infant mental health treatment

1. Infant Mental Health Treatment Angela M. Tomlin, Ph.D., HSPP Stacey Ryan, LCSW IAITMH 2007

3. IMH Interventions Core Concepts Contributions Strategies Approaches

4. 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)

5. 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.

6. 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

7. Infant Factors Individuality of each Infant Temperament Characteristics Sensory Functioning

8. 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

9. Contribution of the Relationship Fit between expectations and reality Flexibility in the parent and the infant Degree of conflict or disappointment

10. 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

11. Cultural Factors Understanding context so that stereotypes or assumptions aren’t made Differences in dealing with feeding, sleeping, crying and conflicts.

12. 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

13. 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

14. Providing for Material Needs Facilitates access to community agencies Assists with transportation Forms alliances with other professionals on behalf of family

15. Supportive Counseling Observing Listening Feeling Responding

16. Development of Skills and Support Develops Social Supports Models Problem Solving Skills Models Decision Making Skills Teaches Problem Solving Processes

17. Developmental Guidance Provides Information Speaks for Infant Encourages Observation and Interaction Models Appropriate Interaction Encourages Developmentally Appropriate Activities

18. 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

19. 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

20. 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

21. 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

22. 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

23. Intervention Methods Infant-Parent Psychotherapy Interaction Guidance Play approaches

24. 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

25. Corrective Attachment Relationships Internal Working Models Parent IWM and child outcomes Function of therapist to making change in the parent-child relationship

26. Internal Working Model What relationships are like What I am like in a relationship Related to attachment security

27. 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

28. 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) Coined by Peter Fonagy and others (See Fonagy, Gergely, Jursit & Target, 2002)Coined by Peter Fonagy and others (See Fonagy, Gergely, Jursit & Target, 2002)

29. Reflective functioning Develops through early experiences with social relationships Is essential for social relationships Is regulating Is protective in cases of trauma

30. 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

31. 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 Overall goal is to return to normal activities of living and further development in both child and adult. Traumatized children and adults may lose their ability to appraise and respond to danger. They may either minimize or overreact. Being in a state of hyperarousal further damages ability to manage emotions. Since the body is primarily the way that one remembers trauma often the sensation of touch is shut down. This blocks nurturing, and stalemates development. Preserving attachment and helping each member of the dyad to see the other’s perspective is critical A frame of meaning and validation of the universality of traumatic responses helps move people beyond trauma Assist the child and caregiver in determining the difference between then and now and focusing on the safety of the current environment Teach and build awareness of how to gain control of overwhelming emotions. Learn to savor the good things that occur and not focus primarily on trauma. Overall goal is to return to normal activities of living and further development in both child and adult. Traumatized children and adults may lose their ability to appraise and respond to danger. They may either minimize or overreact. Being in a state of hyperarousal further damages ability to manage emotions. Since the body is primarily the way that one remembers trauma often the sensation of touch is shut down. This blocks nurturing, and stalemates development. Preserving attachment and helping each member of the dyad to see the other’s perspective is critical A frame of meaning and validation of the universality of traumatic responses helps move people beyond trauma Assist the child and caregiver in determining the difference between then and now and focusing on the safety of the current environment Teach and build awareness of how to gain control of overwhelming emotions. Learn to savor the good things that occur and not focus primarily on trauma.

32. 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

33. 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

34. 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

35. Play Encouragement of Play with Dyad Help the Parent Understand and Support Use of Play Allow the Parent to Be Main Supporter to Child

36. Child Fears Support Parent Understanding of Fears Bring Attention to Cues Child Gives Regarding Fears Develop with Parents Strategies for Containing Fears

37. Video Example Review video Discussion

38. 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 Difficult to reach, treat Multiproblem families Multiple stressorsDifficult to reach, treat Multiproblem families Multiple stressors

39. Interaction Guidance Therapeutic stance Ask if family thinks you will help Culturally sensitive, non-judgmental approach Identifying problems with family Emphasize strengths; recognize vulnerability

40. 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

41. 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

42. 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

43. 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

44. 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

45. Play Approaches Theraplay DIR Model (Floortime)

46. 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

47. 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

48. 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

49. Theraplay Usually 12 to 15 sessions (may go up to 20) 4 follow up sessions over the next year All sessions videotaped

50. 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 MIM: developed by Anne Jernberg;s mom!MIM: developed by Anne Jernberg;s mom!

51. Theraplay No coercive touch Works are preverbal level Direct parent coaching done Might not be appropriate with abusive parent

52. Floortime Stanley Greenspan, MD & Serena Weider, PhD Use of play at specific developmental levels Play as communication Following the child’s lead

53. 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

54. 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

55. Working with Foster Parents Correcting false beliefs Understanding the role of the foster parent Supporting parent to respond to difficult behavior

56. 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 Faciliatate discussion about why people may have been told this in the pastFaciliatate discussion about why people may have been told this in the past

57. 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. From Vig, 2005From Vig, 2005

58. 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

59. 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

60. Arousal-Relaxation Cycle Child feels upset From Fahlberg, 1990 When children are upset or experience displeasure, they need to know that adults will do things to make them feel feel better. The parent’s role is to help the child move into a feeling of contentment by providing the relief that comes when a need is satisfied. With repeated successful completions of this cycle, the child come to feel trust, security, and an attachment to the helpful caring adult. We can help children who did not get to experience this cycle with their birth parents to get this experience in foster care.From Fahlberg, 1990 When children are upset or experience displeasure, they need to know that adults will do things to make them feel feel better. The parent’s role is to help the child move into a feeling of contentment by providing the relief that comes when a need is satisfied. With repeated successful completions of this cycle, the child come to feel trust, security, and an attachment to the helpful caring adult. We can help children who did not get to experience this cycle with their birth parents to get this experience in foster care.

61. 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

62. 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 Foster parents can help children in several ways: Always keep in mind that the child really does need you, no matter how little they show it. Look at rejecting or pushing away behaviors as old coping strategies. This is just what the child learned to do in other relationships. He does not know other ways to act yet. Say, I think you might be feeling angry about/afraid about/…. Say, I think you might be remembering that scary time when X happened. That is not happening now. What your own response to these behaviors. Try NOT to pull away, pull back, or lash out. Encourage, but do not force touch. (NOT the same as holding therapy) Help the child feel that they can make things happenFoster parents can help children in several ways: Always keep in mind that the child really does need you, no matter how little they show it. Look at rejecting or pushing away behaviors as old coping strategies. This is just what the child learned to do in other relationships. He does not know other ways to act yet. Say, I think you might be feeling angry about/afraid about/…. Say, I think you might be remembering that scary time when X happened. That is not happening now. What your own response to these behaviors. Try NOT to pull away, pull back, or lash out. Encourage, but do not force touch. (NOT the same as holding therapy) Help the child feel that they can make things happen

63. 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

64. For more on foster care Mary Dozier, Ph.D.

65. Reflective Supervision Reflective Supervision is clinical supervision using a reflective-practice model Considered essential in infant-toddler work

66. 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

67. Reflective Supervision “A safe place to process complex situations and emotions”

68. Components of Reflective Supervision Reflection Collaboration Regular Meetings The practice of meeting regularly to discuss experiences, thoughts, and feelings related to the workThe practice of meeting regularly to discuss experiences, thoughts, and feelings related to the work

69. Use of Self In Relationship-Based Work Clinical Process Skills Perspective taking Use of background and foreground Living with the “press” Inhibiting actions

70. 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

71. Use of Self In Relationship-Based Work Concepts that confuse Neutrality Boundaries Interpretation vs attunement “supportive” approaches Strength-based work Cultural competence

72. 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

73. Questions about Treatment

74. For Later Questions… atomlin@iupui.edu yphsdir@cmhcinc.org