This is a very exciting event, our first publication of the Infant Toddler Mental Health Coalition of Arizona Newsletter! Through the newsletter, we hope to increase the organization’s visibility statewide and, more importantly, establish another means of connection with all of our members.

This first newsletter features a clinical piece by William Schafer, PhD., "Planning as an Attachment Experience", which is being reprinted with permission from the Michigan Association for Infant Mental Health. For those of you who were not able to attend the 6^th Risk to Resiliency Institute, Dr. Schafer was the key note speaker on the second day who presented "Out of the Mouth of Babes--- What 30 Years of Infant Mental Health Have Taught Me". It seemed fitting to have him as our featured author for this first edition. The inclusion of clinical articles will be a hallmark of the newsletter and we would encourage our members to submit clinical articles for consideration in future editions.

Each newsletter will also provide a profile of an individual who is working in some capacity with infant mental health within our communities. This newsletter features Deborah Harris who works in Northern New Mexico at the Las Cumbres Learning Services. The intention is to facilitate connections and provide support for one another.

The newletter also features an article written by Emily Fenichel who is the editor of the Zero to Three Journal. Zero to Three has established an Infant Mental Task Force who is currently attempting to give definition to the concept of Infant Mental Health. I am very grateful to Emily Fenichel, Deborah Harris, and Dr. Schafer for their valuable contributions and the support of our organization.

The newsletter will also address all of the upcoming events of the organization such as training dates and topics, community forums and other infant toddler mental health activities and/or information currently taking place within our local communities.

The Board is very interested in hearing from you. We would like to know how we can better support your work with infants, toddlers and families. We welcome your letters and e-mails. See the Board Information included in the newsletter.

Please feel free to e-mail your comments, interests and concerns to me. bwightman@co.coconino.az.us (928) 522-7931.

Have a Wonderful Holiday!
Barbara Wightman, Chair of the Coalition

William Schafer, PH.D.

(Reprinted with permission of the Michigan Association for Infant Mental Health Association, Crier, July-September 1991)

A group of us were discussing clinical stalemates the other day. One woman brought up a case, which was presenting her with a particularly frustrating problem. As she described her difficulty with the case, others around the table began to nod. It seemed the problem was familiar to everyone. Basically, it was a question of how to intervene with a mother who seems incapable of making and following through with any type of a plan.

The baby in question was less than one year old. He was the third of a twenty-one year old single woman who had grown up in poverty and who had few useful social supports. Although there was no medical emergency, the baby was small and appeared undernourished. He has received no routine inoculations, and one of his mother’s concerns was that she has been unable to bring him in for well baby visit.

The mother actually had many stated concerns, all given in the first few interviews. She wanted to finish high school. She wanted to have a better relationship with the baby’s father. She needed transportation. She needed to get the front door fixed. She wanted to be a better mother to her third baby. She needed a place to live. She wanted to bring her baby for his shots. She was also pregnant again, and wanted to decide whether to keep her baby or place it for adoption. The list was long, and given without any distinction between projects large and small. It was a litany of wishes, not an enumeration of plans.

In the two months since the case had opened, the worker had grown increasingly frustrated. Sometimes she arrived to find the mothers home, other times at her own mother’s, and yet other times at her aunt’s. There were never phone calls to notify the worker of any change. Yet when they did connect, the woman seemed genuinely welcoming, and the worker had come to believe that the client was not deliberately avoiding her, but did not herself know from one day to the next where she would be.

Soon the client’s inability to make and keep plans became the worker’s problem as well. She worked hard to set up convenient appointments with the pediatrician, but something always happened to ruin them. The same thing happened with visits scheduled to the obstetrician. The clinical worker soon took on the feeling of a catch-as-catch can effort, constantly geared to picking up the pieces of the last broken idea.

One vignette was particularly poignant. The baby’s mother repeatedly kept asking about adoption possibilities, but never got around to calling an adoption agency for real information. The worker’s encouragement seemed appreciated, but quite useless. The given reason was the mother’s lack of access to a phone. At one occasion, when they were in the neighborhood of the worker’s office, she offered the client the use of her own telephone to call the adoption agency. The client accepted, placed the call, and was told that the only thing else she needed to place the baby for adoption was the father’s signed consent. The client quietly said "thank you" and hung up. This was out of the question, she explained, because she had not told the man that the infant she was carrying was his, and was afraid to do so now.

At this point, people around the table began discussing their own similar experiences, and some of the tactics they had adopted to solve the problem. One worker gave her clients large calendars at the beginning of their work together and had clients write down appointments and schedules on a weekly basis. Some used color-coded markers for different types of events. A few had even attempted to take over the task of planning from the client, and as far as possible did the scheduling and appointment-keeping themselves. None felt that their tactics worked very well.

Finally, someone asked what kind of early experience led to an adult state of mind which made the making and keeping of plans so difficult. The woman who has presented the case ventured that it was probably the very same kind of experience the baby in her case must have. "He never knows from one day to the next where or when he will eat, in what bed he will sleep, or who will put him down or wake him up."

In infant mental health work, we take it as axiomatic that early experience becomes the model for later functioning. For us, this belief has become a given. And that is dangerous, because it oft3n prevents us from thinking through what we do not know, namely just how this early experience has been kept alive and nurtured over time. As we all discover fairly soon, it doesn’t help much to tell a client that she does such and such because something similar happened to her as a child. Since she has no memory of any of this, it doesn’t help her understand her own behavior. As a result braver clients challenge such a notion, while the more timid ones simply nod in apparent consent.

It becomes our task then to pay close attention to the baby’s experience, and to ask ourselves what it must feel like. With regard to the issue at hand, one might try the following; admittedly rather silly, thought experiment. Suppose that you left the house this morning for work only to find that your car had disappeared overnight. You would probably experience an immediate sense of panic: who stole my car, and how in the world am I going to get to work? When the panic subsided sufficiently you would probably start looking for the car, and failing to find it would call a friend and get a lift to the office. Now suppose that upon arriving at the office you discovered your car waiting for you in the parking lot. You would probably feel immediately overjoyed. The worry you felt the whole way downtown would lift, and you would be left only a nagging doubt as to how the whole thing occurred in the first place.

But suppose things kept happening over and over, as though some malevolent spirit had taken possession of your car, moving it around the city at odd moments. The relief you would feel at finding it each time would quickly wear thin. You would soon learn that it was a waste of time to think through where you last parked it, or where you intended to drive it next. Finally, you would begin to experience a definite sense of foreboding and dread each time you reached for your key ring in your pocket or in your purse.

All analogies limp, of course, and it is important to note the handicaps this one possesses. Perhaps the most obvious limp here is that your experience of constantly losing and finding your car would probably not generalize to the way you conducted your entire life. Yet that is precisely what we assume happens to the baby. Why? One possibility is that the baby’s mother is far more important to him than your car is to you and that her loss is far more overwhelming. The more overwhelming the trauma, the longer lasting the effects. Thus in our adultomorphic way we conclude that the baby’s early experience with his mother has taught him not to trust anyone.

But does this really explain anything? Why should the baby continue to believe that one is trustworthy, when in fact some people are? Why should the mother in the case example not trust that her worker will be there where and when she says? (She always is). Why doesn’t she learn that showing up at the pediatrician’s office without an appointment can waste even more time? Why doesn’t she learn that no prenatal care results in smaller, sicker babies? More generally, why don’t people simply unlearn early lessons which later experiences tend to disconform? Go back to the baby’s experience once again. We can almost always learn from it. When mothers disappear, babies do not sit idly by, waiting for them to return. They search for them, they try to remember when they left them, and they use whatever considerable intelligence they possess to bring them back again. And when they regularly fail, they lose faith, not just in mothers, but in their own rational efforts as well. Thinking and planning become something like the key ring in our example above-prologues to feelings of foreboding and dread.

This is an example, I believe, of the clinical importance of a development in attachment theory introduced by Mary Main in a seminal paper (Main, 1985). In it she gives evidence for her thesis that attachment experiences influence not only later human relationships, but also developing strategies for attending, thinking and remembering as well. Thus what we later observe as a mother’s insensitivity may be instead the woman’s developmentally induced inability to attend to certain attachment related events. Likewise, an exemplified in the case example above, her inability to create and carry through a plan may be understood as an attachment history outcome, namely the underlying mistrust of thinking as a useful device for living.

This in turn suggests a clinical strategy. When treating the parent who seems unable to plan, pay strict attention to the feelings lying just under the surface whenever any plan, no matter how insignificant, is broached. For example, when the mother described above placed the call to the adoption agency, she allowed herself a short moment of hope. That call simply has to be accompanied by some thought of being able to influence events. But the hope was dashed, and what she then experienced was a sense of defeat because she could not actively produce something she wanted to very badly to happen. She had attempted to do something, and she may very well have done it simply out of loyalty and trust in her worker. She may have been thinking: "I did what you wanted me to, and look what I got for it." What she needs now is for someone to acknowledge her frustration and sense of failure. When that is accomplished she needs to be reminded that her "failure" is in truth a victory. She is a person who has learned, bitterly, that hope is a dangerous luxury. Yet nevertheless she had taken the risk of trying to plan something for her children, and that is quite a cause for celebration. If we can help her to both mourn and celebrate each of these mini-encounters with thinking and planning, we may eventually be able to lead her to value them.

Deborah Harris, MSW, LISW

"Look behind to see where we are today" is a quote from the 2001 NTI Plenary that resonated for me. Particularly in light of being asked to provide a synopsis of my work for this newsletter. As an infant mental health practitioner and trainer in a rural area, this provides me with an opportunity to take stock of the progress in this field and what has been accomplished in the area I serve.

I was fortunate to train at the Infant Parent Program, in San Francisco, which was begun by Selma Fraiberg. My tenure at IPP was an incredible inspiration and pivotal experience in my life. The training and mentoring that I received formed the foundation for my work and my supervisors continue to be "held in my mind" despite the fact that I moved back to New Mexico almost fifteen years ago. This model of reflective supervision and support is what I strive to emulate in my practice and with the staff that I supervise and consult with.

Early on, I found that innovation was initially easier in my rural area then in the urban centers. Over the past ten years we have built an infant, child and family mental health program at Las Cumbres Learning Services, in Northern New Mexico, where I serve as the Director of the Mental Health Division. The mental health division provides therapeutic services for children birth to five through a continuum of programs which include infant-parent psychotherapy, a therapeutic preschool, counseling, parenting groups, behavioral respite and a number of other family resources. The mental health team also provides services to infants and families in the Part C program at Las Cumbres. In addition to providing direct mental health services to families, the mental health staff are part of the early intervention assessment team, and consultation with the Part C team is provided regularly. An exciting out growth of this has been a number of new collaborations with other agencies where we provide training and consultation on infant mental health, with a particular focus on services in rural areas of New Mexico.

The infant mental health programs at Las Cumbres have evolved over time despite, familiar and unique barriers. Right now we seem to be entering into a particularly rich and exciting time for this work. The interest in and need for infant mental health services can sometimes feel as daunting as the initial hurdles I encountered. However, if I allow my self to slow down, take stock and imagine the ever-growing bigger picture, I find comfort in imaging a ripple effect of gently widening circles - and of the value of focusing on one child, one family, and one supervisee at a time to create change. This I consider real progress.

Deborah Harris developed the infant and child mental health division at Las Cumbres Learning Services in 1991. She currently provides supervision, consultation and training in infant mental health in multi-disciplinary settings.

ZERO TO THREE: National Center for Infants, Toddlers and Families

The term "infant mental health" means many things to many people. Some people define infant mental health as the healthy social and emotional development of babies and toddlers – a sensible and straightforward approach (but then, of course, you have to define "healthy social and emotional development"!). Some people react to the words "infant mental health" as if they were a "polite" way of saying "infant mental illness." And some people use Infant Mental Health (with or without capital letters) to refer to a field of practice with infants, toddlers, and their families.

ZERO TO THREE’s recently formed Infant Mental Health Task Force realized that before we could hope to improve practice, training, systems development, policy, and public awareness related to infant mental health, we needed to develop a definition that would be meaningful to the field (and that would provide a touchstone for efforts to communicate key elements of the definition to specific audiences in terms meaningful to them). Here is what we came up with, over a period of several months:

Infant mental health is the developing capacity of the child from birth to three to: experience, regulate, and express emotions; form close and secure interpersonal relationships; and explore the environment and learn – all in the context of family, community, and cultural expectations for young children. Infant mental health is synonymous with healthy social and emotional development.

ZERO TO THREE’s Infant Mental Health Task Force is very interested in people’s responses to this definition. Please email yours to me at e.fenichel@zerotothree.org. Meanwhile, we will be working to develop definitions of similar length for "infant mental health disturbances" and "infant mental health practice."

The August/September 2001 issue of the Zero to Three bulletin includes essays by Robert M. Emde, Deborah Weatherston, Charles Zeanah, and others that explore aspects of infant mental health, infant mental health disturbances, and infant mental health practice in the context of Early Head Start, infant/toddler child care, and other community-based programs. For more information about this issue of Zero to Three and other infant mental health resources, visit www.zerotothree.org.