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Steps Toward Evidence-Based Practices for Parents
with Mental Illness and their Families
San Francisco General Hospital: Infant-Parent Program
San Francisco, CA
Program Description
The Infant Parent Program (IPP) is a specialty mental health program serving infants, toddlers and their families. Relationships between parents and children are the focus of treatment. IPP provides infant-parent services to families in distress through weekly in-home visits. IPP's approach includes concrete assistance, emotional support, non-didactic developmental guidance and insight-oriented psychodynamic psychotherapy. Other available services include developmental neuropsychological assessment, mental health consultation to childcare, and a one-year training program for mental health professionals focused on infant/family mental health.
Program History
IPP was established in 1979 as part of the University of California, San Francisco (UCSF). The vision behind IPP was Selma Fraiberg's Child Development Project, an infant mental health program developed at the University of Michigan, and brought to UCSF by Fraiberg herself. Fraiberg resisted the notion of a single "model" of infant mental health. She noted, "Our … conception of infant mental health would embrace a large number of models, each reflecting the unique problems of a particular infant population, each adapted to the setting in which the work is performed and the professional expertise represented in its staff." (Fraiberg, 1980). IPP continues to embody Fraiberg's vision. However, the families currently seen by IPP are different from those originally treated by Fraiberg. IPP families are often dealing with multiple stressors, not just mental health issues. IPP families are impacted by substance abuse, poverty, and immigration issues that must be integrated into the therapy offered by IPP. In addition to these changes, IPP has added two new programs: mental health consultation to childcare, and Neuropsychological/Neurodevelopmental assessment.
Funding History
Initially, a consortium of five foundations provided seed money for IPP. This was supplemented by county funds (Community Mental Health, Department of Social Services), the University of California, and physical space and in-kind resources from San Francisco General Hospital. Since its beginning, IPP has received additional funding from a number of sources including a Career Development Grant for preventative intervention from the National Institute of Mental Health as part of a mentoring effort for young professionals, money from the Children's Trust Fund of the California Department of Human Services, and state and city monies from the Department of Children, Youth and Family. Private foundations and independent donations have also provided funding over the years. As of August 2000, IPP had 18 separate funding sources.
Target Population
IPP is a program for young children determined to be at risk for socioemotional or developmental problems as a result of parent-child relationship issues. Children aged 0 to three years and their parents are eligible for IPP. The child is the "identified client" for IPP.
Theory and Assumptions
Mission. The IPP works to "protect and support the natural capacity of very young children to grow up valuing themselves, care about others and competent to contribute to society.
Program Goals. The goals of IPP are "to provide outpatient mental health services to infants, toddlers, and their families when serious difficulties exist in their relationship, and to offer consultation and collaboration to other child-serving agencies in the community around cases involving infants and toddlers."
Theoretical Orientation. Based on Selma Fraiberg's seminal work in infant mental health, IPP builds on prevention and early intervention concepts that recognize the importance of healthy infant-parent relationships and the potentially damaging effects of neglect, deprivation and early trauma for infants and toddlers. IPP seeks to intervene with children and families before problems become entrenched and impact functioning in school and the community. IPP staff practice infant-parent psychotherapy and its four components: concrete assistance, emotional support, non-didactic developmental guidance, and insight-oriented psychodynamic psychotherapy. Through concrete assistance, therapists help families identify struggles and develop problem-solving strategies. Concrete assistance may include finding resources, advocating for families, transportation to appointments, and securing childcare. As families need emotional support, therapists listen to and elicit information from parents and children, offering understanding about the struggles of families. Therapists provide developmental guidance about age-appropriate behaviors, issues and concerns to help understand children's experiences in responses to parents' questions and concerns. And insight-oriented infant-parent psychotherapy involves work with parents to clarify their perceptions of and feelings about the child - with the aim of freeing the child from misperceptions arising from the parents' past experiences.
Community Context
California Mental Health System. Like all mental health programs in San Francisco, IPP is influenced by the organization of public mental health services in California. The California Mental Health System is organized and funded at the county level. Consumers are eligible for flexible, intensive case-management services only after they have used over $100,000 in mental health services. Thus, while case-management is available for consumers with the most severe problems, there is a lack of case-management services geared toward individuals at the earlier stages of mental illness, and in particular for women with young children. As a result, potentially manageable conditions progress to more chronic and entrenched disorders that can not be well managed even with case-management that becomes available after high-end service use. Case-management is reported to be a good service once in place, but is not available to many who could benefit in both the short and long-term.
Community Strengths and Weaknesses. San Francisco is one of the most vibrant, affluent, and culturally diverse cities in the United States. It is rich in resources. However, it is also plagued with urban problems common to American cities - poverty, substance abuse, lack of affordable housing. The proportion of poor, inner-city neighborhoods to middle class and affluent ones is high. Thus, although relatively rich in resources, supply does not meet demand.
Mental Health Resources. According to providers and consumers, mental health issues are deeply embedded in local economic and social issues. San Francisco has one of the highest standards of living in the United States. There is little affordable housing available. Adults with mental illness are therefore at high risk for homelessness and substandard housing in crime-ridden neighborhoods. Substance abuse is also a major local issue. San Francisco reportedly has the highest rate of substance related Emergency Room visits in the United States. These issues impact consumers of mental health services in greater proportion than the general population.
Community Collaborators
IPP collaborates with as many individuals and systems as the family desires and as seems useful and relevant to enhanced outcomes. For many families, IPP works with DHS child welfare workers, attorneys, public health nurses, social workers, mental health case managers, pediatricians and psychiatrists. IPP has a very good collaborative relationship with DHS. Other collaborators can include school systems and childcare providers.
Methods of Collaboration
IPP collaborates with multiple providers around treatment and service planning for families. These collaborations occur formally in scheduled team meetings, and informally on an individual, as needed or urgent basis. Often, the quality of the IPP clinician's relationship with collaborators significantly impacts both the collaborative process and family outcomes.
Agency Context
IPP falls within the administrative structure of several institutions and organizations, each of which affects its operations. Eligibility for clinical services and documentation requirements are determined primarily by the county community mental health system. Funded in large part by this system, IPP follows its eligibility priorities of children and parents with no private means to pay. IPP client records and other protocols comply with standards set for all community mental health providers. The Program is part of the UCSF Department of Psychiatry at SFGH, and staff are employees of UCSF. Both SFGH and UCSF have administrative regulations which apply to IPP. Within this context of multiple affiliations, IPP has maintained its own clear mission.
Funding The Department of Psychiatry receives funding to provide mental health services to the public sector from San Francisco County Mental Health. Further public funding has been secured by IPP through contracts for particular projects.
Agency Characteristics. As noted above, IPP staff are employees of UCSF. IPP has approximately 16 employees, including a Director, licensed clinicians, and up to ten trainees. The IPP staff consists of clinical psychologists, a developmental neuropsychologist, a family therapist, social workers, and a consulting psychiatrist.
Program Model: Services and Interventions
IPP has several components: 1) day and evening in-home infant-parent psychotherapy, 2) consultations to childcare agencies to improve services to children, 3) developmental neuropsychological testing, 4) assistance to one classroom working with SED children, and 5) training of clinicians. This paper focuses on the first of these listed programs - in-home infant-parent psychotherapy. Infant-parent psychotherapy focuses on the relationship between parent and child, emphasizing the development of empathy for and understanding of the infant's experience so that parents may come to respond in ways that further enrich the infant-parent relationship and the child's social and emotional development. IPP clients work with a single clinician who is closely supervised by a clinical psychologist with extensive experience in infant-parent psychotherapy. Because clients referred to IPP have multiple stressors and vulnerabilities, IPP clinicians are often play a case-management role in which they access and coordinate needed services that support the viability of their therapy. They also provide concrete assistance as needed.
Evaluation
IPP systematically evaluates its services from a variety of perspectives: the families' served, referral source (e.g., DHS), and the IPP clinicians. They track family characteristics, family satisfaction, and family outcomes.
Demographics. Most IPP families have single mother heads-of-household, with children ages zero to three. Grandmothers head eight percent of all IPP families. During fiscal year 2000, 31% of clients (parents and children) were African American, 21% Hispanic, 17% Caucasian, 9% Asian/Pacific Islander, and 1% American Indian/Alaskan Native. Twenty-one percent of clients identified with more than one ethnic group.
Referral Source. Families are referred from pediatric providers, nurses, social workers, emergency room staff, and social service workers.
Diagnoses. Parental diagnoses are often not recorded in the Program, as children are the identified client. However, IPP staff report that the majority of parents and approximately half of all children have a diagnosable difficulty. Intake information indicates that approximately 20% of parents meet the criteria for serious and chronic mental illness, including Depression, Bipolar Disorder, Schizophrenia and Personality Disorders.
Co-occurring Disorders and Issues. Ninety-five percent of families experience co-occurring disorders, including substance abuse and some medical disorders (e.g., HIV/AIDS). Parents working with IPP often have histories of trauma and/or domestic violence, and are confronted with multiple environmental stressors such as poverty, lack of adequate housing and involvement with the legal system. While most parents have physical custody of their children, about half of the families seen at IPP are involved with DHS/child welfare because their children have been deemed to be at risk of neglect or abuse.
Family Outcomes. IPP also measures therapeutic progress by using pre- and post-treatment assessment on the Home Observation for the Measurement of the Environment (H.O.M.E.). This instrument is scored by IPP clinicians and provides assessment of parental functioning. IPP also tracks the number of children who are successfully reunified with their parents each year, and who are safely maintained in the home six months after reunification.
Family Satisfaction and DHS Satisfaction. IPP distributes a Satisfaction Questionnaire to all families served, and has polled DHS workers in the past. Responses to the family satisfaction survey indicate that 85-100% of families served each year have a positive experience with IPP. In addition, although over half of IPP families are mandated for services, and are reluctant to participate, year after year, at the end of treatment, 100% say that they would refer a friend. Polls of DHS workers indicate that that DHS finds IPP a responsive and valued resource.
Client Path
Clients are referred to IPP from multiple providers concerned with children and their parent-child relationship - pediatricians, nurses, social workers, and child welfare workers. As part of the referral, an extensive intake assessment is done over the phone. This assessment covers the reasons for the referral (the "worry" or concerns initiating referral), the parents functioning, and medical history of the infant if relevant and available. In addition, IPP assesses whether the parent knows about the referral and what their thoughts and feelings are about IPP involvement. Together, the IPP staff and the referral source develop a "Recommendation for a Service Request" for IPP services, and a plan or disposition that outlines an agreed upon plan for IPP to make contact with the family. This plan may call for IPP to contact others involved with the family prior to contacting the family. Names of other important contacts are gathered, and releases arranged. Often, there is a waitlist. IPP makes recommendations for services and supports that may be helpful while clients wait.
When there is IPP availability the referral source is contacted again to assess client need and interest, and "best" plan for initiating contact with the referred client. An IPP clinician is assigned and supervised initially about contacting the client, and then continually about clinical work with the parent and child. Clinicians work with parents to develop an understanding about what IPP is and can do, how the IPP clinician might be useful to the parent, and what should be the focus of treatment. Central to this is an assessment of the parent's concerns and hopes for their relationship with their child and their own future. A formal assessment and Plan of Care is developed within 60 days (as required by Community Mental Health). Both clients and clinicians must sign the plan of care. On-going assessment of progress, parent concerns, clinician concerns and clinician usefulness is central to IPP's relationship to the parent.
A Success Story
This story highlights a cooperative relationship between IPP and DHS, and exemplifies the strengths of IPP's intervention approach. Joe is a fifty-year-old man with features of Narcissistic and Borderline Personality Disorder. He has a one-year-old daughter, Laura. Laura had been in foster care for most of her life when Joe was referred to IPP. Laura's mother has a diagnosis of paranoid schizophrenia, is not involved in parenting Laura, and is not an IPP client.
Joe was referred to IPP by DHS as part of a required reunification plan. It was apparent to the IPP clinician that, although DHS has made the referral to IPP and presumably had an investment in Joe's learning how to parent his daughter, DHS expected the intervention to fail. DHS believed that Joe's characterological difficulties would prove an insurmountable obstacle to his forming an adequate parenting relationship with his daughter. Joe was similarly suspicious of DHS. He did not trust their motives or intentions with respect to reunification. This suspiciousness initially extended to the IPP clinician. The IPP clinician advocated for full disclosure of communication between DHS and IPP as a condition of treatment. DHS was resistant at first, but was ultimately persuaded that this was critical to an effective therapeutic relationship between the clinician and Joe.
Joe's limitations were apparent to the IPP clinician; however, he supported Joe's wish to reunify with his daughter and to be a good father. The clinician focused on trying to "give words" to Laura's experience and to translate for Joe, Laura's attempts to make her wishes and feelings known to her father. Although this process was unfamiliar and awkward for Joe, over time he began to value the clinician's input and seek the clinician's suggestions. Successes solidified this approach. When suggestions were not useful, they provided an opportunity for a shared sense of the difficulties of rearing a toddler. Over time, Joe was able to develop a sense of who his daughter was, an empathy for her experience, and the ability to search for ways to respond to her. Additionally, as Joe felt increasingly understood by the clinician, he was able to express his doubts and worries about parenting a toddler in addition to his wishes to do so. The clinician was then able to help Joe to tolerate and normalize these feelings without minimizing the importance of them. Visits increased from several hours each week to overnight visits.
DHS was initially skeptical of the progress described by the clinician, but over time came to see that Laura thrived in Joe's care. In the same way the IPP clinician worked with Joe to normalize and tolerate his doubts, the IPP clinician worked with DHS to tolerate their doubts about Joe. Joe eventually regained custody of Laura and DHS closed the case. As Joe's security and ability as a parent increased, meetings with the IPP clinician occurred less frequently.
Factors essential to the successful collaboration between IPP and DHS on behalf of Joe and Laura included: 1) Sharing a common goal or developing a shared goal as a first order of business; 2) establishing and maintaining good communication and clear expectations; and 3) developing a mutually-respectful and trusting relationship between the IPP clinician and DHS. This relationship and respect for each other's efforts were critical, as IPP and DHS did not always agree about how to proceed.
Challenges
At the client level, most families struggle with finding safe and affordable housing in San Francisco. Families have limited childcare options, and respite for parent and child is costly and difficult to secure. Many families lack social supports in their communities, resulting in isolation. IPP is often challenged to create and support an array of services for families, including individual treatment, after school programs, and childcare. Maintaining IPP funding (all 18 sources!) is time consuming and limits direct family services. For trainees and staff, creating a cohesive treatment experience is challenging; there is no "normal" day, and the circumstances of families are often fragmented and challenged by economic and physical realities. Treatment needs to be continuous, responsive to the shifting needs of families and integrated with other services the family is receiving. Clinicians need support in order to tolerate the inability to bring about changes in the social and economic realities faced by the families they serve while simultaneously staying focused on the aspects of the infant-parent relationship they can impact.
Next Steps
IPP would like to have a therapeutic nursery to serve preschoolers who are having difficulty and their families. This would involve an expansion beyond the current population of children birth to 3 years. In addition, IPP lacks enough bilingual therapists to work with the large multicultural population in San Francisco. Finally, IPP is continually striving to enhance collaboration with other institutions and agencies in the community to exchange information about services that may be of use to the families they all serve.
Logic Model: San Francisco General Hospital: Infant-Parent Program
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