Monthly Archives: January 2012

Caring for Caregivers in Infant Mental Health Course

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First Weekend of the UMass Boston Infant Parent Mental Health Course

This course is essentially related to the focus of this blog – caring for the caregivers. The course was where I developed my ideas more fully and also my clinical skills. 

Our first weekend of the course was exciting, as I have come to expect from my previous experience at the first two courses. We started on Thursday afternoon with an introduction to the program. Berry Brazelton paid an extended visit to the Thursday afternoon class, and in his relaxed and gracious manner and in his wisdom, he offered the program an extraordinary inauguration. 

On Friday morning, Ed Tronick initiated the theoretical framework of the program by presenting his developmental model of match, mismatch, and repair, and its implication for Attachment Theory.  Marilyn Davillier then offered us a paradigmatic case, “Pretend You Feeded Me!” a moving videotape of a young child and her grandmother trying to find each other and create a family together against a background of profound loss, trauma, and insecurity. We thought we would return to this case again and again in our attempts to use new knowledge to understand tragic human dilemmas. After the case, Ed returned us to a focus on theory, laying out the theoretical framework of the infant parent course and explaining his core developmental model of the dyadic expansion of consciousness. Ed illustrated the salient points of the lecture with powerful videotapes of the still face paradigm. The remarkable sensitivity of infants to their mother’s non-verbal communications was demonstrated in these tapes, in which when their mothers suddenly became unresponsive in their presence, the babies made multiple bids for attention (calling out to their mothers, putting up their hands, pointing,) while also self regulating themselves in this stressful situation. Finally, as the 2-minute time period progressed, some babies seemed to give up, even lost postural control and slumped in their infant chairs. The repair of the rupture caused by the still face was again a unique creation in each mother-infant pair. Making use of familiar patterns of behavior that had meaning for the two of them in particular, mother and child rebuilt a sense of connection, a “being together”, but one imagines that, after the still face experience, the ways the two have of being together can never be exactly the same again.

On Saturday, I (Alex) began the program with a presentation of my sandwich model of therapeutic action. I call it a clinician’s attempt to integrate infant research and psychoanalytic theory. As mentioned earlier in the blog, … , the top bread in the sandwich represents the very very big (the wide scope of nonlinearl theories describing how all open systems change). The meat or veggie in the sandwich represents the interactive processes taking place in the time frame in which language and other symbols are made; it tells the story.  And the lower slice of bread represents the microprocess, in a time frame measured in seconds and split seconds. This micro level is what I refer to the music and the dance of therapeutic (and developmental) process, and it is rarely taken into account in clinical case descriptions. And yet nestled within it are micro versions of patterns that are more evident at higher temporal levels in the form of gross actions and language.  I illustrated the model with the case of a dyadic treatment of a young child and his mother. In this case demonstration, the coming together of meanings from multiple domains and time frames – language, actions, coordinated vocal rhythms –with the shared intention of creating a new meaning, was a modest attempt of illustrating the multiple simultaneous meaning making processes constantly at work in human beings as they try to move forward in their lives. 

We had a FIGS group lunch in which I got to know some of the remarkable fellows in greater depth. Out of our seven international fellows, a Peruvian and a Chilien, were included in my group. Our conversation ranged from our individual journeys to the program and to infant mental health, to projects we are passionate about. I talked about the reunification law in El Salvador, because I had the feeling that these people would comprehend the impact of the law.

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Second Morning’s Workshop

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Image of Supporting the Caregivers: Leonardo’s “Virgin and Child with Ste. Anne”

In this morning’s workshop we again started with the image of Leonardo’s Virgin and Child with Ste. Anne to remind the participants of the symbolic representation of supporting the caregiver. Then we moved to Sarah’s videos of last evening in the Home. We wanted to follow up our yesterday’s workshop discussion in which we talked about how the caregiving relationship can grow the children’s brains. 

1. A, with V, the cook: The Papusa Maker

In this video, A, a little girl now 7-years old, is watching intently as the cook, V, makes papusas.  The video demonstrates the role models of caregivers in constructive adult activities provide the children. The children observe the caregivers in their roles and imagine themselves engaging in the same activity.

The video shows A imagining becoming a papusa maker. In her expressive face, you can see her longing to be doing what the cook is doing.  Even though there are computer games going on in the same room, A stands enthralled by the papusa maker for about 20 minutes. She is observing the whole sequence of activities involved in making the papusas. As she observes, she is building the capacity for sequencing the steps in an activity, a critically important capacity for development.  She is learning by watching, by imagining, by anticipating, and finally by practicing. V is very patient in letting A be there and get in the way a bit and letting her feel as if she is part of what is happening. This is a great gift. A is beginning to anticipate a little bit, pointing to a papusa that she thinks is nearly ready. Kevin, an older boy, shares her interest, and V allows him to turn a couple of papusas over, because he is older, which is completely right. A can look forward to being older, when she will be able to make papusas too. Continue reading →

Continuation of First Morning’s Workshop

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Continuation of the first morning’s workshop after the break:

After the break, Sarah and I wanted to address the losses the Home had experienced since the implementation of the law for reunification. We started the process by showing a video of one of the little boys, R, one of the first who had been sent home to live with his mother. He was a newborn when he came to the Home, and the videos of him as a robust, happy little boy were painful to watch, because he was no longer with them. One of the CG became tearful at the sight.  I said that there had been a great deal of sadness and hurt the Home had experienced in the last months and wondered if the CG’s could tell us how their experience of their work and with the children had changed.

One CG said that because of their relationship with the children, the children want to share with them the smallest details of their home visits when they come back to the Home (some of the children have not yet been reunited with their families but have been going on home visits in preparation for reunification, and others have been reunified and come back to the Home for visits). They talk about how they miss them all (at the Home) and about how they miss the meals.

 L, another CG, told a story about a 10-year old boy who went on a home visit and returned after New Year’s.  He said that he missed everybody at the Home. He told L all the things he has at the Home that he doesn’t have in his family’s house. L told the boy that what really matters in life is relationships with your family, and that he hopes that the opportunities he has had at the Home will benefit him when he grows up to be a man and allow him to be like L, who feels he can always rely on his family when he is in need.

 I said that L was giving the boy what he had given J in the video, a chance to identify with him as a strong man, and that was good.  However, I knew that all the children had strong emotions – sadness, anger, fear – and that the CG’s would have to make room for those feelings too. If the children couldn’t find a way of experiencing those painful feelings and making some kind of peace with them, they would have a hard time holding onto the good things the Home had given them. I invited the CG’s to tell their stories of the children’s painful feelings. Continue reading →

First Morning Workshop

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Best Laid Plans

This time it was Sarah and I alone who made the trip. I had organized the workshop according to my last bog posting on January 1.  Sarah had some excellent suggestions that we incorporated over an early breakfast in the hotel.  I had looked over the evaluations of the participants from the last workshop yesterday afternoon, and had noticed that many people expressed appreciation for videos, which I had not included in the plan for this workshop. I was not sure which videos I had on this computer. At breakfast I suggested to Sarah that we start the day with an emphasis on what good the orphanage has done for their children and a reminder of the importance of the caregiving relationship, especially in the early years. Sarah agreed.  She looked through her computer and found some excellent videos that she had taken of theses caregivers, demonstrating the attentiveness and affection that characterizes a good caregiving relationship; we made a new plan. I had located an image of Leonardo’s Virgin and Child with Ste. Anne, thinking that we could use it as an introduction to get across our point about the importance of supporting the caregiver – the mother (Mary) is holding the baby (Jesus) while she herself is in the lap of her own mother (Ste. Anne). Then I found a wonderful video made by my friend, Ed Tronick, demonstrating through the still face experiment the importance to the infant of the emotional connection with the caregiver. We decided that we would first show the Leonardo image and then show several positive videos of the caregivers who we knew would be present at the workshop. However, our experience this morning confirmed our suspicions that no matter how well we plan, we always revise our workshop during the course of the event. Here is what happened.

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Planning a Workshop for Caregivers in El Salvador

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Happy New Year, everyone.  This is a picture of me wearing the gift from my Shanghai hosts in front of my family Christmas tree.  Now, I will leave the theme of Shanghai and return to El Salvador, where I am planning a new workshop next week.

  WORKSHOP

The new Salvadoran law requiring all children in institutional care to be reunited with their biological families presents a crisis to orphanages in El Salvador.  Many or most children in care are being returned to families who may not be prepared to receive them and care for them.  Often, neither children nor families have chosen this transition and may feel afraid, sad, and angry.  Community services to support the reunification in most cases do not exist.  Orphanage administrators and workers were also unprepared to deal with these changes – to support the children, to support the families, and to support themselves and one another.  Yet, it is also an opportunity to make positive changes in childcare. Many studies show that family care is superior to institutional care for the developing child (this is not uniformly the case, however). (McCall, J. N. (1999). Research on the psychological effects of orphanage care: A critical review. In R. B. McKenzie (Ed.), Rethinking orphanages for the 21st century. Newbury Park, CA: Sage Publications, Inc.) Supporting care within the family may have more far-reaching benefits.  Supporting care within the family and community preserves local institutional (such as church and others) and cultural assets. 

The workshop (1) maintains a primary focus on the caregiving relationship – whether the relationship of the child and the orphanage caregiver, or the relationship of the child with the biological family caregiver, (2) the use of the “behavior of the child” (Touchpoints Model”, or the words of the child to communicate with the caregiver, and (3) an emphasis on opportunities for mastery.  As in the Touchpoints Model, the workshop stresses a positive attitude and empathy towards caregivers, and a collaborative approach rather than advice from “experts”. 

Here is an example of a case of a child being reunited with his mother: E is 6-years old. His mother has never taken care of him. She has had a hard life.  She reports having been sexually and physically abused as a child, and she escaped from a children’s home when she was 16. She has always been dependent on men, seeming to lack the motivation to succeed on her own. She can be rude and act entitled to the help she wants from the Home. She claims strong moral values, but she struggles to live according to these values. For example, she is easily offended if she perceives E to be mistreated by someone, yet she will often mistreat other children. E is a competent child and generally has good relationships, but he is strong willed and able to play one adult against another when he is upset. The Home worries that he will try to control his mother and cause her to become discouraged or to give up.

The participants will be invited to discuss the case.  Questions to begin the discussion might include: (1) What positive characteristics of the mother can the caregivers identify? (2) How can the caregivers find ways to empathize with this mother? (3) What are the mother’s goals and ambitions for E? (4) How can the caregivers communicate what they know about E to the mother and still emphasize her knowledge of her own child? (5) How can the caregivers support the mother in recognizing the problems they anticipate after the reunification? (6) What ongoing support do the caregivers think would be best for this family?