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THE PROCESS AND PROMISE OF MENTAL HEALTH
AUGMENTATION OF NURSE HOME-VISITING
PROGRAMS: DATA FROM THE LOUISIANA
NURSE–FAMILY PARTNERSHIP
NEIL W. BORIS AND JULIE A. LARRIEU
Tulane University
PAULA D. ZEANAH
Tulane University and Louisiana Office of Public Health, New Orleans
GEOFFREY A. NAGLE
Tulane University
ALISON STEIER
Southwest Human Development
PATRICIA MCNEILL
Louisiana Office of Public Health, New Orleans
The Nurse–Family Partnership 共NFP兲 model is a well-studied and effective preventive
intervention program targeting first-time, impoverished mothers and their families. Data documenting
the negative impact of maternal depression and partner violence on the developing young child can be
used to make a strong case for augmenting NFP programs to focus on mental health problems impacting
the mother–child relationship. This article reviews the rationale for and process of augmenting an NFP
program in Louisiana. Data on the prevalence of depression and partner violence in our sample are
presented alongside a training protocol for nurses and mental health consultants designed to increase the
focus on infant mental health. The use of a weekly case conference and telephone supervision of mental
health consultants as well as reflections on the roles of the mental health consultant and the nurse
supervisor are presented.
ABSTRACT:
El modelo de ‘Cooperación entre la enfermera y la familia’ 共NFP兲 es un programa de
intervención preventiva efectivo y bien estudiado que se ocupa de madres primerizas de bajos recursos
económicos y sus familias. La información que documenta el impacto negativo causado por la depresión
maternal y la violencia de la pareja sobre en el desarrollo del infante puede ser usada para arguir
fuertemente en favor de incrementar los programas NFP con el fin de que éstos se enfoquen en problemas de salud mental que tienen un impacto en la relación madre-infante. Este ensayo se ocupa de los
argumentos en favor y del proceso realizado para lograr el crecimiento de un programa NFP en Loui-
RESUMEN:
Direct correspondence to: Neil W. Boris, Community Health Sciences, Tulane School of Public Health and Tropical
Medicine, Tulane Health Sciences Center, 1415 Tulane Avenue, New Orleans, LA 70112; e-mail: [email protected].
INFANT MENTAL HEALTH JOURNAL, Vol. 27(1), 26–40 (2006)
© 2006 Michigan Association for Infant Mental Health
Published online in Wiley InterScience (www.interscience.wiley.com).
DOI: 10.1002/imhj.20078
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Louisiana Nurse–Family Partnership
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siana, EEUU. Se presenta la información sobre la prevalencia de la depresión y la violencia de la pareja
en nuestro grupo muestra conjuntamente con un protocolo de entrenamiento para enfermeras y especialistas de la salud mental, diseñado para incrementar el enfoque en la salud mental infantil. Se
presentan también el uso de la conferencia semanal de casos y la supervisión telefónica de los especialistas de salud mental, así como las reflexiones de los papeles desempeñados por el especialista y la
enfermera supervisora.
Le modèle de partenariat infirmière-famille 共“Nurse-Family Partnership” en anglais, abrégé
NFP兲 est un programme d’intervention préventive bien étudié et efficace ciblant des mères pauvres, pour
la première fois mères, et leurs familles. Les données qui documentent l’impact négatif de la dépression
maternelle et la violence du partenaire sur le jeune enfant qui se développe peuvent être utilisées pour
encourager l’augmentation de programmes NFP pour mettre l’accent sur les problèmes de santé mentale
qui ont un impact sur la relation mère-enfant. Cet article passe en revue la logique de l’augmentation
d’un programme NFP en Louisiane aux Etats-Unis, ainsi que pour son application. Des données sur la
fréquence de la dépression et de la violence du partenaire dans notre échantillon sont présentées en
même temps qu’un protocole de formation pour les infirmières et les consultants en santé mentale, conçu
pour accroître la concentration sur la santé mentale. L’utilisation d’une réunion de cas hebdomadaire et
d’une supervision par téléphone pour les consultants en santé mentale ainsi que la réflexion sur les rôles
du consultant en santé mentale et du responsables des infirmières sont présentées.
RÉSUMÉ:
ZUSAMMENFASSUNG: Das Krankenschwestern-Familien Partnerschaftsmodell 共NFP兲 ist ein gut untersuchtes und effektives Präventionsprogramm, das als Ziel die erstgebärenden, verarmten Mütter und
deren Familien hat. Zahlen belegen den negativen Einfluss mütterlicher Depression und Gewalt durch
den Partner auf das sich entwickelnden, junge Kind und können dafür verwandt werden, um als starkes
Argument für die Ausweitung des NFP Programms zu dienen, das sein Augenmerk auf die seelische
Gesundheit der Mutter-Kind Beziehung lenkt. Diese Arbeit reflektiert die Gründe für die Ausweitung
des NFP Programms nach Louisiana, USA. Zahlen zur Prävalenz der Depression und der Gewalt durch
den Partner in der Stichprobe werden gemeinsam mit dem Ausbildungsprogramm der Krankenschwestern und der Berater für seelische Gesundheit gezeigt, welches darauf ausgerichtet war das Augenmerk
auf die seelische Gesundheit des Kindes zu lenken. Die Anwendung einer wöchentlichen Fallbesprechung und von Telefonsupervision der Berater für die seelische Gesundheit, als auch die Rolle der
Berater für die seelische Gesundheit und der Supervisoren der Krankenschwestern werden präsentiert.
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The promise of preventive intervention in early childhood is beginning to be realized
共Beckwith, 2000兲. This special issue offers a chance to present data from differing homevisiting intervention models and also to reflect on the process and promise of implementing
these models. In this article, we first review our rationale for augmenting Olds and colleagues’
共Olds et al., 2002兲 Nurse–Family Partnership 共NFP兲 intervention model in Louisiana by
training and supervising mental health clinicians to interface with selected nurse teams. We
then describe the process of training and supervising the mental health clinician and interweave quantitative and qualitative data gathered across 4 years to present a picture of the
mental health issues encountered in our community trials. Finally, we reflect upon lessons
learned from the Louisiana NFP trial and share recommendations for future NFP interventions.
In the world of preventive intervention, the track record of the NFP model is unparalleled. Serial randomized, controlled trials have established the NFP’s efficacy with a variety
of populations 共Kitzman et al., 1997; Kitzman et al., 2000; Korfmacher, O’Brien, Hiatt, &
Olds, 1999; Olds et al., 1997; Olds et al., 1998; Olds et al., 2002兲. Nevertheless, one of the
theoretical underpinnings of the NFP model, human ecology, suggests that contextual factors
impacting the mother and developing child are likely to strongly influence family adjustment
over time 共Olds et al., 1999兲. It has been argued, in fact, that the sum total of environmental
risk factors in infancy is the best predictor of developmental outcome over time 共Sameroff,
1998兲. The social context in Louisiana, relative to other parts of the United States, was at the
highest end of the risk spectrum at the time that our NFP trial was undertaken: Louisiana
ranked 47th in perinatal risk summary ratings at the time of our intervention trial 共March of
Dimes, 2003兲. Local data from the Pregnancy Risk and Monitoring Study across the years of
our intervention revealed that the mean age of first-time mothers in Louisiana is less than
20 years and that more than 50% of pregnancies were unplanned 共Kim-Whitmore, 2003兲.
RATIONALE FOR AUGMENTING THE NFP WITH A
MENTAL HEALTH COMPONENT
Our review of both quantitative and qualitative analysis of previous NFP trials documented
significant challenges inherent in delivering the program. Of particular interest to our group
was the fact that longitudinal analysis of the degree of intimate partner violence 共captured as
self-report of numbers of incidents over time兲 was associated with program impact on child
maltreatment. Analysis of the follow-up data from the first NFP trial revealed that 48% of the
women reported some form of violence from pregnancy to 15 years later. For these women,
the mean number of self-reported violence events experienced was 43.1, with a median of
11.7 and a range of 1 to 225 incidents. Unfortunately, the NFP program did not decrease the
incidence of domestic violence 共Eckenrode et al., 2000兲. Furthermore, when the number of
partner violence events reached a critical threshold, the nurse home visitor’s positive effects
on child maltreatment washed out. In other words, it was only for the 79% of mothers who
reported less than 29 events of domestic violence that a statistically significant reduction in
state-verified reports of child abuse and neglect was found. For the 21% of women who
reported at least 29 events of violence, no reduction in child abuse was observed.
The impact of partner violence on child maltreatment was observed when examining
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either minor 共throwing items, pushing, and slapping兲 or major violence 共kicking, biting,
hitting with a hand or an object, beating, choking, threatening with a knife or gun, or use of
a knife or gun兲. In each separate model, the minimizing effect of partner violence was observed indicating that even the less severe forms of partner violence, when recurrent, undermined the intervention effect on child maltreatment 共Eckenrode et al., 2000兲.
Perhaps unexpectedly, there was a nonsignificant positive correlation between partner
violence and the number of nurse home visits. In other words, women experiencing domestic
violence tended to have an increased number of completed nurse visits 共Eckenrode et al.,
2000兲. The good news is that it was possible to keep women engaged in the program despite
the occurrence of intimate-partner violence. The bad news is that an intensive home-based
intervention did not impact women’s experience of partner violence. In fact, a recent review
suggests that to date there are no well-designed intervention studies which have documented
significant reductions in partner violence 共Wathen & MacMillan, 2003兲.
The data on partner violence bolstered our decision to devise an augmented model of the
NFP. The work of Kitzman et al. 共1997兲 was equally influential in giving us a rich qualitative
view of the common daily challenges faced by nurse home visitors working on a more recent
NFP trial in urban Memphis, Tennessee. As might be predicted, contextual factors played a
significant role in the family-to-family variance in program impact. In fact, the first challenge
listed by the authors was “gaining and maintaining access to the families” 共Kitzman, Cole,
et al., 1997, p. 98兲. Of course, access was not merely a matter of being invited into the home;
rather, it was clear that nurses had to gauge how to engage a stressed and/or defensive client
to address that client’s areas of need. We wondered how often depression and other mental
health problems served to restrict access to clients, even when nurses were able to physically
enter the home. The same nurses spoke of how difficult it was to create relationships with
selected high-risk clients. Certainly depressed young mothers may appear unmotivated or
even disinterested in others who offer care and assistance. At the same time, there is evidence
that social support is a critical variable in the longitudinal course of depressive symptoms
among community women 共Wildes, Harkness, & Simons, 2002兲, and we wondered how much
support nurses themselves might need to persist in creating a strong relationship with those
rural, isolated mothers who were depressed.
Another common challenge reflected on by program nurses from the Memphis trial was
“waiting for readiness for mothers to change” 共Kitzman, Cole, et al., 1997, p. 106兲. The
relationship between behavior indicative of motivation to change and depressive symptoms is
not well studied and is likely complex. Blume, Schmaling, and Marlat 共2001兲, for instance,
found that alcohol abusers who endorsed high levels of depressive symptoms were no less
likely to change their drinking patterns, regardless of their reported stage of readiness to
change, than those who endorsed being less depressed. Still, we wondered whether depressive
symptoms might not only lead to restricted access to the clients but also compromise their
readiness for change.
We knew full well that the nurses in previous Olds et al. trials 共Zeanah, Larrieu, & Nagle,
1998; Zeanah et al., 2006兲 were extremely committed and well trained, but how prepared
were they to deal with significant maternal mental illness in the context of very high levels of
social risk? Our primary goal in the Louisiana trial of the NFP was to assess the feasibility of
augmenting nurse teams with a mental health consultant 共MHC兲 trained specifically in the
principles and practice of infant mental health 共Zeanah, 2000兲. We were committed to using
the most rigorous research design possible and created an academic–public service partner-
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ship for this trial. On the other hand, we viewed the trial as preliminary in that our funding
would support a sample size that was too small to detect outcome differences that were
anything other than quite large. Though funding restricted us to one region of the state for the
randomized, controlled trial, nurse teams were started shortly thereafter in two other regions
just as our research trial site came online. Since we did not have the capacity to train and
place MHCs with each nurse team in each region at the outset, only one of the nurse teams 共in
the region where the research trial was ongoing兲 had an MHC at their inception; other nurse
teams in other regions incorporated an MHC after they had already begun serving families.
The accidental experiment of having one MHC begin with the nurse team, while others joined
teams that we already formed, proved to influence team dynamics in interesting and potentially important ways. We captured these team-dynamic issues from focus groups; lessons
learned from some of these focus groups about how role definitions appear to impact team
dynamics are reviewed in an accompanying article 共see Zeanah, Larrieu, Boris, & Nagle,
2006兲.
DEFINING THE MHC’S ROLE
The important issue of how to craft the MHC’s role within the NFP was complex. We had no
clear data on the type and severity of mental health conditions impacting first-time, poor
mothers in Louisiana. Certainly, like many states, the availability of mental health care for
poor, rural women in Louisiana is extremely limited 共Mulder et al., n.d.兲. While the women in
our sample were Medicaid eligible based on income criteria, maternal benefits in Louisiana
expire 2 months after the birth of the child. Although we expected relatively high levels of
depression among the sample, we predicted that other forms of mental illness and risk conditions such as intimate-partner violence would be relatively prevalent as well. We also knew
that the training of our MHCs would have to be carried out using local resources, and because
some of our MHCs would join nurse teams already in progress, their training would have to
mesh well with the nurses’ training. Finally, we suspected that much could be accomplished
by working through rather than alongside the nurse 共i.e., directly with the client兲. This philosophy was shaped by the NFP model itself, wherein the client is encouraged to take the lead
in identifying goals for intervention. In previous NFP trials, mothers in violent relationships
did not necessarily make the violence their primary issue; we suspected that even when nurses
recognized signs of mental illness, some clients might choose to work on less difficult or
painful issues.
As it turned out, both depressive symptoms and the experience of partner violence were
common in our sample. For instance, 26% of study participants scored above a conservative
screening cutoff for depressive symptomatology at the prenatal research visit. In addition,
41% of women visited in pregnancy reported experiencing at least some violence in their
lives, 19% reported at least one act of violence perpetrated by a current partner, 20% reported
perpetrating the violence against the current partner, 21% reported ex-partner violence, and
11% reported that they perpetrated the violence against an ex-partner. The co-occurrence of
depressive symptoms and partner violence was common. For women who reported current
violence in their lives 共either as the victim or the perpetrator兲, 11% reported both depressive
symptoms and partner violence. Of women who reported any lifetime partner violence, 39%
were above the depression cutoff. Perhaps of greater concern is that of the women who
reported depression symptoms above the cutoff, 62% also reported a history of partner vioInfant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the World Association for Infant Mental Health.
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lence. These data, gathered while our program was in existence, underscore the prevalence of
depressive symptoms and the co-occurrence of depression and partner violence. Fortunately,
our nurses and MHCs were trained to recognize these clinical challenges and work together to
address their impact on the mother, the infant, and the evolving mother–infant relationship. In
the next sections, we will present our training programs for both nurses and MHCs.
TRAINING FOR NURSES IN PRINCIPLES OF INFANT
MENTAL HEALTH
The nurses providing intervention in this program frequently were drawn to the work because
of the opportunity for home visitation as well as the ability to work intensively with families.
Nevertheless, several of the nurses were unprepared for the nature, severity, and chronicity of
the families’ mental health problems 共see Zeanah et al., 2006兲. While many nurses had
worked with poor, disenfranchised, unemployed parents, this program included families in
whom depression, domestic violence, substance abuse, and child abuse, including incest, were
alarmingly commonplace. To educate and support the nurses, we developed an intensive,
ongoing series of workshops regarding relationship building, identifying and intervening with
mental health issues for infants and parents, and recognizing the impact of the nurses’ own
values, goals, and personal functioning on their work. Not only did the training impart specific
content that we believed was essential for the nurses to have to facilitate their comfort with
recognizing mental health issues but the structure and process of providing the training also
was designed to build relationships among the nurses and with the nurses and trainers. One of
our goals was to have the model of training parallel the development of relationships among
the mothers and nurses, and the mothers and their babies. We were struck with how important
our relationships as trainers became to the nurses, and how the trust and credibility we
developed enhanced the nurses’ ability to identify difficult issues with the families as they
provided the NFP intervention.
The first program we offered that provides the foundation for all the training experiences
is entitled “Infant Mental Health.” This series consists of 30 hr of didactic instruction, with
much discussion of examples from the nurses’ and trainers’ clinical field experiences. The
training is based on a relationship-focused family-systems approach, and begins with definitions of infant mental health and an overview of development in the first 3 years of life. How
early relationships between caregivers and infants impact the infant’s functioning is discussed,
with a focus on attachment theory, underscoring the importance of secure attachment relationships to later social-emotional and cognitive development. We also discuss the impact of
family, culture, and the larger societal context on parent–infant functioning. Descriptions of
major approaches and challenges to studying psychopathology in infancy as well as symptoms of various disorders, including posttraumatic stress disorder and attachment disorders in
infancy, are covered. We outline components of assessment, focusing on dimensions of caregiver functioning, infant functioning, and the quality and nature of the caregiver–infant
relationship. We discuss parenting styles, including discipline techniques, maternal functioning, especially depression, domestic and community violence, substance abuse, and risk factors for maltreatment. We identify specialized interventions to enhance infant–caregiver relationships, including dyadic treatments. We emphasize the impact of the nurses’ attitudes,
beliefs, and values 共including countertransference兲, as they influence their work with infants
and caregivers.
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At the conclusion of the training, the nurses have a substantial knowledge base about
normal and abnormal infant and child development, developmental psychopathology, and
multiple risk factors and challenges to healthy development. They also have acquired knowledge about various methods of assessment of psychosocial and psychological difficulties of
infants and their caregivers. They can identify strengths in the infant–caregiver dyad upon
which to build further competencies. They have learned about the variety of interventions
available, and when and how to make referrals for mental health issues. They have developed
expertise in assessing the infant–caregiver relationship using observations of feeding and
teaching episodes between parents and their babies. The nurses have given us extensive
feedback about the benefits of the training, particularly in their ability to determine the extent
and limits of their competence in dealing with mental health issues of the families with whom
they work.
Although this training is intensive, the training of the MHCs was even more so; however,
many of the same topics were covered so that both nurses and MHCs would have common
perspectives and a common language.
TRAINING THE CONSULTANTS
We were fortunate in that we were able to recruit a sufficient number of mental health
professionals who had both extensive clinical experience with children older than 6 years and
established networks in their communities. Although these clinicians were valuable resources,
few had expertise in assessing or treating infants, young children, and their families. Therefore, our training program was designed as a crash course in the theory and practice of
relationship-based assessment of children birth to 3 years of age and their caregivers.
The MHCs had to commit to two coordinated training segments: 共a兲 a 4-month, half-time
block in New Orleans consisting of didactics, clinical case consultation, and clinical assessments in a variety of settings; and 共b兲 an 8-month, full-time, supervised field experience at
their home sites.
The didactic series in the first segment of the training included the topics listed in Table
1. The approach was to cover both topical research and its implications for practice as well as
to provide tools and techniques for assessment and intervention. Selected special issues
thought particularly relevant for work with the NFP were addressed as well.
Clinical field placements at a variety of sites were critical in bringing the didactic sessions to life. Though placement sites rotated, a large portion of each MHC’s clinical training
time was spent with the Infant Team, which provides intensive intervention for maltreated
children 48 months and younger and their caregivers in Jefferson Parish, Louisiana 共Zeanah,
Larrieu, & Nagle, 1998兲. The team is staffed by a multidisciplinary group of faculty and
trainees from Tulane University Medical School, all of whom have expertise in infant and
child development and developmental psychopathology. Exposure to the legal, child welfare,
educational, healthcare, and mental healthcare systems resulted from this placement. Each
trainee became immersed in the program and applied some of the tools and techniques
reviewed in didactic sessions 共e.g., parent–infant interaction procedures, parent perception
interviews兲. Trainees also completed intake interviews, visits to the biological and foster
parents’ homes, and numerous ancillary assessments.
The MHCs also engaged in a supervised observation program at Tulane University Medical Center’s childcare center. This center is open to very young children, and thus MHCs were
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TABLE 1. Didactic Topics in Training of the Mental Health Consultants
1. Topical reviews
a. Development in the first 3 years
b. Defining infant mental health: the relationship focus
c. Psychopathology in infancy
d. Substance abuse and infant mental health
e. Maternal depression and infant mental health
f. Family and community violence
g. Trauma and dissociation
h. Adolescent parenting
II. Assessment tools
a. Caregiver–infant interaction assessment: Crowell
procedure
b. Caregiver–infant interaction assessment: Nursing
Child Assessment
Satellite Training 共NCAST兲 approach
c. Caregiver perception interview: Working Model of the
Child Interview
III. Intervention
strategies
a. Intervening with developmental concerns 共e.g., feeding
and sleep problems兲
b. Interaction guidance
c. Infant–caregiver psychotherapy
IV. Special issues
a. Countertransference in parent-infant work
b. Role definitions
c. Consultation–liaison
d. Ethics in practice
able to develop expertise in observation of infants and young children from birth to 5 years of
age. Variability in infant and toddler behavior was examined from unique perspectives. A
faculty sponsor accompanied MHCs to the nursery.
As their confidence and expertise grew, the MHC trainees went from observing treatment
interventions to conducting treatment under supervision. Typically, each trainee conducted
caregiver–infant interaction guidance or psychotherapy on one or more cases. Developmental
guidance and behavior management skills were often the focus of intervention for foster
parents, and trainees were active in providing this service. Individual psychotherapy with
caregivers was provided in select cases 共e.g., parents presenting with psychiatric illness and
conflicting relationship styles兲, as was individual therapy with maltreated children.
While this clinical immersion took place, the MHCs were offered experiences meant to
model effective team interactions. A key experience in this vein is the weekly Infant Team
comprehensive case conference, which includes representatives from many systems that interface in caring for young children and their families 共i.e., Child Protective Services, the
Bureau of General Counsel, community substance-abuse counselors, childcare providers,
etc.兲. In this conference, clinicians present aspects of cases to the group to illustrate individual, dyadic, and family characteristics, emphasizing strengths and concerns. Specific recInfant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the World Association for Infant Mental Health.
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ommendations for intervention are typically arrived at collectively. The model of consultation
provided a framework from which the MHCs could work when they returned to their communities.
Once the MHCs completed the half-time, 4-month program in New Orleans, they returned to their region of the state to provide services to interface with their nurse teams and
serve the NFP families in need of mental health intervention. For an 8-month period after the
completion of their training, the MHCs consulted regularly with supervising faculty. The goal
of the long-term follow-up consultation was to provide additional expertise and support to the
MHCs, tailored to the issues that arose in their unique settings. This weekly consultation
occurred by telephone with faculty trainers, and is described in a later section of this article.
A focal point of the MHCs’ work, and consequently of supervision, was the reformulation
and maintenance of case conferences with each nurse team. The case conference was where
the MHCs could showcase their newfound knowledge and skills and move toward independent functioning as infant mental health specialists.
DESCRIPTION OF CASE-CONFERENCE MODEL
Ongoing group case conferences involving nurse teams and the nurse supervisor have been
part of the NFP since its inception. Material covered in these case conferences includes the
family’s demographic information, plans and goals in areas of personal health, environmental
health, life-course development, maternal role, and support networks 共Cole, Kitzman, Olds, &
Sidora, 1998兲. The nurse’s views of the strengths and vulnerabilities of each family are
reviewed, and the relationship between the nurse home visitor and the family is emphasized,
including the nurse’s personal reactions to the parent, infant, and family situation. Because the
case conference provides the opportunity for nurses to grapple with all variables that influence
the family’s responsiveness to the program, including overt or underlying mental health issues, we believed the case conference was the perfect forum for introducing the MHC’s
consultative role. Because the addition of the MHC into the teams occurred at differing points
of time, there was some variability in how the MHC was integrated into the case conference;
in general, the MHC and the nursing supervisor led the conference.
In the first Louisiana region to receive the NFP, the MHC joined the team from the start,
met with the nurse supervisor, and took the lead-facilitator role for the conference. In the
initial weeks, because their caseload was small, all nurses presented briefly about the families
they visited. This format worked well in that it built group cohesion and enabled each nurse
to recognize that others’ cases were equally difficult and bewildering. As the nurses’ caseloads
grew, the conference was formalized to a 1-hr presentation covering the basic information on
one client, the nurse’s clinical dilemmas and range of personal reactions to that client, and a
group discussion of the most perplexing and concerning issues of the case, clinical impressions and conceptualizations, and recommendations. A subsequent second hour of consultation was left for ad hoc discussion of other particularly confusing or worrisome clinical
situations. With the exception of a few prepared talks 共e.g., use of psychotropic medications
during pregnancy, postpartum mood disorders, personality disorders, perinatal loss and grief兲,
didactic material was conveyed as it naturally arose in the course of case discussions.
The nurses in this group were welcoming to the MHC from the start. In the early months
of the program, however, they also revealed their nervousness about working with a mental
health professional, and their uncertainty and general skepticism about just what it is that
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mental health professionals do. Periodic comments, questions, and jokes suggested that the
nurses felt somewhat vulnerable—afraid of saying the wrong thing to the consultant as well as
to their clients, of being analyzed by the MHC, or being judged as having mental health
problems themselves. The overall goal of the MHC was to promote a reflective model of
consultation, with its essential constituents of regularity, collaboration, a climate of mutual
respect, trust, and emotional safety, and myriad opportunities for thoughtful pause and consideration of what one is seeing, doing, and feeling with regard to the work 共Fenichel, 1992兲.
The reflective model of consultation and supervision, valued and common in the training of
mental health clinicians, is often entirely foreign to those who are not mental health professionals, and it did not seem to have been the usual experience of these nurses in their training
and work. The nurses differed in their individual inclinations toward reflection and their
dispositions to consider the potential meanings of their own and their clients’ behavior; however, over time, all of the nurses developed greater “psychological-mindedness.” Many times,
nurses would report trying to consider what the MHC might say to a client during a home visit
or would anticipate the MHC’s question or comment during the consultation with statements
such as “I know what you’re going to say.” Toward the end of 1 year of mental health
consultation, 1 nurse reported with delight that she and her peers had been discussing a young
mother and speculating on the reasons for a particular pattern of behavior. She remarked “You
would have been so proud of us. We sounded like a bunch of psychologists!”
Although the MHC in this group led the case consultation, several factors seem to have
contributed to the spirit of collegiality and collaboration that was co-created over time with
the nurses. From the MHCs’ perspective, the occasional opportunities that arose for visiting a
home together with a nurse helped convey the support of the MHC and the idea that the
nurses were “working with a net.” These visits also made their point, more dramatically than
mere conversation, that the nurses had impressive expertise—including many skills generally
not held by mental health professionals. The MHCs could then reflect back to the nurses their
admiration with greater genuineness and specificity.
As time went by, nurses began to raise issues about their own children, from current
struggles to regret that they had not known when their children were babies some of what they
were now learning. They sometimes asked the consultant for an opinion about various childrearing issues. These personal disclosures seemed to indicate a growing trust in the MHC, the
group, and the process of reflection. Taking time and paying respectful attention to questions
and concerns about their own lives offered an opportunity to deepen team trust and to model
the kind of communication advocated for work with families.
Feedback from the nurses indicated that they perceived the MHC as having expertise and
providing useful conceptualizations for understanding clients. They perceived the consultations as balancing seriousness of purpose with the use of humor, and they appreciated the
MHC’s occasional use of self-disclosure. At midyear, some nurses indicated that they felt
pressure to implement immediately the many recommendations that arose from the consultations and were overwhelmed—an unintended consequence of enthusiastic, idea-generating
discussions. The MHC bore this in mind during subsequent consultations and regularly
framed the intention of recommendations as possibilities for intervention as relationships with
families unfold and opportunities present themselves. End-of-year feedback reflected a shift in
nurses’ perceptions of recommendations generated during the consultations to what 1 nurse
called, “options and food for thought.”
Nurses also indicated that it was a relief to them for the consultant to remind them of
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some of the fundamental realities of the work, including the complexity of many families’
circumstances and the fact that they could not control whether someone made use of an
opportunity for change. One nurse stated that she had learned that she “can’t want someone to
change more than they want to change.”
In other regions, the program began prior to the identification and training of the MHCs,
so the nursing supervisors initially led the conferences, with the MHC being one voice in the
group discussion. The MHC needed to earn the trust of the nurse home visitors, and the
process of doing so included the same elements these nurses were utilizing in the formation of
their relationships with the mothers participating in the program. Thus, being available, keeping appointments in a timely fashion, listening respectfully to concerns and issues, and offering information when asked contributed to a feeling of trust, community, and common purpose between the MHC and the nurse home visitors. For these teams, the preparation of
didactic information following a nurse’s case review of maternal and infant mental health
issues served to both further educate the nurses about complex issues and to highlight the role
and expertise of the MHC. Soon, nurses wanted to check in with the MHC regarding the
status of their case, and periodic reviews in which several of the cases were briefly summarized quickly became the norm. For example, some of the mothers in the program demonstrated symptoms of serious mental illness, including postpartum depression with psychotic
features and bipolar disorder. The nurses were generally able to recognize problems or symptoms, but needed assistance with intervention. Case conferences served as the place where the
nurse home visitors and the MHCs could devise the plan for introducing and implementing a
mental health intervention with a given client.
At each site, the nurses and the MHC developed a common language to identify psychosocial, psychological, and social-emotional issues with which families were struggling. This
process was extremely useful, as it facilitated the nurses’ identification of common challenges
for the families and the families’ unique strengths as well as transference and countertransference issues. The nurses developed customary ways of posing questions and dilemmas to
the MHC, and eventually engaged in group and peer consultation as frequently as turning to
the MHC for answers to the dilemmas posed by the families’ multifaceted mental health
needs.
WORKING WITH THE NURSE SUPERVISOR
The original NFP program employed a nurse supervisor to support the nurse team. We were
concerned that adding an MHC would lead to problems in role definition for the nurse
supervisor. In fact, once the MHC is established as a member of the team, the stress on the
nurse supervisor, who typically oversees a team of 8 nurses serving approximately 160 families, decreases. One supervisor reported feeling that she no longer was “having to carry the
responsibility of serious mental health issues we have seen in these families alone.” When
nurses are carrying a full load of cases, and when, as in Louisiana, depressive symptoms and
partner violence are common, the viewpoint of the nurse supervisor—who is constantly in
contact with the nurse team and can track which cases should be presented in conference and
which clinical challenges are recurring and in need of group discussion—is critical.
Nevertheless, creating a structure for sharing perspectives has been important. For instance, the MHC and the nurse supervisors typically meet the day after the case conference,
in person or by phone, to process both case material and recommendations. The MHC may
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reflect on the nurses’ different personalities and the different way each approaches the issues
in the families she deals with while the supervisor reinforces the idea that the nurse is the
“expert on the client”—a fundamental premise of the NFP model. In time, this dialogue helps
the supervisor in determining when the nurse should seek consultation with the MHC and
thereby, hopefully, intervening before situations reach the crisis stage. Weekly processing also
has led to the supervisor requesting inservices on particular topics or clinical problems encountered frequently.
The nurses in Louisiana encountered considerable psychopathology and high levels of
job-related stress. Ongoing support and validation that they were making a difference was
important, but so were tools and techniques. The collaborative approach of the nurse supervisor and the MHC is clearly important to the nurses. After 5 years of work as home visitors,
the nurses reported little severe burnout, and all but 1 of the original 8-member team remain
on the job. We hope to study the impact of relationship-based training and a reflective mode
of supervision on nurse burnout more formally in the future. Of course, supporting and
supervising the MHC, who is asked to interface with a team of nurses and a nurse supervisor
as well as conduct home visits and track a large portion of 160 family cases, is critical. We
elected to link the supervision of MHCs with the training of MHCs by providing regular
telephone contact with one of the trainers. The long-term relationships that developed between trainers and MHCs were important, although supervision by telephone can be
challenging.
SUPERVISION OF THE CONSULTANTS
The complexity of relationship-based interventions and of working through others with
stressed parents of young children is daunting. Although there are no studies of how long it
takes to gain competence in applying interventions using the tools and techniques of infant
mental health, published practice parameters for evaluation of early childhood mental health
conditions have noted the need for long-term supervision 共American Academy of Child and
Adolescent Psychiatry, 1997兲. We elected to have the senior faculty involved in the training of
the MHCs provide ongoing weekly consultation to the MHCs in each region of the state. The
most efficient manner in which to conduct the consultation was to use the telephone. This
format was supplemented by face-to-face visits, ideally on a quarterly basis and, as frequently
as possible, review of videotapes of procedures conducted with families. Hour-long telephone
sessions were held weekly, in which the MHCs presented particularly challenging cases to the
faculty consultants, who assisted in conceptualizing the dynamics of the case as well as
developing practical steps that could be taken by the nurse home visitors and/or the MHCs to
attend to the families’ difficulties.
The most common challenges presented to the faculty consultants were parent–child
relationship problems, maternal depression, family or neighborhood violence, posttraumatic
stress disorder, substance use or abuse, and child maltreatment or elevated risk of maltreatment. Particularly in the case of relationship problems, the faculty consultants had to probe
carefully and as completely as possible for information about the dynamic interactions between the parent and baby, the parent and the nurse home visitor, the baby and nurse home
visitor, the baby and the MHC, and the parent and the MHC. By assessing the patterns of
interactions with all involved, a clearer picture of normative and nonnormative relationships
could be ascertained. Because of the sophistication and complexity of the issues involved,
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periodic viewing of videotapes and being on site at the region were very important to solidify
and maximize the benefit of the weekly telephone consultation. We have found that these
methods for training and supervising professionals by remote means can be quite successful in
facilitating the services provided to infants and their families regardless of their geographic
locations 共Wajda-Johnston, Smyke, Nagle, & Larrieu, 2005兲.
For example, unanticipated but distinct benefits of use of the telephone for consultation
became apparent over time. The MHCs had to clearly articulate their feelings about families
and the nurse home visitors, and describe subtle nuances of facial expressions and other
nonverbal material not able to be observed by the faculty consultants. This exercise resulted
in the MHCs becoming exquisitely attuned to their observations of the families, the nurse
home visitors, and themselves so that they could describe this information in detail when the
faculty consultant inquired about it. Another important function of the consultation was to
allow the MHCs to discuss any difficulties they encountered in their role vis-á-vis the nursing
home visitor and the nursing supervisor. The intricacies of these relationships were particularly important and also challenging for the MHCs to understand. Interestingly, it was for
these types of difficulties that using the telephone as the primary medium for consultation had
particular advantages. Since many of the MHCs were seasoned experts in mental health but
saw themselves as novices in infant mental health, the telephone allowed for a useful distance
in their discussions of issues of infant mental health and their feelings of limited competence
with the material. That is, the telephone allowed the MHCs to bring up more easily material
that they may have been reticent to discuss in face-to-face meetings, where their nonverbal
signs of discomfort may have been more easily discerned by the faculty consultants. With
their exposure constrained by the telephone, MHCs were more forthcoming than they might
have been in person with issues they felt uncomfortable with or less knowledgeable in
discussing.
CONCLUSIONS
Adding a mental health component to the NFP is complex. While the model, as developed by
Olds and colleagues 共2002兲, already focuses on improving the social and emotional functioning of the entire family, a focus on depression and other common mental health conditions is
lacking. As the neuroscience community tackles important issues such as whether there are
critical periods during which the foundations of social and emotional functioning are laid
共Bailey, Bruer, Symons & Lichtman, 2001兲, the field of preventive intervention must still
move forward with research on ways to enhance developmental outcome in early childhood.
The NFP remains one of the best-studied and most effective intervention programs for families at risk 共Rotheram-Borus & Duan, 2003兲. Our data confirm that in Louisiana, the burden
of social risk and the prevalence of depressive symptoms among young mothers are high.
Given the impressive evidence about the negative impact of maternal depression on the
developing infant and mother–infant relationship 共Zeanah, Boris, & Larrieu, 1997兲, one main
goal of our research agenda was to study the process of implementation of a new mental
health augmentation of the NFP.
We do not have data suggesting that adding a mental health component to the NFP is a
panacea. Nevertheless, our experience suggests that it is possible to train mental health clinicians to become effective infant mental health consultants and to strengthen the team approach of the NFP. We are hopeful that this in turn will result in more effective interventions
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for those families struggling with maternal depression and/or partner violence. We view
training of both the NFP nurses and the mental health consultants as critical. We also are
convinced that the mental health consultant must learn to use the case-conference forum to
both educate and support the nurses. A strong relationship with the nurse supervisor and
ongoing supervision are equally important. Infant mental health interventions are sufficiently
developed to inform clinical encounters such as those which arise in the NFP. Our experience
suggests that mental health consultants can work through well-trained and supervised professionals, such as nurses, to reach a greater number of families than once thought possible.
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