“So . . . why are you here?” the young mother of two small children asks.Her question is a pointed and poignant one. The answer is complex. The infant mental health practitioner is there to support the social and emotional well-being of an infant and toddler within the caregiving relationship with their mother. The task is an ambitious one. It will require patience and persistence on the part of the practitioner, as well as careful observation, sensitive inquiry, and thoughtful response. It will require courage on the part of the parent to be present and to enter into a working relationship with the practitioner on behalf of her young children and herself. The practitioner will listen carefully, understand the parent’s agenda, communicate clearly, and invite a supportive relationship with the family.
Once the relationship is under way, parent and practitioner will begin to acknowledge what is going well and what is not, what the children’s developmental capacities are and where the risks lie, what the mother’s caregiving strengths are and where the concerns lie. Together they may wonder about the mother’s feelings related to the care of two small children and the changing responsibilities of parenthood. They may discover core relational conflicts, old hurts, and unresolved losses that make the care of her children difficult. Their work together may take many months. Parent and practitioner will need to remain open, curious, and reflective. In sum, they will embark on a journey together, looking for the “treasure” that Selma Fraiberg (1980, p. 3) so artfully described—new knowledge and understanding “returned to babies and their families as a gift from science.”
TRAINING TECHNIQUES. An infant mental health trainee or practitioner needs to learn to observe and listen carefully to a family referred for assessment or treatment services. Course work, as well as observation experiences with a typically developing, low-risk infant and family, prepares a practitioner-trainee to assess strengths and risks when an infant or toddler and family is referred for assessment or treatment. In instances where there is no formal training program or where it is not possible to observe a low-risk infant and family, the training supervisor plays a particularly important role. Experienced in providing relationship-based assessments and treatment services, the training supervisor will need to guide practitioners as they develop the art of careful observation, listening, and relationship-focused practice. In all instances, the practitioner-trainee must learn how to define the relationship (Schafer, 1995; Zeanah et al., 1997). This means that the practitioner-trainee will try to observe and understand the infant and parent within the context of their relationship with each other. This will help the practitioner appreciate the dynamics of interaction moment to moment and to contain the feelings expressed or aroused. In order to do this, the trainee needs to observe the infant and parents together. For many, this is a unique requirement. Students and professionals are customarily trained to work either with children or with adults. By contrast, practitioners within the field of infant mental health are taught to work with the infant and parent together (Fraiberg, 1980; Trout, 1982; Lieberman & Pawl, 1993). In relationship work, the presence of the parent is considered vital in understanding the infant (Hirschberg, 1993). Of equal importance, the presence of the infant is a powerful contributor to understanding the dynamics of relationship within families and caregiving responses, both nurturing and problematic.
When possible, trainees may arrange to visit parents and infant in the home, at a time that is convenient for the family. In instances where home visiting is not possible, trainees will work with parents and infant in an office, playroom, or center-based program. Regardless of the location, trainees must be taught to approach families with kindness and respect, keeping in mind the centrality of the therapeutic relationship to the success of assessment and treatment. These expectations are consistent with infant mental health practices as described by Fraiberg (1980), Lieberman and Pawl (1993), Wright (1986),Weatherston and Tableman (2002), and Trout (1987). They are most important when a parent expresses concern about the development of an infant, when a professional is worried about the caregiving capacity of a parent, or when an agency suspects a relationship disturbance or disorder due to serious neglect or abuse or placement in foster care.
THE SUPERVISORY RELATIONSHIP. The supervisory relationship is crucial to the development of clinical competency within the field of infant mental health.Whether enrolled in a formal training program or learning about infant mental health practice on the job, a practitioner new to the field of infant mental health needs a supervisor who will guide and support the integration of knowledge about infancy and early parenthood with best practice skill.
Because relationships affect relationships, the supervisory relationship offers the trainee a context for clinical growth that shapes the trainee’s capacity to offer the same to the infants and families served. Secure in the relationship with a trusted supervisor, the trainee is encouraged to think deeply about infants and families and services within an infant mental health framework. The trainee also learns to reflect on personal aspects of infant mental health work. Over time, and within the context of the supervisory relationship, the trainee or practitioner new to the field integrates principles with practices of infant mental health.
With these ground rules in place, how do trainers or supervisors help trainees reach an understanding of the infants and families referred to them for services? What tools do they need to guide them through the process? What training techniques encourage clinical growth? How can trainers or supervisors move trainees from knowledge to application? What follows is a brief discussion of methods that translate infant mental health principles into practice.
INFANT AND PARENT TOGETHER. First, the trainee watches the baby in the context of a relationship in order to understand who that baby is, what the baby brings into the relationship, what the caregiver provides, and the nature of their relationship with each other. Looking at one or the other alone will yield half of the story. As Winnicott (1965) so beautifully reminds us, “There is no such thing as an infant” (p. 39). By this statement, he meant that there is always a baby and a caregiver. This powerful concept directs the infant mental health practitioner to consider both infant and parent together, not one in isolation from the other.
FAMILIAR SETTING. Second, the assessment occurs in a setting familiar to the baby and to the family—most ideally, the home. The trainee observes the surroundings in which a young child is raised in order to understand what life is like for the baby and the parent, what is going well, and basic wants or needs.
Another argument, eloquently stated by Fraiberg (1980), is the fact that a parent caring for a new baby and overwhelmed by the baby’s care may find it difficult to get out of the home. Lack of reliable transportation for many families makes this even more problematic. Some parents and infants may need the trainee to reach out, knock on the door, and enter their home. In addition to better ensuring that the infant and family will be seen for an assessment, visits in the family’s own home may be more comfortable and less threatening than those at an unknown agency. Of additional importance, home visiting may strengthen the working relationship between the practitioner and family, reinforcing the practitioner’s interest and offering a basis for greater trust.
TIME. A third important principle involves the number of visits needed to appreciate the problem with the baby or the reason that the infant and family were referred. Fraiberg (1980) advised her staff many years ago that an assessment might occur over four to six visits, including the use of informal and formal strategies. Others suggest four to eight visits (Lieberman et al., 1997). It is important to understand that a thoughtful, systematic assessment takes time. The process requires attention to the concerns that parents have, the opportunity for a relationship to develop with the infant or toddler’s parents, structured and unstructured observations, details of the child’s development, and family stories, past and present (Greenspan & Meisels, 1996). The trainee needs time to observe, listen, and begin to understand what is going well in a particular family, in addition to what concerns exist and how to be helpful.
WORKING RELATIONSHIPS. Finally, but of singular importance, is the fact that parents must be considered partners throughout the assessment process. The working relationship between each parent and infant mental health trainee is vital to the success of the assessment (Davies, 1992). A parent or caregiver is present, allows the practitioner to be involved, and understands why the infant has been referred. One significant challenge that the new practitioner or trainee faces is earning the parent’s trust.Without trust, very little intervention can happen. In relationshipfocused service, a working alliance with each parent or caregiver on behalf of a young child is considered essential for best practice.
Infant mental health principles, stated eloquently by Fraiberg (1980) and
restated by Hirshberg (1993), Lieberman and Pawl (1993), Lieberman,
Van Horn,Grandison, and Pekarsky (1997),Meisels and Fenichel (1996), Meisels and Provence (1989), Trout (1987), and Weatherston and
Tableman (2002), are integral to infant mental health practice and early
development services. They shape the ways in which practitioners
approach infants and families and influence the ways in which infants
and families may be understood.
Trainees who are new to the field of early intervention or infant
mental health will use these principles to guide them in their work.
For some, the “rules” will seem odd or inconsistent with previous
training they have had. They may struggle to integrate a relationshipguided
assessment approach with one that focuses more individually
on an infant or the parent of a child. Over time and within the context
of supportive training relationships, infant mental health practitioners
and trainees from very diverse fields can learn to provide
relationship-based assessments and interventions with the following
important tenets in mind.
What training experiences do practitioners from multiple disciplines need to have to prepare them for infant mental health services? Training requirements are complex. First, practitioners need to build a knowledge base from which to understand infants or toddlers and the adults who care for them, as well as the complexity of early relationship development. Second, they need to develop a wide variety of practice skills appropriate for observation, assessment, and intervention with children under the age of three and with caregivers whose capacities and needs vary. Third, they need opportunities in which to discuss the details of what they see and hear, a place in which to ask questions about infancy and early parenthood, relationship risks, disorders of development, and strategies for effective work. Fourth, they need individual guidance and opportunities for reflection with a training supervisor who is knowledgeable about early development and relationships and is able to sustain them in their work.
These four training elements—a knowledge base, skill development through direct service experiences, opportunities to question, and reflective supervision—are consistent with the training experiences first proposed by Fraiberg and her colleagues in the Child Development Project in Ann Arbor,Michigan, in the 1970s (Fraiberg, 1980). They reflect the early training guidelines recommended by the Michigan Association for Infant Mental Health in 1983 and revised in 2002 to influence the design of university and community-based programs in the preparation of infant mental health trainees and to strengthen the practice of infant mental health (Michigan Association for Infant Mental Health, 1983/2002).
The training elements mirror the training principles proposed by staff affiliated with the National Center for Clinical Infant Programs in Washington, D.C., who are highly regarded for their leadership in preparing infant and family practitioners (Fenichel & Eggbeer, 1990).
They also reflect current thinking among those who are preparing practitioners from multiple disciplines to assess and treat young children with respect to the social and emotional context in which they are raised (Meisels & Fenichel, 1996; Harmon & Frankel, 1997; Lieberman,Van Horn, Grandison & Pekarsky, 1997;Weatherston & Tableman, 2002; Trout, 1987; Fisher & Osofsky, 1997).
Unique in its focus on children under the age of three, on parents, and on relationships, the practice of infant mental health requires specific course work and supervised, clinical training. Graduate students, interns, and professionals from a wide range of disciplines need to learn how to identify capacities and risks in infancy and early parenthood and how to structure relationship-based interventions.
It is important to understand that from an infant mental health perspective all contacts with an infant and family are integral to the intervention process. The first phone contact, early observations, and formal assessment experiences affect the infant and family and need to be seen as part of a continuum of service to the family (Meisels, 1996).How might the infant mental health practitioner develop a plan through careful observation, assessment, and intervention? There are several different ways in which the practitioner might work (Stern, 1995). The practitioner may look closely at the infant’s behavior within the context of the parent-infant relationship and work hard to bring about change there. The practitioner may focus on the parent’s behavior in an effort to increase sensitivity to the infant or toddler’s needs. The practitioner may work at the representational level, alert to the parent’s thoughts and feelings about the infant and the meaning of early parenthood and change. In addition, the practitioner may focus on the interaction between parent and infant and their relationship, secure or insecure.
The Fraiberg model of infant mental health service encourages the infant mental health practitioner to consider all of these things as appropriate to an individual infant and parent pair. In addition, the practitioner integrates these in developing an approach that is interactional, behavioral, and psychodynamic (Hofacker & Papousek, 1998). The infant mental health practitioner often visits families in their homes. Close to the source, the practitioner has many opportunities to watch the infant and parent together, to ask questions, to listen, to support their interactions and offer help within the context of the therapeutic relationship. The practitioner enters without judgment and makes the family comfortable. The practitioner is sensitive to the parent who is vulnerable: the mother who finds it difficult to hold and feed her baby, the father whose baby has multiple disabilities and delays, the foster mother who is caring for two toddlers who were removed from their mother’s care.
Carefully following the parent’s lead, the practitioner observes who is there and what is happening, asks careful questions, listens, and responds respectfully. A guest, the practitioner does not overwhelm, intrude, or offer judgments prematurely. The practitioner is there to learn what concerns the parents have and how to help them.
The context in which an infant or toddler is raised is an additional and important concern. Homelessness, hunger, joblessness, poverty, alcoholism, and drug use place enormous burdens on families. These factors exacerbate the risks that parents face in taking care of their children and in responding to their needs to be fed, clothed, sheltered, comforted, and kept safe. Any of these conditions may place infants and families in jeopardy and at risk for developmental failures. In combination, they alert infant mental health practitioners to a family’s need for immediate outreach, observation and inquiry, careful listening, nurturance, and relationship-focused responses.
In a substantial number of cases, a referral may be made during pregnancy or immediately following a baby’s birth. The pregnancy may be healthy and the infant may be constitutionally robust at delivery, with capacities to adapt and interact from the moment he opens his eyes. The referral is made because someone is worried about the parent or parents.Will the parent be able to take care of the baby without clinical support? What factors may concern practitioners? If pregnant, a parent may express strong ambivalence or hostility about the birth of another child. A woman may have considered abortion or adoption up until the delivery of her baby. She may have lost previous pregnancies or delivered a stillborn child. Older children may have been removed to foster care due to substantiated reports of abuse or neglect. All of these factors raise red flags and suggest that the supportive presence of an infant mental health therapist may reduce the risk of rejection of the new baby, a jeopardized attachment relationship, neglect, abuse, or developmental delay.
Other conditions may also place infants and infant-caregiver relationships at risk. The primary caregiver, usually the mother, may appear unprepared for the care of a baby, overburdened, or seriously depressed. She may be inattentive to the baby’s needs, unable to be emotionally present. She may not be able to hold or feed or provide routine care. She may not be able to enter into a loving relationship, provide developmental encouragement, or keep the baby safe. A parent may have a history of early and unresolved losses that make the care of this baby troublesome (for example, extended separations in early childhood, maternal rejection, neglectful care, placement in foster care).
Another parent may be too young, alone in the care of her baby, impulsive or unrealistic in the expectations that she has. Of additional concern is a parent who has a serious mental illness or developmental delay and when faced with the responsibilities of parenthood is not able to provide consistent or contingent care. All of these factors place an infant or toddler and parent at risk. Early referral to an infant mental health service for assessment and treatment may reduce the likelihood of developmental failure, abuse, or parental neglect.
Practitioners learn to appreciate the variety of risks that encompass early development programs. The infants referred may be constitutionally vulnerable babies who cannot wait beyond the first weeks or months of life for prevention or early intervention support. They may be premature babies, underweight, irritable, difficult to comfort, or difficult to feed. Slow to gain or failing to thrive, they are at high risk for significant disabilities or developmental delays. Others may be difficult to engage, inattentive, unresponsive, withdrawn. Still others may be highly active and hypersensitive, disorganized in their approaches to people or playthings, and unable to send clear signals to tell their caregivers what they want or need. They may be unrewarding babies to take care of and at high risk for problematic care.
Some babies may be referred because of maturational concerns. A health care provider may suspect a delay in one or several developmental domains (for example, slow to sit or crawl, slow to smile or respond, unable to separate). A parent may worry about a disturbance in development, a regression, or a developmental arrest. Still other referrals may be made because of a toddler’s behavior (for example, biting, head banging, aggression that is out of control, significant withdrawal, emotional retreat). Infant mental health practitioners must learn to recognize a range of conditions in early infancy in order to become familiar with a range of developmental risks and delays.