Model (Floortime)
Theraplay
• Attachment based treatment developed by Ann Jernberg
• Basic approach is to replicate interactions between well-functioning parent-baby dyads
• Adult directed but play based
• Can be used with many different parent-child dyads
Theraplay
Dimensions
• Structure: therapist selects and leads activity• Nurture: use of soothing, calming caregiving
activities• Engagement: intense personal interactions and
use of fun, surprise• Challenge; mild age appropriate risks lift
confidence and support feelings of competence
Theraplay
• Sessions are 20 to 30 minutes
• Often use two therapists: one to interact with the child and one to interpret to parent
• Parent will be taught games and encouraged to use at home
• Can be used in conjunction with other treatments
Theraplay
• Usually 12 to 15 sessions (may go up to 20)
• 4 follow up sessions over the next year
• All sessions videotaped
Theraplay
• Information gathering session
• Marschak Interaction Method (evaluation, one session with each parent)
• Review of MIM
• Sessions 5-12: parents first observe and then participate in sessions
Theraplay
• No coercive touch
• Works are preverbal level
• Direct parent coaching done
• Might not be appropriate with abusive parent
Floortime
• Stanley Greenspan, MD & Serena Weider, PhD
• Use of play at specific developmental levels
• Play as communication
• Following the child’s lead
Case Study
• Identify Strengths and Needs of Family and Child
• Determine Parent/Child Interactions
• Determine Parent’s Ability/Willingness to Work on Issues
• Determine Strategies
What Evaluation Research Tells Us (Landy & Menna, 2006)
• Home Visiting is Critical Component• Need to Distinguish Between Early Intervention and
Prevention• Starting Early is Critical• Intensity and Duration Counts• Ongoing Assessment is Critical• Services Most Effective for Moderate Levels of Risk• Need for Well Trained Service Providers• Use a Variety of Approaches
Working with Foster Parents
• Correcting false beliefs
• Understanding the role of the foster parent
• Supporting parent to respond to difficult behavior
Connecting to Foster Parents
• Some foster parents may have been advised to avoid getting close to children placed with them
• At this time we know that having a positive and close relationship with foster parents is useful to the child now and in the future
What Helps
• The most effective mental health intervention for young children in foster care is prevention of multiple changes in caregivers.
• Multiple disruptions in placement have been associated with the most problematic outcomes.
• The relationship between the child and the foster parent is a primary piece of the plan.
Connecting to Foster Parents
• Child feels safe, cared for and has better behavior
• Better understands role or child vs role of parents
• Allows for some advantages of secure attachments
• May help child be better connected to parent if reunited or adoptive parent
Ways to Help Foster Parents
• Help foster parents understand that the child needs them even when they do not show it
• Understand that rejecting behaviors are old coping methods
Arousal-Relaxation Cycle
Child experiences a need
Child feels upset
Adult satisfies need
Child feels content
Ways Foster Parents Can Help
• Understand your own ways of thinking about relationships between children and adults
• This usually is related to experiences in your family of origin
• These ways of thinking affect parenting actions and relationships
How Foster Parents Can Help
• Recognize that the child needs you, even when they do not show it
• Understand rejecting behaviors as old coping methods
• Listen
• Put words to behaviors
• Attend to your own reactions
• Encourage touch, but do not force it
Ways Foster Parents Can Help
• See things from their perspective
• People, events, situations that are not scary to use may be terrifying to them
• Consider the coping patterns they developed to live in the world they came from
For more on foster care
• Mary Dozier, Ph.D.
Reflective Supervision
• Reflective Supervision is clinical supervision using a reflective-practice model
• Considered essential in infant-toddler work
Reflective Skills
• Listening• Demonstrating empathy• Promoting reflection• Observing the parent-child relationship• Respecting role boundaries• Respond thoughtfully • Understand, regulate, and use one’s one
feelings
Reflective Supervision
• “A safe place to process complex situations and emotions”
Linda Gilkerson
Components of Reflective Supervision
• Reflection
• Collaboration
• Regular Meetings
Use of Self In Relationship-Based Work
Clinical Process Skills
• Perspective taking
• Use of background and foreground
• Living with the “press”
• Inhibiting actions
Use of Self In Relationship-Based Work
Clinical Process Skills
• Holding the tension
• Reframing parent’s interpretation of child
• Observing own reactions
• Gentle inquiry
• Deploying feelings
Use of Self In Relationship-Based Work
Concepts that confuse
• Neutrality
• Boundaries
• Interpretation vs attunement
• “supportive” approaches
• Strength-based work
• Cultural competence
Last Words (Pawl, 2000)
• Trust in parents
• Mutual clarity
• Hearing and representing all voices
• Hypotheses, not truth
• Maintaining an appropriate role
• Knowledge, beliefs, biases, meaning
• Inclusive interaction
Questions about Treatment
For Later Questions…
