Where does the heart belong in relationshipbased care

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Where does the heart belong in relationship-based
care?

• Jon Korfmacher
• Erikson Institute
• Chicago, IL

2006 Institute Infant Toddler Specialists of
Indiana
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Examining program implementationPutting a
window on the Black Box
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Meaning
Relationships
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Why relationships?
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Why relationships?
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Why relationships?
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How do we think about helping relationships?

• Facilitative
• Means to an end
• Supportive
• Reduce stress and isolation
• Corrective
• Infant Mental Health orientation
• Goal-oriented partnerships
• Early Intervention, Child care settings

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How do we measure relationships?

• Paper and pencil measures
• My home visitor is someone I can rely on
• I have a great deal of respect for my home
  ..visitor
• Problems
• Reductive ? I like my home visitor
• Skewed ? I really like my home visitor

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Example EHS National StudyHelping Relationship
Inventory (5 point scale)
Avg 4.78 Std .74
26 month Parent Interview (n507)
(home visiting program only)
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EHS National StudyHelping Relationship Program
Satisfaction
Helping Relationship
Satisfaction with services
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Other ways of knowing
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Helping Relationship Study
Doula Program
Infant Mental Health Program
Paraprofessional Support Program
EHS Center-based Program
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Sources of Information

• Interviews
• Semi-structured
• Multiple times
• 30 - 60 minutes long
• Tape-recorded Transcribed

• Areas of Focus
• Motivation for joining
• Initial impressions
• Description of relationship
• Change over Time
• Similarities Differences
• Involvement of Family
• Conflicts Disagreements
• Ways provider is helpful

• EHS center-based
• Focus groups

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Ex Paraprofessional

• ...Its very comfortable. I feel relaxed
  when Im around her. Im not nervous. I feel like
  Im home...I feel like shes somebody that I can
  talk to without having to have my guards up or
  anything. Shes very understanding... So we have
  a good relationship and I like that because its
  like family oriented. Im like OK, I have
  another family....Its like Im going to some of
  my relatives house. Thats how the relationship
  is with her...she calls me when I dont visit.
  And she comes to the office and bugs me and Ill
  be like Girl, leave me alone! I like it because
  she makes me smile. I like her a lot.

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Ex Doula Program

• I believe she's starting to trust me more
  because her mother will come up the stairs
  Natalie have a discharge And I'll look and say,
  Okay. And Natalie would just look, look at her
  weird, and say, "Why did you tell her that?" So
  now Natalie calls me and says, "You know, I'm
  having a discharge. What do you think it is?" Or
  this and that. So now, it's like I believe the
  trust is going.

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Ex Mental Health Therapist

• When she was feeling least accepted by me or
  confused by me or worried about our relationship
  or worried about how I was hearing her or evenif
  I asked her a question that she was glad to be
  asked but also kind of incredulous that it
  mattered. So like How are you thinking about
  that?...I think as much as she liked me to
  wonder about that, she couldnt believe that I
  really cared...that she would start laughing and
  rolling her eyes. And I think that she always
  feels so humiliated and she does a good job of
  pushing people away and humiliating them. But in
  the last few sessions that has really changed
  dramatically and she has not been doing so much
  laughing or eye-rolling at all, and in the past
  session it was the first time in a long time that
  she did not mention not coming back.

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What about child care?

• Caring community of learners as part of
  developmentally appropriate practice
• Caregivers/Teachers form strong attachments with
  children in their program
• Parent-Caregiver relationships can be sources of
  tension
• Ex Staff talk about having just enough of a
  relationship with parents

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Themes Personal vs Professional

• Viewing relationships in personal terms
• Need to make pieces of yourself available
• Used friend and family terms to describe alliance
• Sense of comfort and familiarity
• Contrasts with professional development
• Tension noted occasionally in interviews
• Not seen with IMH therapists
• Child care staff warned about slippery slope

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Doula Personal Connection

• Doula
• But I think the more clients I get to, the
  more I realize you have to give a little to get
  from them. So sometimes you are sending a little
  piece of yourself. You have to share to let them
  realize that you are not an alien, you're not by
  yourself, there's someone that understands.
• Doula
• I think before my approach was although I cared
  for these clients and I made myself available, it
  was also more of an adult authority figure,
  whereas with (her) it was like a big sister. Big
  sisters don't have too much authority, they are
  just there for you when you need them.

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Paraprof Family member

• Young Mother
• She just took me in just like...I feel like
  she's a second mama, I'm like a second daughter
  to her. She'll call me. She'll say
  everything..."Girl, guess what happened?" I say
  "What happened, momma?" We just talk.
• Young Mother
• Um, like a friend, you know, like a close
  friend but also like a mother-daughter thing, you
  know, a grandmother kind of thing.
• Young Mother
• You know how grandmothers like to lecture
  you?

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Paraprof Comfort Familiarity

• Family Advocate
• I can go and I can sit back and you know, I
  can sit back and we can just talk. And then
  sometimes after we find ourselves on a totally
  different subject. And I'm like "Oh girlfriend,
  you be doing my part and get over here so we
  could do this." So it's like so comfortable and
  relaxing. So the times spent with her it's like I
  could sit and hang with Tammy.
• I'm trying to keep it sort of balanced. I want
  to be there. I want to be your friend, your
  mother, whatever you need me to be. But I don't
  want to overstep my professionalism either.

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Therapist Personal Connection

• Therapist
• In her becoming comfortable with me, shes
  becoming afraid and that the closer you get with
  somebody maybe the more likely you would want to
  be to discuss deeper issues, and that she still
  is resistant against wanting to go any deeper so
  shes kind of keeping me at a friendship arms
  length or distance.

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Therapist Personal Connection

• Therapist
• She started to become very interested in details
  about my life, who I am, do I have children... I
  think I'm becoming a person to her. but I'm
  negotiating that, because... basically she's the
  focus of the treatment and I want to be most
  helpful to her. Basically the reason why we may
  not be talking about my own personal information
  is that it may take up too much space and then
  the focus would be on me, and I really want the
  focus of treatment to be on her.

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Themes Intimacy

• With familiarity comes intimacy
• Early childhood is a time of intimacy
• Home visiting can be an intimate experience
• Attending a birth is an intimate experience
• Providers and mothers talked about love
• Doulas and Paraprofessionals freely discuss love
• Therapists more circumspect
• Child care staff love the children they care for
• Hard to work here without ending up loving them

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Intimacy love in the relationship

• Doula It labor and delivery almost made me go
  against my big rule to never cry. And I was
  just like okay, I just couldnt believe it, and
  after everything was over she hugged me so tight
  and she says, I love you. And I said, Oh I love
  you
• Mother Ive been knowing her for the longest
  and thats just how we communicate, but shes
  just like a friend. Weve been through like
  everything, labor was really hard, but she was
  there for me though. I actually asked if she
  would be my babys godmother. Thats because I
  feel that close to her now.

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Therapist Use of Love

• Therapist
• When I get there it seems like she's excited to
  see me. The kids are excited to see me. She has
  let me in a lot more than she did in the
  beginning but she uses me and she uses the
  treatment to talk about things that are going on
  with her.
•  
• I like her a lot. I like to be in the house. I
  love to be around the kids. I love to be around
  her. I enjoy the relationship that we have.

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Aside What is love?
Affection based on admiration, benevolence, or
common interests
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Aside What is love?
Strong affection for another arising out of
kinship or personal ties
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Aside What is love?
Unselfish loyal and benevolent concern for the
good of another
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Aside What is love?
Attraction based on sexual or romantic desire
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Aside What is love?
What does it mean to love your client?
What happens when you are disappointed by
someone you love?
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Costs of the personal relationship

• Can bring up difficult feelings
• workers feel taken advantage of
• mothers feel workers take them for granted
• workers take mothers problems personally
• workers feel unappreciated

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Paraprof Take problems personally

• Family Advocate
• It really hurt me that she wasnt back in
  school. Because I felt like our relationship was
  much better than thatThe beginning, I was happy
  to know she was my client. She was the happy
  client. And now, I just get frustrated because
  she's not in school, she's not working. She's
  getting lazy. And it really pisses me off
  actually, you know? Because it seems likes she's
  going backwards when she needs to be going
  forward.

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Paraprof Taken for Granted

• Young Mother
• Shell go visit other clients before she go
  visit me, cause she thinks Ill understand
  cause I know how sometimes they get busy. And I
  feel like, no, I wont understand.

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Doula Underappreciated

• Doula
• When you get so up close and personal you have to
  really put yourself out and give back and realize
  they're going to do what they want to do.
• When you think that you've made an impact on
  them, that might not be the impact. It might for
  you but not for them. When I saw her I said
  Man, I thought I was really getting down with
  her, but I've never seen no expression like that
  coming out of herIt wasn't my doing. It was the
  carrier. She really needed it at the time. But
  I think that's what makes a difference.

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Costs of the personal relationship

• Workers may react as friends, not helpers
• Express anger at mother
• Ignore mother until she gets her act together
• Dealing with conflict
• Paraprof Alternate avoidance with accusations
• Doula Discuss disagreements
• Therapists More willing to deal with hostility

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Paraprof Avoiding conflict

• Family Advocate
• She always ask meWhy you don't give me no
  opinion?" "Because for one reason. If I give
  you an opinion and it's wrong, then, you're gonna
  dislike me because you're gonna say, (She) gave
  me the wrong opinion.'"

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Paraprof Anger disappointment

• Family Advocate
• If I put a little authority in my voice, she
  did it.I had come over and the baby's pamper
  would be soaking wet. So I'm like, "Tammy,
  what's going on?And I say, "Get up off your ass
  and put'em on a pamper!" And that's how you have
  to talk to her.
• Family Advocate
• I just tell her, "I'm just gonna block you
  out." And that's the way things are going with me
  and her. Until she really gets herself back into
  school, I think me and her gonna be like that. I
  think, we're not really drifting apart in the
  client and the family advocate way. We're
  drifting apart in the mother and daughter way.

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Doula Breastfeeding disagreement

• Mother
• Thats the only thing we disagreed aboutI
  didnt do it, I didnt want to go through it.I
  was just like hm, hm, hm, hm, hm, hm. I listened
  to her, and Im like Im still not doing it. And
  you know she finally accepted the fact that this
  girl has made up her mind.
• Doula
• Right and she didn't breastfeed. So it was
  never like an issue with me because in the back
  of her mind, it's ultimately her decision. I'll
  just give you an opinion.

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Therapists Bring on the emotions!

• Therapist
• Now at times she'll cut me off, by for example
  having a long phone conversation in the middle of
  a session or having her best friend present.
  She'll titrate the emotional intensity of a
  sessionI feel like when she communicates
  something in a more hostile way or a more
  up-front way then we can address it in a better
  way.

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Implications

• Supervision!
• Take professional development seriously
• Boundaries
• Think about where love belongs

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Reflection

• Family Advocate
• I see things how I wanna see them and how I want
  them to goSo when something happens, its like a
  setbackI just assume the way I want it, thats
  the way that they wanted it. So now, I have to
  learn to accept change. I have to learn that
  everybody is differentIt changed me and let me
  see, You are not always right. You have to
  learn from these kids too because they are trying
  to tell you something. You just arent listening.

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Acknowledgements
This project was funded by grants from the
Maternal and Child Health Bureau and by the
Irving B. Harris Foundation Thanks to the
following for their contribution to data
collection, coding, and analysis Isabela
Marchi (paraprofessional study) Marisha
Humphries (doula study) Bonnie Schwartz
(infant mental health)
jkorfmacher_at_erikson.edu