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HISTORICAL CONTEXT AND THE BIRTH OF A MOVEMENT

NEW DIRECTIONS TOWARD AN INTEGRATION OF EARLY INTERVENTION AND INFANT MENTAL HEALTH Jane D. Hochman, Ed. D. Gilbert M. Foley, Ed.D. HISTORICAL CONTEXT AND THE BIRTH OF A MOVEMENT. EARLY CHILDHOOD: A FIELD IN FORMATION (1860s-1940). Philanthropy and Social Reform

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HISTORICAL CONTEXT AND THE BIRTH OF A MOVEMENT

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  1. NEW DIRECTIONS TOWARD AN INTEGRATIONOFEARLY INTERVENTION AND INFANT MENTAL HEALTHJane D. Hochman, Ed. D.Gilbert M. Foley, Ed.D.

  2. HISTORICAL CONTEXT AND THE BIRTH OF A MOVEMENT

  3. EARLY CHILDHOOD: A FIELD IN FORMATION (1860s-1940) • Philanthropy and Social Reform • Advances in Medicine and Public Health • Government Actions • The New Science of Child Study • The Progressive Education Movement • Behaviorism • Psychoanalysis • Mental Hygiene and Child Guidance

  4. DEVELOPMENTS IN PSYCHIATRY, MEDICINE AND SPECIAL EDUCATION (1940-1960) • Infant Psychiatry/Infant Mental Health • Pediatrics and Rehabilitative Therapies • Special Education

  5. Institutionalization and Standardization of Early Intervention: 1960-Present

  6. 1960s - Early Federal Initiatives, Laws and Policies • 1961: Federal Office Established (BEH) • 1965: “ War on Poverty” – Head Start • 1967: Early and Periodic Screening Diagnosis and Treatment Program (EPSDT) • 1968: Handicapped Children’s Early Education Program ( HCEEP)

  7. The 1970s - Early Programs and Policies • Early 1970s: A controversy of Models • 1975: PL 94-142 • Late 1970s: Good Practice Models Emerge

  8. The 1980s - Early Childhood Becomes Law • Early 1980s: Outreach Replication Networks and Personnel Preparation • PL 99-457 • Late 1980s: Collaboration

  9. The 1990s - IDEA and Later Revisions • Americans with Disabilities Act (ADA) • 1990: PL 99-457 renamed Individuals with Disabilities Education Act (IDEA) • Early 1990s: Early Intervention Implemented • 1995: Early Head Start • 1997: Family-Centered > Family-Directed

  10. 21st Century - Revisions, Refinements, and Challenges • Revisions to IDEA • Economic Challenges • New Technology • Personnel

  11. MARTIN: A CHALLENGE OF CATEGORIES

  12. MEET MARTIN • 26 Months Old • Charming • Dreamy • Autistic? • Uneven Language Development • Weak Pragmatic Skills

  13. TUMULT AT HOME • Stormy • Father Left • Mother Depressed and Searching • Babysitters

  14. “THE CHILD WILL ALWAYS TELL YOU”Sally Provence, M.D. • Martin Tells a Story to his Occupational Therapist • What might it mean? • How to React? • What to Do? • Who may be able to help? • Implications for the Service Delivery Paradigm itself?

  15. THE INTEGRATION OF INFANT MENTAL HEALTH (IMH) AND EARLY INTERVENTION (EI): Concepts, Characteristics & Rationale

  16. A HOLISTIC SYNERGISTIC FRAME OF REFERENCE~“Embrace Complexity! ”Sally Provence, M.D.

  17. MODELS OF DEVELOPMENT • Architectonic • Hierarchical • Linear • Epigenetic • Organic • Unfolding • Plastic • Transformational • Holistic • Dynamic

  18. A DEVELOPMENTAL-BIOPSYCHOSOCIAL-TRANSACTIONAL MODEL • “Infant as a Work in Progress”

  19. THE NATURE OF DERAILMENT • Cumulative Adversity: A Cascade of Multiple Misfortunes vs. Single Incident/ Disease/Natural History Model of Derailment • Healing the Organic-Functional Split • Context…

  20. PARITY FOR PSYCHOSOCIAL DOMAIN OF DEVELOPMENT & MENTAL HEALTH IN DEFINING ELIGIBILITY & DELIVERING SERVICE

  21. Infant mental health refers to the multifaceted formative process impacted by myriad forces, including: • Totality of development itself • Organized as the structure and content of the inner life • Arising both from within and without and • Expressed in functional behaviors used to mediate between the internal and external world of self and other with affective range, intensity and color.

  22. Infant mental health includes: • Formation of attachments • Inner construction and emerging portrayals of the self and love-objects with feeling • Ability to regulate impulse, affects and the seeds of self-esteem • Capacity to manage anxiety and form flexible and adaptive mechanisms of coping and defense • Ability to form and sustain relationships beyond the immediate attachment system • Ability to experience the world with a range and intensity of feeling.

  23. Infant mental health includes: (con’t) • Appropriate assessment of social-emotional functioning and the well-being of the family • A role for mental health members of the team to function in therapeutic as well as assessment and referral capacities

  24. FAMILY-CENTERED RELATIONSHIP-BASED PERSPECTIVE

  25. THE CENTRALITY OF RELATIONSHIPS “A baby cannot exist alone, but is essentially part of a relationship.” D. W. Winnicott • The Family is a Network of intimate Relationships • The development of the baby is to large extent dependent on the well being of the relationships that compose the cradle of “holding” and nurturance.

  26. A Self-Family/Centered Copernican Universe Community Relationship Network Family Child

  27. FAMILY STRESS & DISTRESS • Loss-Grief • Personal Mythology • Reframing the Representation of the Child

  28. FAMILY STRESS & DISTRESS (con’t) • Damage and Reparation/Fear and Wish: Unseen Forces in the Family Psyche • Uncertainty About the Future • Amplified Demands of Daily Life

  29. RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY INFORMED APPROACH TO SERVICE DELIVERY • Identifies the relationship as the “Unit of Service” • Provides comprehensive, intensive, continuous, supportive and engagement-focused services • Addresses the expected and unexpected stress, coping and adjustment reactions and general well being of families

  30. RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY- INFORMED APPROACHTO SERVICE DELIVERY (con’t) • Addresses the meaning the child holds for the family • Works through the alliances of caregivers to the child and support systems to the caregivers • Works from the inside out: • addressing history, representation, affective states and the forces of fantasy

  31. RELATIONSHIP-BASED, PSYCHOTHERAPEUTICALLY- INFORMED APPROACH TO SERVICE DELIVERY (con’t) • As well as the outside in: • Addressing resources, knowledge, skill, coping and concrete services • Multi-Modal

  32. RELATIONSHIP-BASED PSYCHOTHERAPEUTICALLYINFORMED APPROACH TO SERVICE DELIVERY (con’t) • Embraces parenthood as a developmental process • Supports every member of the team to deliver his or her discipline-specific services in a relationship-based psychotherapeutically –informed style

  33. A MULTI-CROSS-DISCIPLINARY TEAM MODEL OF STAFFING~The Transdisciplinary Approach • Role Extension • Role Release • Reflective Supervision • Intervention as Enacted Thought • A Cardinal Feature of an Integrated Model

  34. DEMANDS OF THE WORK • Hopefulness • Readiness to Cope with Negative or Troubled Experiences of Both Parents and Practitioners • Preparedness Concerns • Range of Reactions • Availability of Resources

  35. PARENT-PRACTITIONER RELATIONSHIPS IN EARLY INTERVENTION:UNSEEN FORCES

  36. EARLY INTERVENTION PRACTITIONERS REPRESENT MORE TO FAMILIES THAN THEIR DESIGNATED ROLES

  37. TRANSFERENCE AND COUNTERTRANSFERENCE • “ Transference consists of the ‘experiencing of feelings, drives, attitudes, fantasies and defenses toward a person in the present which do not befit that person but are a repetition of reactions originating in regard to significant persons of early childhood, unconsciously displaced onto figures in the present ‘ ” ( Greenson, 1967, p. 155)

  38. TRANSFERENCEAND COUNTERTRANSFERENCE, con’t. • Communicated via the infant through the care-giving style • Identified via Inappropriate Attributions

  39. TRANSFERENCE AND COUNTERTRANSFERENCE con’t. • Intensity • Ambivalence • Capriciousness • Tenacity

  40. OPTIMAL DISTANCE, #1 • There is NO absolute optimal distance • A relative position influenced by history, culture, and temperament • Differs family to family

  41. OPTIMAL DISTANCE, #2 • A Range Between Remoteness and Excessive Closeness Relatively Free of Ambivalence • Reality-Based Middle Ground • Ongoing Self-Regulating Relational Range

  42. OPTIMAL DISTANCE, #3:REMOTENESS • Unconscious Desire to “Shield” • Illusion of Safety in Distance

  43. OPTIMAL DISTANCE, #4:TOO MUCH CLOSENESS • Over-Identification and Fusion • Excessive Nurturing • Defense Against Guilty Feelings

  44. OPTIMAL DISTANCE, #5: AMBIVALENCE(most disturbed) • Shadowing • Darting • Unreliable

  45. OPTIMAL DISTANCE, #6: PRACTITIONERS MUST…. • Tolerate Anxious Uncertainty • Use Own Emotional Experiences as a Guide • Have Capacity to Observe, Listen and Reflect • Ask oneself two important questions………..

  46. OPTIMAL DISTANCE, #6con’t • “ Am I Maintaining an environment of safety, security, compassion, and support for the infant and parents?” “ Am I impeding the family’s self-awareness, self-sufficiency, and self-determination?”

  47. PRACTICE SUGGESTIONS FOR NON-MENTAL HEALTH PRACTITIONERS

  48. MAKE NO ASSUMPTIONS ASSUMPTIONS

  49. BEGIN WHERE THE FAMILY IS • …Not Where you Wish it Would Be • Beware of halo effect or tendency for countertransference fantasies • Successful Family-Practitioner Relationships Progress from A Base of Security.

  50. PRESENTING YOURSELF TO THE FAMILY • Titles of Address • Initial Introduction • Dress Code • Safety Concerns …Formality and informality reflect remoteness, excessive closeness, or optimal distance…

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