The Michigan infant mental health home visiting model

Selma Fraiberg's pioneering work with infants, toddlers, and families over 40 years ago led to the development of a field in which professionals from multiple disciplines learned to work with or on behalf of infants, very young children, their parents, and the relationships that bind them together. The intent was to promote social and emotional health through enhancing the security of early developing parent–child relationships in the first years of life (Fraiberg, 2018). Called infant mental health (IMH), practitioners from fields of health, education, social work, psychology, human development, nursing, pediatrics, and psychiatry specialize in supporting the optimal development of infants and the developing relationship between infants and their caregivers. When a baby is born into optimal circumstances, to parents free of undue economic and psychological stressors and who are emotionally ready to provide care and nurturing for an infant's needs, an IMH approach may be offered as promotion or prevention, with the goal of supporting new parent(s) in developing confidence in their capacity to understand and meet the needs of the tiny human they are coming to know and care for. However, when parental history is fraught with abandonment, loss, abuse or neglect, or the current environment is replete with economic insecurity, threats to survival due to interpersonal or community violence, social isolation, mental illness, or substance abuse, the work of the IMH therapist may require intervention or intensive treatment and becomes more psychotherapeutic in nature. The underlying therapeutic goal is to create a context in which the baby develops within the environment of a parent's nurturing care without the psychological impingement that parental history of trauma or loss or current stressors such as isolation, poverty, or the birth of a child with special needs, can incur.     

The role of the infant mental health therapist in the framework of preventive mental health

The role of the infant mental health therapist is differentiated from that of other infant interventionists as being a secondary prevention treatment approach employing the techniques of long-term, insight-oriented psychotherapy. Such an approach encourages the caregiver to recall his or her own childhood experiences and conflicts to gain an understanding of feelings directed at his or her own baby. The prevention models of Caplan are considered as is the development of the work of Fraiberg and her colleagues.     

Relationship assessment in infant mental health

Infant-caregiver relationships are the crucial context for infant development and psychopathology. Considerable evidence suggests that infants may construct qualitatively different relationships with different caregivers. For these reasons, infant-caregiver relationships should be a centerpiece of assessment in infant mental health. We advocate assessing infant relationships with all important caregivers in both clinic based and naturalistic settings. In this article we describe our approach, which attends both to the external component of the relationship, behavioral interaction, as well as the internal component of the relationship, subjective experience. By integrating results from assessments of these two components, we determine both level of relationship adaptation and the specific domains of strengths and weaknesses. © 1997 Michigan Association for Infant Mental Health     

The training of community mental health clinicians as infant specialists

This article describes the training program and collaborative effort between the Department of Mental Health, the Child Development Project at the University of Michigan, and community mental health agencies. The in-service training is described with special attention to content and process, including the role of case supervision. The effect of the training program as a catalyst to service development is noted.     

Making the case for dedicated infant mental health services

SUMMARY

This paper seeks to demonstrate the case for establishing dedicated Infant Mental Health Services. It is argued that the 0–3 age-group is not well served by the current arrangement for the provision of mental health services along child/adult lines, and falls between these two stools. It is further argued that priority should be given to services for this group because of the immense potential of early intervention programmes. The nature and ethos of such services are discussed, and it is suggested that the time is now ripe for Infant Mental Health to be given institutional recognition as a distinct specialism in its own right.     

The father's role in the facilitation of infant mental health

Many recent studies have focused on the nature and significance of father-infant relationships. These studies show that men are as capable of behaving sensitively as women are, although cultural sex-stereotypes usually prevent them from assuming a prominent role in child care. Nevertheless, most infants become attached to both their parents during the first year of life although they tend to establish primary relationships with their primary caretakers. During the second year of life, fathers encourage boys to focus attention on their fathers. This may facilitate the development of gender identity. In addition, the security of the father-infant attachment relationship may affect the infant's orientation to novel social situations. Fathers also affect infants indirectly via their influence on the children's mothers.     

Modeling as an infant mental health intervention

Within the context of family therapy focused on the behavioral problems of a six year old, several observations of inappropriate interactions between the parents and their infant concerned the therapist. In consultation with an infant specialist it was decided that the therapist would avoid identifying parent-infant interactions as a further problem and would, instead, begin to model appropriate interactions during the on-going therapy sessions. The infant, initially passive, began to respond to the therapist and gradually the parents became more appropriate in their interactions with their infant. It was concluded that the modeling process minimized the stress and eliminated the need to process feelings of anger and guilt often associated with professional identification of family problems.     

Tuning into the psychotic wavelength: Psychoanalytic supervision for mental health professionals

In this paper, material is presented from supervision groups run for mental health professionals in different mental health settings. I will argue that a psychoanalytic framework, which puts the transference and countertransference at the centre of clinical practice, offers an important model for thinking about psychosis and psychotic means of communication. When staff are able to ‘tune in’ to their patients' communications it can help to change a patient's monologue about his/her delusional world into a meaningful dialogue about their emotional world.     

Perceptions of infant boys' behavior and mental health: Relation to infant attachment

Two studies were conducted to determine the impact of infants' attachment classifications and behaviors on naive adults' impressions of their behavior and mental health. In Study 1, three groups of 44 adults viewed a videotape of episode 8 of the Strange Situation for either an avoidant, a resistant, or a secure male infant. After viewing the videotape, they made judgments about aspects of the infant's mental health. Adults viewed the resistant baby as less socially competent and more negative in affect than the other two babies and the secure baby as the least independent of the three babies. Parents rated babies as more intelligent than did nonparents. In Study 2, 15 parents were matched on race and gender with 15 nonparents. All adults viewed a videotape of the reunions of two secure, two avoidant, and two resistant male infants. Avoidant babies were viewed as more socially competent and independent than secure babies and the C2 baby was viewed as the least intelligent, least independent, least socially competent, and most affectively negative of the infants. Results are interpreted as underscoring the need to educate parents and paraprofessionals about the importance of infant distress and physical contact with parents.     

Competencies for infant mental health therapists: A survey of expert opinion

We report on data provided by a nationwide panel of 23 infant mental health (IMH) experts who provided numerical ratings of the relative importance of 143 competencies desirable for licensed mental health therapists working with infants/children birth to 5 years of age and their families/caregivers. The competencies were developed based on prior state and national efforts and our own experience in training IMH therapists. The competencies were grouped conceptually into seven areas: (a) Normal infant and toddler development; (b) Atypical development (perturbations in development); (c) Emotional/behavioral disorders in infants and young children; (d) Assessment; (e) Intervention; (f) Community resources and referrals; and (g) Organization, communication, and collaboration. We calculated means, SDs, 95% confidence intervals to rank order each competency. We conducted reliability analyses and tested for mean differences in ratings for the seven areas. Interrater and intraclass correlations were modest, likely the result of restriction of range in the ratings. The seven areas showed high levels of internal consistency and, with few exceptions, did not significantly differ in the means of their ratings. The utility of the competencies are discussed as a framework for training and professional development for IMH clinicians.     

The growth and development of an infant mental health program: An integrated perspective

This article details the development of the Infant Mental Health Clinical and Training Program at the University of Colorado School of Medicine from 1976 to the present. The article discusses the clinical sites where the program takes place, which include the Neonatal Intensive Care Unit, outpatient child psychiatry clinic, and day treatment programs. Trainees from several mental health disciplines participate in the program, including predoctoral psychology externs, interns from the Clinical Psychology Internship, residents from the Child Psychiatry Training Program, and postdoctoral research fellows in developmental psychopathology. Recently, the Infant Mental Health Program has also been able to offer its own training positions. The philosophical models of clinical service and training are outlined. The article concludes by looking at future directions and challenges for the Infant Mental Health Program. © 1997 Michigan Association for Infant Mental Health     

Women's mental health during pregnancy influences fetal and infant developmental and health outcomes

Women's mental health during pregnancy has important implications not only for the well-being of the mother, but also for the development, health, and well-being of her unborn child. A growing body of empirical evidence from population-based studies suggests that two indicators of women's mental health during pregnancy--psychosocial stress and social support--may exert a significant influence on fetal development and infant birth outcomes, such as birth weight and length of gestation, even after controlling for the effects of established sociodemographic, obstetric, and behavioral risk factors. This paper describes the role of three major biological systems involved in the physiology of pregnancy and stress physiology: neuroendocrine, immune/inflammatory, and cardiovascular systems. These systems have been hypothesized to mediate the effects of maternal mental health on fetal developmental and health outcomes, and a central role has been proposed for placental corticotropin-releasing hormone in this process. However, not all women reporting high prenatal stress and/or low social support proceed to develop adverse birth outcomes, raising the question of the determinants of susceptibility/vulnerability in the context of high stress and/or low social support. In this context, the role of race/ethnicity and genetic predisposition are discussed as two promising avenues of further investigation.     

A transgenerational conceptualization of psychosomatic distress during pregnancy: Implications for infant mental health

A conceptualization of psychosomatic distress during pregnancy is suggested, stemming from a developmental psychopathology framework and based on contributions from the psychosomatic and attachment literature. A link is suggested between psychosomatic distress during pregnancy, patterns of representational activity, and transgenerational risks of relationship disturbances. Developmental transformations during pregnancy are reviewed, with an emphasis on the vicissitudes of integrating internalized relationships with a person's family of origin. Psychosomatic theory is used to generate hypotheses about the representational activity of mothers who experience psychosomatic distress during pregnancy. Attachment theory is used to discuss the link between maternal representational activity and the transgenerational transmission of relationship patterns. As an example of psychosomatic distress during pregnancy, relevant literature on severe nausea and vomiting during pregnancy is reviewed, and clinical vignettes are presented to illustrate how this condition may sometimes be a forerunner of mother-infant difficulties.     

The importance of cooperation among child health professionals and agencies in an inner city infant mental health service

The clientele of our Infant Mental Health Service mainly consists of unwed teenage mothers and babies beset by medical, social, and psychological complications. Efforts to help these families usually extend beyond the caregiver-infant dyad and may include working with grandmothers, pediatricians, and high-risk neonatology nurses, as well as outside social agencies and foster homes. Thus, cooperation among various disciplines, departments, and agencies'is indispensible in infant mental health practice. Problems and successes in building and maintaining such cooperation, its impact on clinical practice, staff work, administrative functioning, and therapeutic strategies are discussed. Clinical examples illustrate the nature of the cooperation.