In part I (which was posted on November 3rd, 2010), I set the stage by briefly describing and providing examples for the following continuum:
worldview <==> ideology <==> methodology <==> intervention
I like to keep this continuum in mind because it challenges me to consider such things as worldviews, ideologies, and methodologies when hearing about new information on treatment or intervention programs. As Jeremy Holmes writes in the introductory pages of his 2010 book Exploring in Security: Towards an Attachment-informed Psychoanalytic Psychotherapy …
Any activity, whether intellectual or practical, is informed by an ideology: a set of more or less conscious underlying guiding beliefs and principles. These taken-for-granted facts and theories form the seedbed from which new ideas arise, but if unexamined, also trammel creative thought.
Lets move along by looking at a series of bullet points taken from my notes as I listened to the information presented during Dr. Ippen-Ghosh’s workshop. My comments within quotes are in brackets.
- Susan Herrera and Mary Hendrix introduced Dr. Ippen-Ghosh. It was during these introductory comments that we learned that New Mexico looked at a home visitation program developed by David Olds. This was a name I was not familiar with. A Google search (after the fact) turned up the following blurb over at the Robert Wood Johnson Foundation web site:
Motherhood can be daunting for low-income, first-time mothers. In 1977, David Olds, Ph.D., began developing a nurse home-visitation model designed to help these young women take better care of themselves and their babies. Nearly 30 years later, with support from the Robert Wood Johnson Foundation and others, the “Olds Model” has blossomed into the Nurse-Family Partnership, as this Grants Results Special Report illustrates.
- You can click on this link to access the grant report mentioned (in PDF format). Apparently the Olds Model is very expensive to implement mainly because it employs nurses. Here in New Mexico the Olds Model was passed over because it is simply too expensive to implement and New Mexico is a poor state with limited funds. Here we see an economic reality or worldview placing constraints on the types of interventions that can be employed.
- Ippen-Ghosh started out by saying that trauma can (and often does) adversely affect early child development. In fact, trauma affects both parents and their children. Ippen-Ghosh pointed out that in our western culture, the link between trauma and development is not always recognized. Ippen-Ghosh then stated: ”Trauma is an epidemic in our country.” She continued, “One out of five children in our culture is exposed to domestic violence.” This is a staggering statistic. However, Ippen-Ghosh did not offer up any explanation for where this epidemic is coming from or what continues to drive it.
- Ippen-Ghosh told us that there are a number of different programs designed to treat trauma in children. She said that the National Child Traumatic Stress Network has looked at many of these programs and have found that they do share core beliefs. Here’s the continuum that she presented to us:
core concept <==> objectives <==> practice element <==> skill
- Interestingly, this continuum expands the continuum I presented above but starts below the levels of worldview and ideology.
- Ippen-Ghosh simply stated that mother and child functioning is intertwined. She then asked the following questions: “How do we get to objective using a model or core concept? What treatments do we put into place?” Ippen-Ghosh then gave us these trauma factoids:
- trauma disrupts the regulation of emotion that takes place within the mother-infant attachment relationship
- trauma generates trauma reminders or triggers that take place at the level of the body (a la the work of trauma expert Bessel van der Kolk)
- trauma generates relationship difficulties for life
- we need to teach kids to regulate emotions, but …
- … young kids are more body-based than mind-based, so teaching programs alone will not work here
- regulation is dyadic, it takes place within a connection to others, others who can “scoop you up in their arms,” rock you, sooth you, bring down harmful hormones like cortisol
- Ippen-Ghosh then told us about a home visitation program that was tried in Hawaii but failed miserably. Apparently after the program got underway, 62% of the participants ultimately decided to terminate services. Twelve percent never got as far as the first home visitation. Ippen-Ghosh listed the following factors as having played a role in the poor outcome:
- ethnicity
- socioeconomic status
- environmental context
- To me, it seems as if such things as worldview and ideology are in fact creeping into the picture here.
- Ippen-Ghosh gave us an example of where a cognitive-behavioral technique designed to bringing about relaxation (called the “tin soldier”) simply did not work with a particular population located in Alaska. She told us, “Here we see a practice element [e.g., an intervention] not fitting with the beliefs and practices of a particular population.”
- One of Ippen-Ghosh’s slides made the following claim: “When affect is charged we are more likely to loose perspective [and persepctive-taking] and go back to what we ‘know.’ ” I take “go back to what we know” to mean that we go back to such things as Bowlby’s Inner Working Models, which, in turn, are held by worldviews. In essence, Ippen-Ghosh is telling us that interventions and worldviews must be matched to a certain level for there to be therapeutic success. Here’s where the story gets interesting.
- At this point, Ippen-Ghosh mentions David Olds home visitation work (mentioned above) in New York. What Olds found was that domestic violence was a huge factor. Forty eight percent of the mothers Olds worked with reported some level of domestic violence. Suffice it to say that domestic violence is a huge problem here in New Mexico. Olds found that his home visitation program had no therapeutic effect as far as treating domestic violence. And as mentioned above, domestic violence can (and often does) lead to negative developmental outcomes.
- Using Olds work as a background, Ippen-Ghosh asked us, “Does your sample population have more risks, like, poverty, hunger, or even domestic violence?” Ippen-Ghosh then went on to suggest that an intervention, like home visitation, may actually elevate these risks. As an example, she said that in cases of domestic violence, the perpetrator may become angry that “outside eyes” are coming into the home. She also told us that home visitations may concretize in the eyes of a child the fact that the primary caregiver is not a “good protective shield.”
- At this point, Ippen-Ghosh asked the audience a series of thought-provoking questions:
- Why is there a problem in the home?
- What can be done?
- Does the family agree with your assumptions?
- Does your sense of “normal development” agree with the beliefs held by the family concerning normal development
- OK, recall from Part I my idea (which I pulled from an edited volume on the subject) that if you divorce development from God’s purpose, and then impose any developmental framework or pattern as being “normal,” your approach could be viewed as playing God. As Ippen-Ghosh pointed out to us, many families she has worked with will say something along the lines of, “It’s God’s will that he or she be that way, and it will be God’s will that changes things … we simply have to wait and see.” Here’s an alternate view.
- Ippen-Ghosh told us about another pattern that she typically sees. A parent (or possibly both parents) will say something along the lines of, “Fix my kid, not me. I’m not the problem, the kid is.” When I worked as a therapist in a RTC (residential treatment center) setting, I did have a father who came in and said to me point blank: “This place better fix my kid because he’s really broken and there’s nothing more that I can do.” Interestingly, from an attachment theory perspective, Ippen-Ghosh told us that in both cases the child does not know where to go for protection and attachment. In other words, in the former case, God is a tough attachment figure for a child. In the latter case, the self (e.g., where the problem and potential solution is located) equally is a tough attachment figure (although both can act as surrogate attachment figures if need be). In essence, Ippen-Ghosh challenged us to ask the age-old attachment question, “When a child becomes fearful and in need of help and care, what belief does the family hold as far as where that child should go to find help and care?”
Without a doubt, home visitation will challenge the answer to the above question on some level because home visitation tends to send the message that help and care must come from the outside by trained experts. Our Foundation has supported two different home visitation programs in the past: one uses paraprofessional volunteers, the other masters level licensed therapists. The executive director of the former program said that they decided to go with a paraprofessional model because it tends to buffer the home visitation message that only outside experts can deliver help and care. Keep in mind that the Olds Model tends to send the message that only nurses can provide help and care.
We’ll stop here for now and pickup again in Part III. Hope to see you there.
