A Mental Health Intervention - First Visits - Sarah's Story

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By Deborah J. Weatherston, M.A. Director, Infant-parent Center for Clinical Service and Training, Merrill-Palmer Institute, Wayne State University, Detroit, Michigan

A home visit 

First Visits

I arrived when I said I would be there – 12:00 noon, Wednesday. I knocked at the door and was first met by a barking dog, then Sarah, who led me down a steep stairway, into a small basement apartment, three rooms wide. Hidden away, unable to see the light of day, Sarah much later explained, “We live in shame.”

As my eyes became more accustomed to the dark, I noticed the baby, Rick, asleep in the corner in his portacrib. Blankets swirled around him, a pacifier close to his mouth. Jay was up and wide-awake to greet me with a ready and engaging smile. Clothed in a diaper, he was stretched out on the couch. “An easy baby,” I might have said, except that he was over two years old. He could not sit alone without support or handle toys or reach with intent. His vocalizations were indiscernible grunts. He was very easily entertained and made few complaints.

My first visit confirmed what the social worker had told me. Sarah had little help with the children and was lonely. Isolated, she had few contacts outside of the home. I asked Sarah to tell me how things were going with two small children to take care of. In the quiet of the darkened room, Sarah replied solemnly, “It’s not easy. I don’t have much help.  Mike’s not around a lot of the time, with work and school and all that. It’s mostly just me and Jay and now Rick.” “You’ve not had an easy time, Sarah,” I said, affirming what she told me. When I invited her to tell me about her children, Sarah began to talk quickly about her firstborn and his needs for her care. It seemed as if no one had asked her to talk about Jay or her experiences with him these past 2 years. She needed to talk and I needed to listen. This would be the first order of business if I was to understand what Sarah had experienced, the breadth of her capacities as well as the risks.

The baby, Rick, stirred in his bed. He awakened, but didn’t cry. Eventually , he sucked noisily on his fingers. Preoccupied, Sarah did not notice that he was awake. She continued talking about being here along, “the outsider.” “My family lives far away. The haven’t been to see us here. They haven’t seen the baby yet.” “Would you like to see them, Sarah”?” I asked. “Yea, I guess. We’re not close. I moved out along time ago. But I miss my mom. I’d like her to come. It’s lonely here.” I acknowledged that “it would not be easy to care for two babies when you’re feeling lonely.” Sarah grew pensive and drew Jay in closer to her side. Rick began to cry now. Sarah made no effort to comfort him. After a few minutes, she got up to get a bottle from the refrigerator, cold, and crossed the room to give it to him. She propped the bottle with blankets beside his head. It was a lonely and sobering picture.

Many questions danced in my head. “What made it so difficult for her to hold and feed this beautiful, healthy baby? What could explain her distance and failure to respond with a comforting response? How did Jay’s disability affect her developing relationship with 3-month-old Rick? What else was awakened as she cared for both babies in this darkened room?”

Before the hour together ended, I asked Sarah if she would like me to come back. “No one every comes to see me,” she said. “I can come next Wednesday at noon.” I gave Sarah my card, inviting her to call me if something came up before our next visit together.

Although I had not expected to meet Mike, I was pleased to see him when I arrived for my next home visit. He was curious about me and wondered how I could help them. “Sarah’s lonely, you know,” he told me. “Her family’s not here and I’m gone a lot.” “You’ve not always lived here, have you”” I asked. He spoke about happier times when they had lived far away, climbed mountains and walked along the beach. Sarah joined in, “We thought we would have our baby and stay there in the sunshine for the rest of our lives.” “It didn’t turn out the way either of you expected, did it?” I replied. “No,” Sarah said quite sadly, “not at all.” She went on to talk in greater detail about Jay’s birth. “He was overdue and I was under a lot of stress. They induced me. They made Mike go out of the room. I remember that the baby turned blue and they whisked him away. I couldn’t even see him for one day. Then, they said he was fine and sent us home.” “You had such a difficult hospital experience! How frightening for you both.” Sarah would tell me the details of her pregnancy, the labor and delivery and those first weeks at home with Jay many times again.

Mike soon left for work, saying that he would see me again. Rick was fretful and needed to be changed, but again Sarah didn’t seem to notice or respond. After I listened to Sarah talk for a while longer, about Jay and her early worries concerning his development, she was able to turn her attention toward Rick, diapered him, and then set him down on the floor. Jay also needed her help. She responded well to his tiniest overtures a grunt and a nod of his head. “Do you want some juice? Do you want to get up? Do you want to get down?” Sarah asked. She was careful in her responses to him.

The need for mothering felt extraordinary that afternoon. “Both children need so much from you right now, don’t they?” I commented aloud. ”It’s overwhelming some days,” she said, “Sometimes, I’m not sure that I can give them what they need.” I understood clearly that Sarah had to feel taken care of herself is she was to hold or feed or comfort her children. This was true for any parent who cares for a baby. I would have to create a context in which she felt held and cared for, a principle integral to the practices of infant mental health. I would arrive when I said I would be there, observe and listen carefully, and follow Sarah’s lead. I would feed her (literally or with my words) and respond with empathy as appropriate to what she told me. I would offer guidance and support related to each child’s development. As I got ready to leave, I was aware of feeling exhausted, emotionally drained. I could see that Sarah was depleted, too. “What you are doing takes lots of energy, Sarah. I will try to help you in as many ways as I can. No one should have to take care of two babies without a lot of support.” We set a time for our next visit.

Several days later, as I discussed this case in supervision, I was taken by surprise as I thought about another mother and her two children, about the same age as everyone in this household. That mother, of course, was me. I was overwhelmed by Sarah’s longings for comfort in the absence of her own family’s care and her children’s needs for her attention. I had not thought about my own loneliness as a young mother in quite a number of years.

I felt incredibly vulnerable and asked, “Was I up to this task?” I mused. This must be a question that Sarah asks every day. “Am I up to this task?” The consultant, my trusted guide, listened carefully. He helped me to separate my own experiences from Sarah’s and to return with empathy and energy and courage to offer continuing support. Sarah needed those things in abundance from me in the same way that Mike, Jay and Rick needed them from her.

As is sometimes the case in home visiting work, I arrived fro my next visit, but Sarah didn’t come to the door. I left a note telling her how sorry I was to have missed her and the children. I told her that I would call her the next day and set a time to come again. I reached her by phone. She seemed surprised that I would call, still tentative in her belief that someone would really listen or be consistent in a response. “Would you like me to come on Friday, Sarah?” I asked. Luckily, I had had extra time available. “Yes, that would be fine,” sounding somewhat surprised that I really had followed through.

Sarah's Story Part II

References

Fraiberg, S. & Adelson, E. (1977( An abandoned mother, an abandoned baby. Bulletin Menninger Clinic, 41, 162-180

Fraiberg, S., Shapiro, V. & Adelson, E. (1976). Infant-parent psychotherapy on behalf of a child in a critical nutritional state. Psychoanalytic Study of the Child, 31, 461-49).

Lieberman, A. & Pawl, J. (1988). Clinical applications of attachment theory. In J. Belsky & T. Nezworski (Eds.). Clinical implication of attachment. Hillsdale, NJ Lawrence Erlbaum Associates.

McDonouch, S. (1993). Interaction guidance: Understanding and treating early infant-caregiver relationship disturbances. In C. Zdeanah (ed.) Handbook of infant mental health. New York: The Guilford Press.

Weatherston, D. & Tableman, B. (1989). Infant mental health services Supporting competencies/reducing risks. Lansing, MI: Michigan Department of Mental health

Wright, B. (1966). An approach to infant-parent psychotherapy. Infant Mental Health Journal, 7.

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