Monday, August 06, 2007

More on the field of Infant Mental Health

I got a great comment, one that took issue with the way I took on the issue of infant mental health.

Jaylark has left a new comment on your post "The Field of Infant Mental Health":

I work in the field of infant mental health, and thought that I would provide a little more context about it. Speaking as a therapist, you wrote “Of course, we love infants, so bring them along, if you'd like.” Speaking as an infant mental health therapist, we're generally seeing the children together with their parents in play therapy, not working with the parents alone in talk therapy... although if it will be useful, we can do both, to be sure. For this reason, the level of reflection about the parents' own childhoods and parenting styles varies a lot from therapy to therapy. However, even with a parent present, play therapy is usually either child-centered or “parent-child relationship”-centered: the parent’s own parenting experiences receive attention to the extent that they appear within, help with or disrupt the parent-child relationship in the room.

Classic articles about this include Fraiberg, Adelson & Shapiro’s (1975) Ghosts in the Nursery and Lieberman, Padrón, VanHorn and Harris’ (2005) Angels in the Nursery.

There may also be confusion about he term “infant”, which in this context includes toddlers who can talk. There is now very compelling evidence that infant mental health (often defined as therapy provided to children ages 0-3, or even ages 0-5) is by far one of the most effective forms of therapy when necessary. For each $1 invested in infant mental health, estimates of effectiveness range from $4-$17 of subsequent savings in physical and mental health costs to society in later life. For more information about the value of investing in early intervention with children, the free resources at the following links may be helpful:

I agree that infant mental health would be a lot less useful when, as you imply, the purpose of the therapy is to make money from parents experiencing normal parenting anxieties. All therapy is most effective when it addresses actual problems that cause actual heartache. It seems to me that when the goal is money, the same criticism could be leveled at any professional endeavor, whether psychological or educational or in business. On the other hand, I imagine that helping a parent to alleviate or address parenting-related anxiety could be phenomenally helpful to both parent and child, since children are always well-attuned to their parent’s moods even when they might not know what those moods mean.
Like most therapy, however, I believe that infant mental health is typically sought if a child has left the normal development track and is having problems.

At the hospital where I work, our therapies are all grant-funded, meaning that they are provided to families free of charge for periods ranging from just a few weekly sessions to 50 or 100 free sessions. Rather than seeing our work as a cash cow, we're trying to help address psychopathology when patterns of behavior are still least fixed and most flexible, and often among society's poorest and least-connected children. When they display problematic behaviors, we endeavor to get them back onto healthy developmental tracks before they begin having behavioral, attentional, social or learning problems in school that can contribute to lifelong social or emotional problems, as well as lifelong struggles with feelings of shame, alienation, rejection or failure.

Just another perspective.

Publish this comment.

So I published it and responded to his comment as follows:
Jay, I don't think I've ever intentionally implied that the purpose of therapy is to make money. As a matter of fact, I'm pretty sure that if a doc wants to make money, I've suggested real estate.

Your comment is so important, however, that I'm going to copy it and post the whole thing on a separate post.

Thanks for your valuable input. When I post on something like this I'm really fishing for input like yours.
And Jaylark wrote back the following:
Thanks for your response. I apologize if I misunderstood about the financial end of things. To share some of my own context, I'm an all-but-dissertation predoctoral intern. As such, I work unpaid and full-time with clients who typically cannot afford to pay. I think I pushed my own hot-button there, and I absolutely agree with you that real estate would have made more sense financially! Reading over my post, which is a little dry, if you approve I'd like to include a few more specific examples about infant mental health.

As with all therapy, of course different things are needed for different situations. When you wrote, “But the therapy's about you and the family you came from (or your spouse's), I'm 99% sure” , I have also found this to be mostly true of any therapy, whether infant, child, adult or family. However, when a little child has lost a parent and is talking daily about wanting to die in order to see them again, and maybe is fascinated with window ledges or knives (and maybe their little siblings), I think you’d agree that the therapy is necessarily about the child. Even two year olds grieve when they lose their parents, through their play if not in their words. When their words fail them, they can still fail to understand that the parent did not want to go, did not mean to leave without saying goodbye, still loves them from up in Heaven, and so forth. That’s where infant mental health can come in, hopefully with the input and active involvement of the caregiver.

At our hospital, see many children who have been abused, molested or have witnessed horrendous acts of inhumanity. To name a few examples, many of these children have repeatedly witnessed one parent being battered by the other, suffered physical or emotional abuse themselves, or seen a parent die or murdered in front of them. Many have effectively lost a parent due to custody battles, prison terms or deportation of the parent by INS/CIS, none of which are within the normal range of a child’s ability to understand... but all of which are becoming distressingly common childhood experiences in this 21st century. These are the issues that can drive adults to therapy: children, while arguably more resilient than adults, nevertheless remain much more primitive in their coping skills and defenses. And while I might wish that these were isolated cases, unfortunately there are often many more children on our waiting list than our staff of 15 or so is able to see, and many more whose parents never follow up on referrals to us after incidents of domestic, community or personal violence.

As any parent can attest, parenting is not an easy job for anyone, but it can be much more difficult for parents of children who have suffered traumatic events. Parents can find their children’s trauma symptoms baffling. As you likely know, in traumatized children we sometimes see overwhelming exaggerations of common problem behaviors like tantrums, nightmares, clinginess, being controlling, or attempts to harm self, siblings or other children. These symptoms are pleas for help every bit as much as they are misbehavior. While love and discipline are both important, if trauma symptoms are not understood in the context of the child’s emotional life and experiences, there is a risk that discipline will actually compound the trauma and its symptoms, rather than alleviate them. For examples of this, I would refer you to Bowlby’s On Knowing What You are Not Supposed to Know, and Feeling What You are not Supposed to Feel, and Slade’s Making Meaning and Making Believe: Their Role in the Clinical Process.

Another thought is that, for two year olds as for older children, play is a critical form of communication in which children not only have fun, but also attempt to process the issues that they encounter in real life. Their play is a window into their thoughts and feelings. In play therapy, we see play in session as an opportunity to strengthen experiences of mutual understanding, attunement and relatedness for both parent and child, creating experiences of happiness and relatedness that can sustain the child emotionally and in relationships for the rest of his or her life.

With a little less grandiosity and more pragmatism, infant mental health also includes assessing a child’s sensorimotor, cognitive and emotional development. This can help to identify signs of the disorders you mentioned, but may also alleviate any potentially unnecessary parental concerns, or help parents to shore up any areas of developmental weakness that might potentially be substantiated.

Some kids (and parents) don’t really know how to play, and infant mental health can help to teach this critical relational skill, as well.

I also agree that one of the most important things that infant mental health therapists do is to help parents to reflect upon how the parenting they learned when they were children themselves does or doesn’t respond to their own children's needs. Many parents are, of course, doing a wonderful job and are very responsive already. However, in many instances we provide services to families in which the parents' own parents were either neglectful, abusive, substance addicted or absent. For a parent who never experienced "good enough" parenting themselves, some time to reflect with a professional upon what they'd like to do, or not to do as parents in sessions with their children and the dilemmas of parenting present in the room can already be an invaluable gift for parent and for child, no matter what the therapy is called. Therapists can help parents to understand the meaning inherent in their children’s play, what it might imply about the child’s inner life as they try to make sense of their world... but highlighting, emphasizing and enhancing the relationship between parent and child is paramount.

We believe that this is most easily and most usefully accomplished with the child in the room.

This is all a very long-winded way of saying that what we do depends upon the children and the parents, which, of course, you know already. But I thought a few more concrete (if long-winded!) examples might help.
See why I love this job? Children on window sills. You bet they need therapy. I wrote back:
Sorry, I mistakenly thought that the field of INFANT MENTAL HEALTH was about INFANTS and thought . . .infants, as in. . .babies.

I stand corrected. Who knew? The Wall Street Journal article said nada about children.

Of course CHILDREN need therapy.
Everyone needs therapy. Infants, apparently, too.

Thanks again, JayLark. Something tells me you're a super therapy doc, ESPECIALLY if you like to play and have some good toys. My bets are that you won't ever sell out to real estate, even when the market picks up.
We look forward to that book on the dissertation, btw. Good luck.



Dylan Emrys said...

Wonderful dialogue!

I also work in the field of Infant Mental degree is in prenatal and perinatal psychology and I work not just in IMH, but also in the idea that what happens before and during birth affects the belief systems, the neurobiology and brain development as well as social and emotional development.

The dynamics between infants and parents is so profound, that often issues from the parents own birth and early infancy could be affecting the relationship and connection between them.

It is so important to recognize not only that we can go back and heal, even change our neurological pathways, but also that we can prevent trauma from imprinting and help parents learn to identify and communicate with their infant so that optimal health on every level can be reached.

therapydoc said...

Thanks Dylan, Projection has no bounds, that's for sure. Nice meeting you.