Month: November 2016

 

 

It’s probably high time to talk about the parent infant experts I have been meeting here in NYC.  Here are just some of them:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

And there are some people I have yet to photograph: Beatrice Beebe, Clinical Professor of Medical Psychology; Tonia Spence, Senior Director-Early Childhood Services; Dr Susan Chinitz, Consultant, Strong Starts Court Initiative.  Apologies that not all have photos yet due to camera shyness or my forgetfulness.

In the next few blogs I hope I can share some of their incredible stories and the learning opportunities these people have given.  So far there have been fourteen (fourteen!) meetings with inspirational individuals.  It seems improbable that this could have happened, given that before this Fellowship I knew no-one and no-body.

With each conversation, pieces of the puzzle have come together.  In my first week I found that my head would hurt with the fast pace of the New Yorker dialogue (think machine gun fire compared to the UK tempo which is relatively steady and with actual pauses).  There were many acronyms and terms that were beyond me.  I had to keep stopping people and asking in my anxious English voice ‘Sorry the what? Pardon?’  Embarrassingly, some of the questions I had to ask were elementary like ‘What is Federal?’.. (it’s the central government of the US). ‘What is a Senator?’ (a bit like an MP) ‘What is CPP?’ (it’s Child Parent Psychotherapy and used by many with parents and babies).

It has been a joy to speak to people in so many places who all have a similar vision and have worked through the very issues that I have faced personally and professionally.  It is impossible to capture the depth of the conversations here but I have begun to notice themes and big questions in UK v US differences to practice.  This is fascinating and will form the basis of the Winston Churchill Fellowship report back to the UK. Here are some initial findings:

How to approach getting funding?   The projects in the US are so different in that many people set up not-for-profits or charities because of the underdevelopment of the public sector.  It is not seen as unusual or brave.  The paths for ordinary clinicians networking with commissioners are well trodden and less daunting.  There are also massive benefactors everywhere it seems.  It is possible to raise millions just by being in the right place at the right time!

There is something else, less tangible but one of the reasons that I chose NYC as a place to visit.  It is the source of the ‘can do’ attitude that is needed in these situations.  There is no fear as people describe setting up their projects, making the right connections and campaigning for a cause they believe in and this is typical New Yorker spirit.  Follow your heart and take risks.

ACE as screening?  ACE means 'Adverse Childhood Experiences' scale and comes from a highly influential long term study https://www.cdc.gov/violenceprevention/acestudy/.  This used a list of 10 items that have long been established as traumatic (e.g. abuse, neglect, having a parent with mental health problems or substance misuse).  It's quite easy to ask a parent to tick how many ACES they have had.  While ACE’s are common, it is an accumulation of them that is predictive.  Nice and simple.  The ACE study demonstrated an association of adverse childhood experiences (ACEs) with health and social problems as an adult.  Importantly, it ALSO suggested that maltreatment and household dysfunction in childhood contribute to health problems decades later. These include chronic diseases (e.g. heart disease, cancer).  Most of the projects and researchers I have spoken to assume the use of ACE questions.  When I ask about reaching the families we really need to reach, they often say that this is a clear identifier.

Early diagnosis in infants? This has been the biggest surprise and something to think about more.  The US diagnostic classification system 0-3 is all about catching babies early and the established optimum time for an autistic spectrum diagnosis is aged 12 months..12 months!  If we compare this to the UK, our National Autistic Society describes aged 2 as 'early'.  The average age of diagnosis in the UK is 4 ½.

My initial response to the early diagnosis issue was to recoil in horror. To label babies aged one?!  'What if you are seeing an attachment related issue???' (e.g. not something ‘wrong’ with the baby at all but wrong with his or her environment) I said.  However, Gil Foley, an expert in this area who I believe has contributed to the latest as yet unreleased diagnostic manual was very rational in his explanation.  He told to me that a diagnosis from every perspective, health cover included, meant that babies and families get the support they so badly need. Recently as I talked to Susan Chinitz,  she explained further that it is possible to ‘lose the diagnosis' with the right support.  I tried to explain that in the UK we are wary of labels as it can be hard to 'lose' them – but from what I gather this rigidity in thinking is a British thing.

I would like to say thank you to these people who have blessed me with their time and wisdom in the first few weeks of the Fellowship.   Also, thank you to the blog commentators so far- it is amazing to get your feedback.  So, what do others think of the themes that are emerging? Does this fit with your experience in the US or UK?  There are some contentious issues here, do tell me your opinion!

 

These are the scenes from the cafe inside and up along 5th Avenue as I write this.

 

It is hard to convey but watching everyone in peaceful protest: holding placards, shouting and chanting together is quite an emotional experience. This is not just today but all week.
So there are many ways of coping with the shock, sadness and anger. Samantha Bee helps us to laugh rather than cry (https://www.youtube.com/watch?v=s1SaD-gSZO4).  Another way is to devise theories and work out how we got here. How did this happen?!

If you will, allow me the following stream of thought.  The need to make a logical connection could lead us to say: Economic crisis = struggle = blame = ripe climate for inciting bigotry = electorate make bad choices.

Let's go back to the economic crisis.  Why did that happen? It's complicated but it started with the bankers.  People were rich and wanted to get richer.  Hence layer upon layer of hot air and exploitation of dreams leading to sub-prime lending. The story has similarities in the US and the UK.  It led to an absolute implosion in the system.  I am puzzled about what prevented us seeing this coming.  It seems we were all excited by the bubble.

Why the need to get richer and richer beyond all rationale? Wealth gives us ultimate power and independence.  It's a good feeling: 'I don't need to depend on others, on relationships, on community, I can do anything with money'. This need for supreme independence (over and above all other needs) would be an 'Avoidant' personality trait.  So you see where I am heading as a parent infant psychologist with this?
Going back to infancy.  As a tiny baby, when our attachment strategies are forming, this is when we could learn that in order to survive, we must inhibit out vulnerable emotions, look after ourselves, be as independent as possible.  Such early formation means these are our deepest instincts.  It's about staying alive.  Let's get this clear I am not saying all bankers had a traumatic babyhood.  Just trying understand why greed superseded common sense.  We are all a little bit responsible.

The next stage in our demise, is coined very well by Mike Baum (played by Steve Carell) in the movie, 'The Big Short'.  In despair he says: 'In a few years people will do what they always do and blame the economic crisis on immigrants and the poor'. Never has that line been more true than 2016's disastrous voting outcomes of Brexit and Trump.

The final step in trying to make logical sense of it is to ask: how were so many people in the red states of America putting all the blame for problems onto immigrants and others?  They were encouraged by somebody, yes - but only because they felt vulnerable, angry, not considered, not heard.  These are quite infantile states.  A psychoanalyst would explain 'splitting and projection' with more finesse, but I will try my best.  Splitting off the negative from ourselves and projecting it onto others, saying they are the ones with the problem, begins in babyhood.  The splitting of our carer figure into 'all bad' or 'all good' is an 'early primitive defence mechanism' (a way of dealing with being overwhelmed).  As we are just tiny we can't understand or cope with the idea that the carer who meets our needs (it's called the good breast to credit Klein) is the same one we are furious with (bad breast) when they don't get it right (as no parents get it right 100% of the time).  To cope, we temporarily believe as if they are two different people.  The theory is that adequate loving care allows us to integrate bad/less satisfactory bits and good bits so that we are able to tolerate that there is both 'good' and 'bad' in all of us.  If we stay with the primitive mechanism due to inappropriate caregiving and without being helped to mature, we are in danger of using splitting as a defence against our vulnerability in later life. For example idealising ourselves, and putting all the negative onto the 'other'.  Does this make sense? Please say if not and I can explain some more.

So could infant mental health have saved us?  Well, obviously this is a generalisation and I am incredibly biased but...YES.  Infant mental health with some of the 'privileged' who struggled so hard to get their needs met as babies and grew up to became hardened and money grabbing.  Infant mental health with the 'underprivileged' who struggled to get their needs met as babies and became ripe for reliance on racism, sexism or homophobia to make sense of their world.

OF COURSE, I am the first to admit this is over simplistic, and perhaps a little bit (okay maybe a tiny bit!) skewed towards my own particular area of work.  But remember that we have now established both through neuroscience and research (replicated and longitudinal) that attachment is the foundation for social and emotional mental health.  Like the foundations of a house, this needs to be solid, secure and safe.  The Center on the Developing Child at Harvard explains this well (https://www.youtube.com/watch?v=VNNsN9IJkws ).

As always I am very curious, what do you think?  Please don't hesitate or be shy to give me your opinion.  Post a response.

It is a really tense time here in NYC and all over the U.S. and worldwide.  It seems everyone is anxious and the tension is palpable. This is understandable, it is election night....

By the time you wake up and read this (as if...of course reading this blog is the first thing you do), we will know the outcome of what feels like the most alarming election in history.  I am having Brexit flashbacks which prevents any sense of being smug that nothing this disastrous a choice could happen in my OWN country.  For now, for colleagues in NYC and I, there is nothing to do but wait.

Back in the parent infant NY scene, there is so much to tell you that it is hard to know where to start.  Maybe some reflections following some excellent clinical teaching?  Apologies in advance for the jargon.  I have included some links to explain the psychotherapy speak.

Last week I attended a fascinating 2 day seminar in 'Mentalisation in Psychotherapy' (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816926/). This was at the New School http://www.newschool.edu/nssr/ and facilitated by Drs George Downing and Howard Steele. It helped me grasp far more about using the concept of Reflective Function (RF) http://www.tandfonline.com/doi/abs/10.1080/14616730500245906?journalCode=rahd20 and how to enhance this in parents. By the way, this is the RF manual I didn't realise we can get it online! http://mentalizacion.com.ar/images/notas/Reflective%20Functioning%20Manual.pdf.

The seminar used video a lot and I love this as it brought it far more to life for me. Howard Steele was joined by Miriam Steele. As they both spoke the room lit up and I felt blessed to be hearing this RF concept from 'the horses mouth' that is, from a people who coined this idea.

I wanted to hug them (I restrained myself). It was worth coming all the way to NY just to hear concepts explained so clearly, concisely and with such direct clinical applications that I could just imagine walking back in to see one of my families and supporting them with thinking about their own and their baby's mind.

Howard at one stage explained, 'RF is a synonym for resilience'.  I am still thinking about this.  If secure attachment in the parent is a function of the capacity for reflection about ones own life (as measured in the AAI http://www.psychologyconcepts.com/adult-attachment-interview-aai/) and this is predictive of secure attachment between baby and parent, then the heart of the success of our work with many families is about increasing RF.
This led me to question, taking away all the clever concepts, what do I believe are the essential ingredients for this? To make this simple and common sense let's imagine a mother with a new baby feeling very vulnerable and sitting in the the therapy room. This is what I think she would say:

1. Think about me, show me compassion, show me that you really care and that you can think about my possible mental state. Only then can I learn about doing this for my baby.

2. Help me stop feeling so fearful and to slow down. Help me know that my baby has a mind and to understand what is going on inside my baby.

3. Show me what I am doing okay with at the moment and build on my strengths. Right now, please don't make me feel worse about myself as I will not be able to reflect any more (my defences will come right up!). I want to know what I can do more of to get better and better at this parenting thing.

I wonder do other people agree with these as the key essentials? Are there more? I am really curious about what other parents and/or clinicians would say.

It is beautiful here in NYC.  Unseasonably warm and blue skies.  What better way to start the day than basking in the sun beside Harlem Meer?

Seminars and meetings of the first week have already blown me away and I can feel myself developing a sense of the NYC scene for parent infant work. On the one hand, it's not so far from our UK system in that there are key professionals moving and shaking (like psychotherapists, psychiatrists and psychologists) all with a clear dedication to infants.  And, as with the UK we are all setting up interesting pieces of work, developing research projects and training and offering support to frontline staff.  On the other hand, it is everything different from our system.  The lack of statutory provision in the US means plenty of room for individuality, innovation and movements toward social change - together with an essential requirement for the New Yorkers famed networking abilities.

For this networking, I am indebted to Dr Jeanette Sawyer Cohenhttp://www.edparenting.com/for taking me under her wing and introducing me to this scene.  She is actually an angel, disguised as a clinical psychologist and has an in depth understanding of this field on top of that.  So, here she is. (see also twitter @motherhoodbk) Turns out, even if Dr Jeanette doesn't know a famous parent infant New Yorker, she will know someone who does.  Thank you Dr J!