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.

LEPINA – Making a Bad Situation Worse?

Alexandra Murray Harrison

Two years ago in January, a law was passed in El Salvador, the LEPINA, designed to protect the civil rights of children. It proposed to remove children in institutional care and place them with their biological families. The law had as its underlying assumptions the conviction that every child deserves to live in a family, and that institutions are harmful to children. These assumptions have merit. Unfortunately, in many cases the implementation of the law is threatening to rupture the fabric of a unique solution El Salvador has found to the problem of its disadvantaged children. 

First of all, the law proposes a universal means of protecting the rights of children, that is, a general standard for what is best for children. This is at the outset problematic. El Salvador is not any country, not even any Central American country. It is unique, and one would expect that there would be a specific solution for El Salvador that would not work as well in Mexico, or Guatemala, for example. In fact, the large numbers of small private children’s homes are part of El Salvador’s unique solution. They are not a perfect solution, but many of these homes have served the country’s poorest and most disadvantaged children very well. 

Children’s homes represent a particular kind of orphanage. They are usually relatively small, taking care of about twenty to twenty five children. In many ways, they are functional, if not biological, families. Often the children grow up together. The children eat meals together, play together, do chores together, go to school together. The children’s caregivers are usually a mix of native Salvadorans and Christian missionaries from the U.S. The homes are organized around a Christian life view and practice that is consistent with the culture of at least large parts of Salvadoran society. The missionaries who have chosen to work in these homes see their work as a God given mission. It is common for them to willingly accept children with disabilities and behavior problems as part of that mission. Of course, religious people have devoted themselves to the care of the suffering for centuries. Though the form that these ministries take may be specific to El Salvador, there is nothing new about this kind of charitable work.

The solution of the children’s homes emerged from a number of interacting factors – the trauma and societal rupture of the civil war, the role of the Christian church in Salvadoran society, and the introduction of evangelical Christians from the U.S.  No one planned it that way. As in all dynamical systems, this particular way of doing things emerged from the unique circumstances existing in El Salvador, not from a blueprint imposed from outside (Sander, 2005). Yet, that is exactly what the law is – a blueprint, a one size fits all formula that is applied to all children and families, regardless of their specific strengths, weaknesses, and needs. The consequences for those children who have been brought up in good children’s homes threaten to be catastrophic. 

It is also true that the court system is not prepared to deal with the consequences of the law. Often the cases are heard in criminal court, and for lack of time, the evaluating social worker’s case report is read aloud in court in front of the children. In some cases painful and even frightening details of their parents’ sexual or criminal pasts are revealed to them without warning or protection. It is apparent that the courts feel great pressure to follow LEPINA, to the extent that when new charges of abuse are reported after the children have been reunited, it has been said that the officials receiving the report have not acted to remove the children, nor even to investigate further.

Many developmental researchers have studied orphanages, or institutions for children within the past decade (Gunnar, 2001; Rutter, 1998; Dobrova-Krol, Van Uzendoorn, Bakermans-Kranenburg, & Juffer, 2010; McCall, Goark, Fish, Harkins, Serrano, & Gordon, in press; Nelson, Furtado, Fox, & Zeanah, 2009; and Vorria, Papaligoura, Dunn, Van Uzendoorn, Steele, Kontopoulou, et al, 2003, Zeanah, Nelson, Fox, Smyke, Marshall, Parker, & Coda, 2003).  Often it is said that institutionalized children suffer long-standing adverse consequences as a result of their institutionalization.  However, one of these authors points out that “institutions vary one to another and over time in the environments they provide the children  … The quality of each alternative is likely more important than its sheer category.” (McCall, p. 53 ). This same author asks, “Is it better to have been in a family if abuse, neglect, alcohol, or drugs were common there?”

A preponderance of recent research has documented the intergenerational transmission of trauma and its consequences, unless the cycle is broken (Perry, Lyons-Ruth, Van Der Kolk, Osofsky, Zeanah, and many more).   The directors of good children’s homes understand that the cycles of intergenerational poverty, deprivation, and lack of education, reproduce themselves again and again. Good nutrition, medical care, education, and especially affectionate and attuned caregiving can break the cycle. The law threatens to take apart the developmentally enhancing supports of the children’s homes and send the children back into the self-perpetuating cycle of poverty, deprivation, lack of education, ruptured caregiving, trauma, and failure.  

It is difficult to manage one’s feelings towards parents who neglect, maltreat, or even abuse their children.  Since the implementation of the new law, caregivers in the children’s homes have had to listen to painful stories about the children they have known and loved. A neighbor in the community where a 6-yo boy had recently been reunited with his mother, called a caregiver in the children’s home to tell her that the child’s mother was not feeding him. Another child contacted a caregiver at her old children’s home to tell her that her grandmother was beating her. The neighbor of a caregiver in a home from which 4-year old and 9-year old siblings were taken a year ago contacted her to tell her that the children were not going to school and were begging in the streets at midnight. A 14-year old soccer star who might have used her talent to escape the trap of disadvantage was reunited with a mother who lived too far away to allow her continue to play in her league.

Yet the children’s homes understand that these parents are not villains. They know that the parents are struggling with desperate poverty, lack of education, and often their own histories of trauma. Some of the directors of children’s homes had already begun their own therapeutic programs designed to support the reunion of children with their biological families, long before the passing of LEPINA. The work to prepare for reunification is hard, and they estimated that doing it well would take several years. Instead, children are often being sent precipitously into families that are not prepared to care for them, without careful screening, and with little or no community support. To complicate the matter more, it appears that the implementation of LEPINA is irregular in that it differs from one home to the next; yet there is no evidence of a rational plan to explain why children from one home are being sent to their families and those from other homes are not. 

I am not Salvadoran, but over the eight years I have been visiting the country I have developed a powerful respect and appreciation for this beautiful and courageous country with a tragic past. I like others am saddened by what I see as the results of an ill-advised legal mandate. The resources of El Salvador’s future – the children – must have their civil rights respected. Yet, the intention of the law in many cases is not accomplished in practice.  In all countries, we must dedicate ourselves to breaking that cycle of poverty, maltreatment, and trauma, and in the case of El Salvador, one step would be interrupting the hasty and ill-advised implementation of the LEPINA.  

Continuation of Description of First Weekend of Parent Infant Mental Health Course

In the afternoon, Dorothy Richardson, presented another clinical case. In this beautiful case, the mother and child discovered each other in imaginative play facilitated skillfully by the clinician. This case was particularly enjoyable and interesting because the openness of the presentation (and the presenter) allowed for a rich clinical discussion among the participants.

As a matter of fact, the many pauses to allow questions and comments from the group generated a feeling of collegiality and also of generativity, in that we felt we were really coming up with ideas. First we would challenge our old beliefs, and then we would find newer, more complex, and more challenging ones. On Sunday we had wonderful videos of babies being brought up in different cultures – hunter-gatherer tribe in the Congo,  a Peruvian mountain culture  – that challenged out belief system about priorities in the caregiving system. Finally, we finished with a moving, and articulate talk by Gerry Stechler.  Gerry has a way of bringing highly abstract theoretical knowledge together seamlessly with a mundane example, and infusing it with human emotion, so that it becomes at once a lasting metaphor and at the same time intensely personal to all of us. Gerry, as had Ed, and all of us, I suppose, had emphasized the need to support one another in this academic and clinical group so that we can take the risk of getting confused, or opening up our previously held beliefs about development, psychopathology, and mental health.  

 

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