Westside Infant Family Network:

A Model for Transformation, Rooted in

Relationships

Sarah Rogers

19-5-2016

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Contents 1. Title..... 1

2. Contents..... 2

3. Acknowledgements, Notes, Background to Report..... 3

4. Attachment Theory: A Brief Introduction..... 4

5. The Impact of Domestic Abuse on Attachment..... 5

6. Research Objective..... 6

7. Research Method..... 8

8. Funding and Strategy..... 9

9. The Partnership Model..... 11

10. The Case for Case Management..... 13

11. Attachment in the Everyday..... 15

12. Cultural Sensitivity and the Strengths-Based Approach..... 17

13. WIN and Domestic Abuse..... 19

14. The Parallel Process..... 20

15. Innovation at WIN..... 21

16. Research Findings..... 23

17. Recommendations for Practice..... 24

18. Websites of Interest..... 27

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Acknowledgements

Sarah Rogers gives sincere thanks to the following organisations:

Winston Churchill Memorial Trust; for funding and supporting this research.

Westside Infant-Family Network; for hosting my visit and sharing their considerable expertise.

West Lothian Council; for granting my leave from work to pursue this opportunity.

Notes

The definition of domestic abuse used in this report is that used by the Scottish

Government1, which I work from both in my professional life and in my feminist

activism.

Throughout this report I will use “women”, “mother”, “caregiver”, “survivor” and

“victim” interchangeably. This should not be read as a refusal to acknowledge male

victims of domestic abuse; however it reflects the fact that I work with women (who

embody all of these roles and make up the majority of domestic abuse victims), as does

Westside Infant Family Network, and as a result the findings of this study - while likely to

apply to some degree to male victims and fathers - are not intended to reflect their

unique experiences.

I will refer to Westside Infant Family Network as “WIN” throughout this report, both for

brevity and because this is what the organisation is referred to by staff members and

partner agencies.

Background to Report

As a practitioner in domestic abuse services, I have a sad familiarity with the damage that experiencing

trauma in the home is liable to inflict on both the inner and outer lives of children. My professional work

- coordinating a group-work intervention for women and children in recovery from domestic abuse - is

rooted in the belief that the development of long term resilience in children comes from strengthened

family relationships, in accordance with popular theories of attachment. From this, the recovery of a

child who has experienced domestic abuse cannot be taken as separate from the recovery of their

parent or carer: the two are deeply intertwined. It is with this in mind that I undertook research which

sought to learn from international best practice in therapeutic work with mother-child dyads in the

aftermath of trauma.

1 Scottish Government (2014) Equally Safehttp://www.gov.scot/Resource/0045/00454152.pdf

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Attachment Theory: A Brief Introduction

Attachment is an inbuilt evolutionary adaptation: children are driven to form attachments to their

primary caregiver in order to stay safe and cared for by them. Infants may display a range of attachment

behaviours; however they all serve the same function: ensuring the close proximity of the primary

caregiver. Although most infants form more than one attachment, there is a strong tendency for them

to prefer a principle attachment figure and due - at least in part - to the gendered nature of parenting in

a patriarchal society; this tends to be their mother.

How a child perceives and relates to the world around them from the earliest age forms their internal

working model: how they process and understand their daily lives. If their caregiver has consistently

responded to their attachment behaviours – by attending to them when they cry, for example – the

child is more likely to develop secure attachment. From this, they see the world as inherently good and

responsive to their needs2. If a caregiver has responded inconsistently or inappropriately to attachment

behaviours, this skews the child’s internal working model towards more negative assumptions – that

they are unworthy, or that the world is inherently hostile.

Secure attachment relationships allow children to explore their world knowing they have a secure base

and safe haven to return to in the form of their caregiver. They are better equipped to develop social

skills which enable them to build healthy relationships throughout their life. However, although their

importance is undeniable in shaping our adult personalities, children are not irreversibly predestined by

their early attachment experiences. As stated by Sroufe and Siegel, “early experience influences later

development, but it isn’t fate: therapeutic experiences can profoundly alter an individual’s life course.”3

2 Weinfeld, Nancy S. et al (2008) ‘Individual Differences in Infant-Caregiver Attachment’ Handbook of Attachment: Theory, Research and Critical Applications, Cassidy, Jude & Shaver, Phillip R. (eds), Guildford Press, New York p. 85. 3 Sroufe, A and Siegel, D The Verdict Is In – The Case for Attachment Theory http://drdansiegel.com/uploads/1271-

the-verdict-is-in.pdf Mind Your Brain Inc

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The Impact of Domestic Abuse on Attachment

We know that children who are securely attached to their parent are likely to recover from trauma with

greater ease throughout their lifespan, and when abuse is present in the home, the development of this

attachment can be disrupted from the offset. The mother-child relationship is a common site of abuse,

with perpetrators intentionally targeting their victim’s ability to parent in a bid to undermine and so

more thoroughly control them. This is in accordance with Evan Stark’s4 theory of ‘coercive control’,

which states that domestic abuse is not a series of isolated incidents, but rather a pattern of behaviour

with the cumulative effect of infringing upon the agency, self-efficacy and human rights of the victim.

Stark notes that domestic abuse, as gender based violence, tends to target areas of gender expression

and behaviours typically gendered by society – for example, how a woman takes care of home, her

appearance and – most importantly, for this report - her children.

Domestic abuse can impact upon the mother-child relationship in a variety of ways. Children can be

pawns in the abuse, manipulated by perpetrators into participating in it: for example, by monitoring

their mother and reporting on her activity. The victim’s ability to meet their child’s needs may also be

undermined by the imposition of the perpetrator’s stringent regulations for her behaviour. It has been

proven that domestic abuse frequently begins or is accelerated at the point of pregnancy5. A recent

study found that only 37.5% of babies affected by domestic abuse have secure attachment, compared to

an average of 65% in the wider population6.This shows a clear need for domestic abuse services to be

attachment informed - and for early years services to be domestic abuse aware.

The development of secure attachment is dependent on a parent’s ability to engage emotionally with

their child: meeting their needs, soothing them in times of distress and providing a safe base from which

their child can explore and grow. A parent suffering from the depression and anxiety that have been

proven to routinely coincide with experiencing domestic abuse would face significant difficulties in

providing this emotional availability. One potential obstacle to the development of secure attachment in

this context is the fact that frightened mothers are perceived by their children as frightening. This can

cause disorganised attachment, as children struggle to seek comfort from the source of their anxiety.

However, it should be noted that experiences of mothering in the context of domestic abuse vary, and

many women are extremely resourceful when it comes to caring for their child in adverse

circumstances.

4Stark, Evan (2007) Coercive Control: How Men Entrap Women in Personal Life Oxford University Press

5http://www.refuge.org.uk/get-help-now/what-is-domestic-violence/domestic-violence-and-pregnancy/

6Buchanan, Fiona (2011) The Effects of Domestic Violence on the Relationship Between Women and their Babies: Beyond Attachment Theory, Flinders University, Adelaide p.40

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Research Objective

The benefits of secure attachment in terms of increasing resilience have been evidenced by researchers

and are now recognised in Scotland by government policy makers7. However, examples of successful

attachment-informed innovation in Scotland - from my own involvement with the Scottish

Government’s Early Years Collaborative - have tended to focus on the accurate identification of

attachment style. The need for evidence-based strategies and models delivering significant

improvement to the status of the mother-child relationship, particularly in the aftermath of trauma, is

great. The early years, as a critical stage of brain development, provide an ideal opportunity for

intervention; reducing the social and economic cost of trauma by addressing inequalities of experience

which may otherwise manifest in harmful ways later in life.

The Centre on the Developing Child at Harvard University has established an international project

‘Frontiers of Innovation’ which works towards these aims; bringing together the most creative and

successful early years agencies from across the United States in a collaborative effort at developing and

testing new, effective models for practice. It was Harvard that I initially contacted in designing this

research project and, having discussed with them my particular interest in trauma-informed approaches

to improving attachment in the early years, Westside Infant Family Network in Los Angeles was the

recommended subject of study. Upon further research, this organisation transpired to be an ideal match

for my objective.

WIN is viewed as a pioneering model of a cross agency, cross sector, collaborative service in the USA. It

operates across multiple partner agencies, with an overall objective of ending intergenerational cycles of

trauma and violence through treating the mental health of young children and their parents/caregivers

together (dyadic therapy)– limiting its detrimental impact on the development of their children – as well

as the children themselves. WIN also provides in-home individual therapy to parents who are receiving

dyadic therapy with their children to ensure that they can better recover their own trauma—the trauma

at the root of their relationship issues with their child.

WIN service users are overwhelmingly of Latinx ethnicity and undocumented status, facing additional

barriers with regards to their language and culture as well as their financial circumstances. All WIN

clients live below the poverty level, and so the study of this organisation opened up interesting

questions about how intersecting oppressions could impact upon early years and the development of

secure attachment. While Scotland’s ethnic composition differs significantly from that of Los Angeles,

the means by which WIN successfully engage their clients – many of whom would be deemed ‘hard to

reach’ by other agencies - had the potential for cross-application to different contexts.

The outcomes achieved by WIN’s approach are impressive: 86% of children who engaged with WIN’s

therapy showed improvement in behaviours associated with secure attachment, and 78% of parents

experiencing toxic levels of parenting stress showed significant improvement following their

7Furnivall, Judy et al (2012) Attachment Matters For All – An Attachment Mapping Exercise for Children’s Services

in Scotland, Centre for Excellence for Looked After Children in Scotland

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engagement with the organisation. My objective in spending time at WIN was to gain an in-depth

understanding of their unique model and learn from the WIN approach, extracting ideas through which

improvements in similar outcomes could be achieved in Scotland and beyond.

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Research Method

The core staff team of WIN is relatively small in number considering their significant reach in the

community. Through spending time with staff members at all levels of the organisation, including those

based in partner agencies, I sought to develop an appreciation of the principles that underlie their work

and the strategy that drives it, as well as practical ideas for application of their model which could be

applied successfully in other contexts.

A key aspect of my research was a series of semi-structured individual interviews I conducted with

frontline workers, high level managers and board members. I spent time onsite at the WIN office

observing the daily comings and goings of the organisation, while also attending case review meetings,

meetings with funders and a Department of Mental Health meeting which gave me a better idea of

WIN’s place in the local context of mental health providers. Fortunately my time with WIN coincided

with the induction of university students on placement there so I was able also to participate in their

sessions, learning important aspects of the organisation’s functioning from a new worker’s perspective.

This gave me a real insight into the way WIN principles translate in practice.

One of the most useful learning experiences in my time at WIN was the evening I spent at their monthly

“Family Night.” This was an opportunity to observe the interaction style between WIN therapists and

clients, and witness the WIN approach in action. It would have been inappropriate for me to attend one-

on-one sessions between workers and clients as these deeply personal interventions take place in their

homes – requiring a significant amount of preliminary relationship-building to access without disrupting

the therapeutic process. At family night, however, I was free to mix with families who attended and

helped to assist in the delivery of the session – bringing my learning about the organisation to life.

Throughout my time at WIN I took notes, anonymising information about individual examples as

required. I also recorded my interviews - with permission - on a dictaphone, transcribing at a later date.

While in the office I was given access to documents such as policies and funding applications that have

also informed this report. I would recommend this mixed style of research as it enabled me to

understand the organisation at both a strategic and practical level, with a personal appreciation of the

working relationships that enable WIN to undertake their important work with such success.

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Funding and Strategy

The evolution of WIN’s partnership model into its current incarnation is an interesting journey which

raises important questions for consideration when trying to emulate its success. Before WIN, a

relationship existed between the agencies that are now involved: the Westside Children’s Centre, Venice

Family Clinic and St Joseph’s Centre. However, the impetus for bringing their respective work together in

a systematic way was the philanthropy of Richard Atlas – an investment banker with Goldman Sachs -

and the foundation he started with his wife, who had experience working at an early childhood

parenting centre. Initially investing patchily in a variety of different services, he then decided to apply

the principles of investment banking to his philanthropy and look for the field which provided the

“greatest bang for your buck” –a place where he could target his funding consistently to make the

biggest difference possible. Infant mental health was assessed as a point where the trajectory of entire

families could be positively influenced, given how crucial this period is in terms of brain development

and its long term impact.

Having funded various early mental health organisations, Atlas invited the executive directors to a

meeting to welcome the president of national policy organisation Zero to Three. Through the course of

this meeting Atlas was surprised to discover what could only be described as an infant mental health

epidemic, where organisations were reporting work with very young children who were to all practical

purposes suffering from symptoms of depression, as well as children as young as aged two being

expelled from services for violent behaviour. Given the significant cost of introducing and maintaining

early childhood mental health programmes, starting one for each agency was an expensive and

unrealistic prospect. Instead, a proposal was made that a collaborative approach be developed, which

Atlas could then help to leverage funding. At this point there were six organisations involved in a two

year plan for what would eventually become WIN.

Anna Henderson was employed as the Executive Director of WIN in November 2005, a role she

continues in to this day. Issues arose at this stage because funds were being used in differing ways, with

differing degrees of success; for example, organisations that integrated case management into their

service were having significantly more success when it came to therapy than those who did not.

Following two external evaluations which came to the same conclusion, it was decided that for the

collaborative to work effectively a quality standard would have to be established. At a programme

committee meeting, where clinical directors representing each agency come together to discuss the

programme, attendees were asked to come up with the definition of good case management which was

then to be adopted as the network’s standard. Receiving WIN funding remains conditional on meeting

that standard which had been proven necessary to fulfil WIN’s objectives by both external evaluations.

As a result of the introduction of this standard, WIN reduced by half to a three agency collaborative,

with the other three either unable or unwilling to change practice in accordance.

Since its inception, WIN has been 65%-97% foundation funded and had been so for ten years. This is an

incredible feat that its Chief Executive admits would have been impossible had they not received high

profile honours commending their work at an early stage (for perspective, foundation funding makes up

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approximately only 10%-20% of the average funding of to non-profits). Having become an independent

agency in 2011 - no longer coming under the fiscal agency of a partner - WIN has now entered the

lengthy process of applying to provide their service via the Los Angeles County government’s

department of mental health. The changes this will require will mainly be administrative; the style of

service delivery will not be affected, and this will lessen their reliance on foundation funding.

One difficulty lies in obtaining additional funding while other infant mental health services continue to

have open psychotherapy spots. It is a testament to the reputation of WIN and the unique service that it

provides in terms of their close-knit referral network and bilingual staff that WIN continues to struggle

with a waiting list in contrast. However - as stated by Executive Director Anna Henderson, “in the field of

infant mental health, every day a family goes without a service is a loss of opportunity for the future of

that child” - therefore it is a priority to ensure the continued funding and expansion of WIN to meet the

need that has clearly been demonstrated for its specialist services. At the current level of demand, even

doubling the number of therapy staff would not be sufficient to do this.

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The Partnership Model

Having learned from the experiences contributing to WIN’s development, the current structure of the

organisation is designed to promote a shared vision across agencies and avoid conflicts of interest

through a system of checks and balances in decision making.

There are two decision making branches to WIN: the programme committee and the WIN board of

directors. While the board of directors deals with the strategic direction of the organisation, the

programme committee is concerned with the more practical aspects of implementing strategy; such as

coordination of the programme, clinical integration and other collaboration issues. Because the

programme committee features representation from across the network - the lead clinical directors and,

as available to attend, the executive directors of each agency - issues are able to be addressed as a

collective. The committee operates on a democratic basis; striving for consensus, but operating on a

vote per agency basis where this is not possible. In this way, decision making is shared equally between

partner agencies. The actions of the program committee are reported to the WIN board of directors by

the WIN executive director. Funding distribution is also managed by the board of directors, avoiding any

conflict of interest that may arise by including partner agencies in this decision making process.

The agencies that make up the network include:

Westside Children’s Centre – an early education facility with integrated family services

Venice Family Clinic – a primary health care clinic

St Joseph’s Centre – an organisation offering a range of services to those in poverty

These partners used to be the sole referral base for WIN services, however this has recently changed;

with WIN now accepting direct referrals from beyond the network. Nevertheless, these agencies

comprise the vast majority of referrals to WIN as a result of their close working relationship and WIN

have an obligation to prioritise families referred by these partners.

WIN provides capacity building funds and case management to these partner agencies in exchange for

their maintenance of the quality standards outlined by the agreed Agency Responsibilities form. WIN

also provides thirty to forty hours of infant mental health training to partner agency staff on an annual

basis. Dr Wendy Sun, WIN’s lead clinical director, states that increasing partner agencies’ understanding

of infant mental health is helpful in improving screening processes and so generating appropriate

referrals. It should be noted that the actual task of diagnosis is not undertaken by anyone but the

designated therapist: the role of partner agencies referring to WIN is to describe the client’s symptoms;

diagnosis is the responsibility of the therapist alone. Therefore, when providing this kind of specialist

training, it is important to emphasise the scope for its application to those participating. To support

agencies in implementing their new knowledge appropriately, standardised screening tools are used

across agencies which assess the appropriateness of referrals. Joint quality benchmarks also help to

ensure standards remain consistent.

A key example of WIN’s approach to partnership working can be found in their regular case review

meetings. These meetings are where here practitioners from partner agencies come together to

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workshop cases and discuss any problems they have faced. This brings together the knowledge of all

partners, ensuring a complete picture of the families being served and potentially preventing important

details from being missed by practitioners in other agencies. Through encouraging collaboration and

group reflection, case review meetings help to develop a shared understanding of infant mental health

and attachment informed practice.

Jessica Bernal of Westside Children’s Centre feels the influence of WIN has ensured that an awareness of

infant mental health is embedded across their curriculum. The sharing of expertise across agencies is

reinforced by the use of collaborative technology: the WIN database. This database was created and

customised to meet the unique needs of WIN as collaboration and all agencies have access to it,

enabling partners to receive notifications if urgent developments occur on one of their cases.

Therapist Diana Pineda notes that changes in patterns of behaviour are noted more easily this way,

allowing practitioners to take action if a family are starting to (for example) miss appointments. The

shared database also allows staff to access support more easily: “When a family is in crisis one of the last

things you think is ‘I better let my team know’ - you’re focused on stabilising the family. The database

expedites this and you’re immediately connected with your team, able to get support in your work at

the point of crisis.” Agencies automatically share information with one another and work from the same

case notes, preventing crucial details from being overlooked, and so practitioners are able to gain a

holistic appreciation of service users’ needs and progress.

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The Case for Case Management

Working with a client base that experiences intersectional disadvantage requires WIN to consider the

holistic needs of each family; the practical issues that need to be addressed before mental health

support can be provided effectively. This is why before and during receipt of mental health services from

WIN, clients are allocated a case management worker who screens the family’s needs, advocates on

their behalf and links them in with other relevant services. This first contact with WIN establishes a

supportive relationship with the family prior to treatment taking place, reassuring clients who may feel

apprehensive about accessing a specialist mental health service.

Case managers are located across partner agencies, embedding WIN in the community and further

reducing potential stigma experienced by families who would benefit from mental health support. Case

managers are familiar with community resources and are able to provide assistance to stabilise the

family in a variety of ways – for example with food vouchers, diapers, cots and clothing donations, or by

simply supporting families to navigate mainstream services.

During treatment, case managers work in an equal partnership with therapists, meaning that WIN has a

more in-depth understanding of the families they work with and clients benefit from having two points

of contact. Therapists report that the information received from case management can be invaluable in

informing the approach of their intervention, with case managers and therapists meeting to share

professional judgements from their respective areas of expertise, enabling the provision of an integrated

service.

There is a great interest in the potential for secure attachment to improve a family’s long term resilience

and life chances, with good infant mental health seen as a predicator for future social mobility. However

it must be noted that this relationship between infant mental health and social status is two-way, with

struggling families less likely to have the time and resources to commit to the development of secure

attachment. As stated by WIN executive director Anna Henderson, “Poverty is an extreme stressor and

really insidious. If you’re constantly worried about losing your housing and not having enough food as

well as looking after your kids… it’s really hard.” Clinical director Dr Wendy Sun agrees that the mental

health impact of poverty makes it “a lot more difficult for parents to be that stronger, wiser person that

children need them to be. If they can’t pay that month’s rent they are not going to be concerned that

their child has a flat affect or developmental delays, it won’t make their list of immediate

worries.”Therefore, individual mental health services cannot be prescribed as a fix-all solution to

poverty – the impact of poverty must be alleviated before mental health services can be engaged with in

any meaningful way.

When considering attachment in the context of social mobility, the real material inequality experienced

by low income families cannot be minimised: parents cannot mindfully parent their families out of

poverty. Although the transformative power of early mental health services is evident, mental health

can't be viewed in isolation, away from the societal context people live in. It is not a quick fix for the

shortfalls of capitalism. To suggest this is to put responsibility, and therefore blame, on individuals for

structural inequality. Where opportunity does lie, however, is in addressing infant mental health as

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another site where inequality manifests and in doing so striving to alleviate its negative impact at this

important stage of development.

Mental health issues are experienced within all social classes; however the ability of a family to seek

support and implement coping strategies is affected by their economic circumstances. In targeting

support at these families and tailoring this support in accordance with the practical difficulties families in

poverty face – as WIN does with their case management service - attachment informed practice can

help to level the playing field – aiming to avoid inequality being reproduced and exacerbated by

negative early development experiences.

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Attachment in the Everyday

WIN is predominantly concerned with providing dyadic therapy: therapy working with both mother and

child where their relationship is the centre of the intervention. Supplemental individual therapy is

available for parents who have unresolved trauma to address before they can focus on their parental

capacity. Working flexibly from an approach called Child Parent Psychotherapy, therapists employ a

range of strategies to help parents make links between their experience of their child and their own

relationship experiences. Parents are supported to reflect on the way they were parented and how this

has affected their feelings about parenting themselves, both positively and negatively.

Therapy focuses on three core values of infant mental health: secure attachment, self-regulation and

interpersonal relationships. Self-regulation is described by clinical director Dr. Wendy Sun as a huge

component of their work; working not only on the child’s ability to self-regulate but also on the primary

caregiver’s ability. This is because, although children are built with some capacity, they develop the

skillset to self-regulate through co-regulation with their primary caregiver. To help support this,

therapists observe the mother’s interaction with their child so they can better understand her triggers

and facilitate reflection on her responses to these triggers. In therapist Diana Pineda’s words “we help

the mother be a detective for her child”: if a child can’t sleep on particular nights, they support the

mother to consider different factors that could be influencing this. If the baby cries, therapist and parent

consider in partnership what the baby may need.

As part of the Child Parent Psychotherapy approach, parents are tasked to consider the “ghosts” and

“angels” in their nurseries - metaphors used to describe the negative and positive memories they carry

from their own childhood into their current parenting style. Fraiberg’s concept of “ghosts” in her infant

mental health studies is still prominent in infant theories and studies today. In her paper “Ghosts in the

Nursery,” Fraiberg said problems in infant development and attachment stem from the ghosts of their

parents. The unremembered ghosts prevent parents from fully developing a deep attachment with their

child that is important to their development. This concept of ghosts is used as a function of

psychotherapy. The function is helping the subject leave their ghosts behind and continue moving

forward with their life.

Acknowledging both sides of their experience helps parents to see their parenting from a new

perspective, bringing an insight into what drives their hopes and fears. Dr Wendy Sun states that “A lot

of parents, once they have that understanding, are able to say ‘I experienced this from my mother, I

didn’t like that as a child, I still don’t like that as an adult, I don’t want to unconsciously repeat that

here.’” In this way, the desired parenting style is elicited from the parent themselves, not prescribed by

the therapist.

Therapists also incorporate psycho-educational approaches into their treatment plans. Through

increasing a parent’s understanding of child development, therapists are able to help them formulate

realistic expectations for their child and look beyond the behaviour to its underlying meaning. For

example, a traumatised mother may perceive her child’s crying to be a hostile act however, with a

deeper understanding of child development, this can be challenged and the true meaning of the

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behaviour is revealed: the cry as a baby’s attempt to communicate. This can ease the mother’s

frustration which would otherwise act as a barrier to her connection with her baby. She is also

encouraged to “speak the unspeakable”, as Diana Pineda says; to say the truths that may be shameful to

acknowledge such as “I’m angry because he looked like his Dad right there.” Cognitive behavioural

therapy may then be employed to help address these negative thoughts.

In one hour, weekly appointments with clients, therapists check in with the parent before practising

strategies which enable parents to maximise everyday opportunities to support their child’s

development. Therapists work from a treatment plan which is updated at points of crisis or significant

improvement and reflects their strengths and needs. Although Child Parent Psychotherapy is the model

therapists use to conceptualise cases, the actual intervention tools are not dictated by this approach.

Instead, therapists work flexibly utilising a range of different strategies tailored to the needs of

individual families. Cognitive behavioural therapy may factor in the treatment plan, as well as

techniques related to mindfulness and relaxation, to encourage reflective parenting and, in Dr Wendy

Sun’s words, “help parents and children fall in love with each other.”

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Cultural Sensitivity and the Strengths Based Approach

At least some of WIN’s success and popularity must be credited to the sensitivity of their response to

the external issues faced by the demographic of their service users, and their awareness of the overlap

between these factors and the internal world of both the parent and child. At the most practical level, in

a sprawling city like Los Angeles - with a public transport system that is for many unnavigable - the very

fact of their service existing on an outreach, at-home basis immediately renders it significantly more

accessible. As explained by therapist Diana Pineda – “A lot of these families would not be receiving

services if we weren’t going out to them.”

All staff members at WIN are bi-lingual, with the vast majority speaking Spanish as well as English. Given

the client base of WIN is majority Latinx in ethnic background, this specialism meets the needs of a

significant segment of the community’s population. Whether service users have a command of English

or not, the ability of staff members to communicate with them in their first language is a clear example

of meeting service users where they are; working within the realms of their daily realities. Jessica Bernal,

Director of Early Childhood, Mental Health and Disabilities at partner agency Westside Children’s Centre

emphasises the difficulties that families would face otherwise: “If you had any kind of reservations about

accessing a service, particularly a mental health service, not being able to connect with your first point

person due to language barriers would make the process very difficult and intimidating.”

In addition to overcoming language barriers, WIN practitioners strive to form culturally-sensitive mutual

relationships with their clients that take advantage of the therapist’s skills but recognise the parent as

the first expert on their child. Therapists are there to facilitate an intervention in which parents are able

to recognise and develop their strengths, ultimately enabling them to increase their own agency and

self-efficacy as individuals and as parents. This subverts conventional ideas of the “teacher” filling the

vessel of the “student” with information, instead creating a more cooperative power dynamic.

For example, while training interns the subject of corporal punishment – a contentious issue around

which there are differing cultural beliefs -arose. In a scenario where a family was practising corporal

punishment, the responsibility of the therapist would be to make clear the legal limitations on this

behaviour while exploring the impact of this behaviour on their child. Without neglecting their duty of

care - whereby any suspected child abuse would be reported to statutory services - therapists are

encouraged to respectfully challenge problematic behaviours, acknowledging cultural norms and

suggesting alternative strategies for parents in accordance with the client’s own hopes for parenting.

WIN staff members acknowledge a particular stigma in Latinx communities regarding accessing mental

health services. Although having a therapist is commonplace amongst Los Angeles’ white, middle-upper

class demographic, for WIN’s service users a cultural barrier exists. What has helped to overcome this is

the collaborative set-up of WIN and its firm grounding in other community services. A service provider

who has a relationship with your family offering practical support and recommending a programme they

have close links with, who will visit you at your home, is a very different referral experience from being

given the contact details of a mental health clinic. From this, even the referral system for WIN can be

seen to be rooted in strong relationships.

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As a community education practitioner with a particular interest in the way that power manifests in the

service provider-service user relationship, I was struck by the way that WIN has built in an appreciation

of power dynamics at all levels of their work. Executive director Anna Henderson acknowledges that the

largely disenfranchised demographic that WIN works with has been used to receiving the bare minimum

of services, with a “better than nothing” attitude prevailing where clients are restricted by their inability

to pay for the best into accepting gratefully the worst. This is the opposite of WIN’s approach, which

instead embodies the belief that those who are most vulnerable must be given the most nuanced,

comprehensive and committed service possible. As undocumented citizens, WIN clients often have an

understandable mistrust of systems and services which WIN has been very successful in addressing as a

result of their respectful approach.

Therefore, it can be said with confidence that WIN’s model has responded to the needs of its client

base: the majority of whom are undocumented, Latina mothers living in poverty who have experienced

or are experiencing trauma that is affecting their ability to parent their baby.

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WIN and Domestic Abuse

An emphasis on nuance and the strengths of the client permeate WIN’s attitude to managing domestic

abuse, which is a prolific feature of the therapists’ caseloads. By no means advocating a victim-blaming

approach - which would unjustly hold women accountable for their own abuse - the perspective of WIN

is to explore the ways in which pre-existing trauma has informed the survivor’s expectations of what she

can and must expect in her relationships, with the ultimate objective being to increase her reflective

capacity and so space for agency. Individual therapy is available for women to name and unpick the

trauma they have experienced; meanwhile dyadic therapy assesses the ways in which this trauma has

impacted upon her parenting style.

Therapist Diana Pineda expands on this approach: “A lot of times clients have low self-esteem and are

used to being told what to do, they’re not used to having control – especially if they’ve also grown up in

abusive situations. Sometimes when they meet a professional there is a tendency for them to expect

you to tell them what to do. We meet clients where they are at – if a woman is in a domestic violence

situation, we respect their agency, we do not tell them to leave. You have to be skilful and gentle; you

turn it around and help her to trust her instincts and her own answers.”

The abusive dynamic is examined in depth with each client – personal triggers are identified and

patterns of behaviour are deconstructed in partnership with the therapist. Although domestic abuse is

not explicitly identified as gendered violence, as it is in Scotland, WIN therapists demonstrated a clear

understanding of gender dynamics and used popular tools such as the Power and Control Wheel to

perform this work – which had parallels with the approach of my own service. Another similarity with

the work I undertake as part of the CEDAR project in Scotland is the way in which WIN strives to address

the misconception that young children are not aware of or cannot remember abuse. Instead, this work

endeavours to help mothers “be a detective” and consider the different ways that trauma is carried and

remembered by young children.

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The Parallel Process

WIN’s values as an organisation extend not just to their clients but also to their staff. In much the same

way as parents are given a non-judgemental space and a skilled therapist to facilitate reflection on their

strengths and weaknesses, staff members are given the same reflective supervision regarding their role

at work. There is an acknowledgement at the highest level that the work that is being undertaken at

WIN is complex, nuanced and emotionally intensive. Clients are vulnerable, and tend to come from a

background of trauma that spans generations. As executive director Anna Henderson says, “Whatever

has been done for that family before has not worked—or not worked well enough to prevent them from

needing our care. For therapists that are willing to take on that challenge, we feel like we need to

provide that same level of support to them. We provide an environment where they feel safe,

supported and able to do their best work.”

In practical terms, this means that staff members are encouraged to reflect upon their personal

relationship to their work – where triggers exist for them, where their strengths lie and the issues that

they feel least comfortable addressing with clients. Clinical director Dr Wendy Sun provides this support

and states that this is a parallel process alongside WIN’s philosophy for their clients: therapists are also

met where they are; their strengths nurtured and their confidence bolstered through their working

relationships.

There is awareness at WIN of the potential for counter-transference: when work with a client recalls a

memory of something the therapist themselves has experienced, and the potential for this counter-

transference to colour the intervention. Therapist Diana Pineda expands on this: “We work with humans

and we’re in for a pretty dynamic ride with them – no matter how experienced you are as a therapist

you’re a human being, and you connect with your clients on a human level. It makes you sad to know

someone is being brought down emotionally. Reflective supervision gives you the space to say ‘this has

affected me in this way’, and think about how to manage this best for both you and the client - so you’re

no longer carrying that.”

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Innovation at WIN

A distinguishing feature of WIN is its position at the frontline of both research and practice. Selected as

one of twelve pioneering organisations nationwide to join Harvard’s Centre for the Developing Child’s

‘Frontiers of Innovation’ venture, WIN is currently involved in the development of two projects aimed at

improving early years experiences. This is yet another example of their commitment to partnership

working. The first of these projects is ‘Ready4Routines’, an intervention based on developing executive

function and preventing trauma. Executive function – the management of cognitive processes such as

reasoning and problem solving – is known to be negatively affected when attachment is insecure and/or

trauma is experienced. This programme is based on using family routines as a means to develop skills in

goal setting, planning and adapting to change for parents and children, who participate collaboratively.

Through the establishment of routine, parental stressors are reduced and anxieties alleviated. There is

an app in development which will measure improvements in executive function as a result of

‘Ready4Routines’, which has already had a successful pilot. This pilot registered a significant need and

improvement in families who were literally off the measuring chart in terms of stress prior to

participation.

Another pilot WIN has been involved in as part of their work with ‘Frontiers of Innovation’ is screening

for ACEs – Adverse Childhood Experiences. This programme endeavours to screen pregnant mothers for

indicators of stress that are likely to impact upon their child, based on the knowledge that a child in

utero while their mother is experiencing significant stress will experience escalated stress levels

themselves in the long term. Partner agency Venice Family Clinic has been involved in screening

mothers, offering diapers as an incentive for participating in the short questionnaire that enables staff

members to determine the mothers’ ACEs score. The result of this questionnaire, which highlights

previous trauma experiences, is a major indicator of later health problems. Both this and the

‘Ready4Routines’ research endeavours to screen and intervene earlier for families in a bid to reduce

trauma and so reduce the overwhelming demand for trauma services as well as the social cost of this

trauma.

A recent innovation for WIN has been the establishment of an internship programme, which over the

course of less than two years has rapidly expanded to accommodate four students; a significant number

for a relatively small organisation. Chief Executive Anna Henderson identifies the motivation for this

programme as being an attempt to grow the field of infant mental health, and in particular to attract

Spanish speaking therapists who may become the future of WIN. Because WIN is a collaborative and

supportive place to work, the hope is that interns return to work there following a positive experience

as a master’s level social work student. In the short term, having interns on board also increases the

capacity of the organisation with each given four cases to work on during their nine month placement. It

is clear that interns receive significant support to work these cases: they are supervised intensively and

paired with a case manager to work alongside, as per the WIN model. Interns are trained by experienced

therapists and it serves an initial purpose for these therapists: consolidating their knowledge and

reaffirming their commitment to the highly specialised and challenging work that they do.

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One obstacle identified by therapist Diana Pineda in her daily work is the lack of appropriate agencies to

which WIN can refer, bearing in mind the specific needs of their client base. For example, a mother

suffering alcohol problems may benefit from specialised alcohol support – however language and

location barriers in Los Angeles reduce her support options to WIN alone. To overcome this

marginalisation from the mainstream, agencies must evolve - as WIN has - to the needs of the city’s

demographic. Spreading the word of WIN’s successes is a potential site for further work, so that other

services can learn from the example of WIN and innovate appropriately. This would benefit the

therapists as well as clients of WIN, who would then be free and supported to focus on their specialist

subject in their work: infant mental health.

WIN works overwhelmingly with mothers, regardless of whether the family in question is two parent or

single parent. The reasons for this are largely cultural and not limited to the Latinx community, as

women are generally accepted across cultures as responsible for parenting - while the father’s role is

traditionally that of breadwinner. Where WIN fathers may be interested in participating in therapy,

many are restricted by the fact that they work several jobs and so cannot be present when the therapy

takes place. Clinical director Dr Wendy Sun did not feel she could comment on what the impact would

be if this was not the case, which opens a potential avenue for further research and innovation. It would

also be interesting to look at the way that gender norms are reproduced during the early years, and

whether WIN’s work offers an opportunity to disrupt this cycle, moving further into the realm of

prevention.

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Research Findings

What is clear from the work of WIN is that infant mental health is an important emerging field. Their

service is based on the understanding that changes in an infant’s environment and crises in their family

do affect them, they do remember, and there are practical ways in which the impact of these changes

can be minimised through the strengthening of connection and relationships. These relationships exist

not only between parents and children, but across the agencies that serve them. WIN is an example of

an agency which has looked at the relationship between infant mental health and the trajectory of a

child’s later life, and taken up that challenge in a bid to improve the lives of families both right now and

in the future. In doing so, they disrupt cycles of trauma that have spanned generations.

Key to their success has been their refusal to deal in binaries. Instead of limiting themselves to individual

or dyadic therapy, they offer both. In pursuing objectives for the overall social good, they employ

business principles. The boundaries between staff members and service users are blurred in that both

are treated by WIN as human beings, with all the vulnerability and strength that that entails. Despite, or

because of, their significant successes, WIN continues to seek opportunities to advance their service and

improve outcomes for the families they work with. A key message from my visit was that WIN should

not be viewed as a prevention service: at the stage where they intervene, they are already working with

a traumatised infant. WIN strives to move ever closer to true prevention through screening earlier and

integrating more. Only through reducing the number of severely traumatised people that need WIN’s

services will this demand ever be met.

“WIN has measured outcomes that show we are doing strong, transformative work and bringing a

complex, nuanced resource to families that they would not be able to buy. Because it is nuanced and

complex, it can address their complex, nuanced issues holistically, so that what we are not doing is

providing a band aid but a different way for families to go through the world and relate to their

children.

Too few understand that what we do right now affects whether our children are going to be

confident, competent, healthy, happy people. We are creating our future. Is it going to be insecure,

desperate, out-for-themselves, traumatised people creating an ugly world where we all have to watch

our backs? Or are we going to create a better, more collaborative world?

And we can do that – we can actually do that.”

Anna Henderson, chief executive of WIN

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Recommendations for Practice

Invest consistently in practice that works – continued experimentation should take place

however this should not take place at the expense of successful programmes.

Quality standards should come from experienced staff members across agencies, in this way

shared investment in meeting standards is fostered and encouraged.

External evaluations can help provide objective assessments of difficult political situations

where there are conflicts of interest at play.

Providing specialist training to external agencies can make the service itself more effective, for

example by ensuring need is identified earlier and referrals made are appropriate.

In partnerships everybody’s role should be clear – infant mental health training is provided to

help partners be more aware in their current jobs, it does not equip them to carry out the work

of therapists.

Joint meetings and technology fosters better partnership working through developing a shared

language and vision and building daily working relationships across agencies.

Technology should be utilised to make information sharing processes as smooth and automatic

as possible.

Regularly scheduled joint meetings provide an opportunity for multi-agency workshopping of

difficult cases, sharing expertise amongst practitioners and providing a built in support network

for them.

Infant mental health cannot be treated in isolation: attachment is dependent on the caregiver’s

emotional availability, which is in itself dependent on the practical circumstances faced by the

family. Basic needs must be met before therapy can make any meaningful changes.

Positive early development experiences are not in themselves a remedy for the adverse effects

of living in poverty - however without intervention, this impact may be exacerbated and

inequality reproduced or worsened.

Having a presence within mainstream services can make accessing specialist mental health

services less intimidating and stigmatising for potential service users.

Models and frameworks should be used to help therapists conceptualise cases, however they

should not be restrictive – therapists should be given the freedom to exercise their professional

judgement and encouragement to explore different approaches in accordance with the needs of

their clients.

Parenting goals should be elicited from the parents themselves, not prescribed by professionals.

This can be achieved through encouraging reflection on their own experiences of being

parented – both positive and negative.

Ensure that your values are consistent across staff members and clients, so staff members feel

supported and invested in the vision of the organisation.

Allow staff members space to “speak the unspeakable” and share difficult times where negative

counter-transference may be impacting their approach. This will minimise any harmful impact

on their work, as well as support staff to develop personally and professionally while ensuring

their wellbeing.

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Identify intersectional barriers for clients in accessing services and take practical steps to

address and acknowledge them – sharing what works with external agencies.

Don’t resort to a “something is better than nothing” approach: with vulnerable families in

particular, poor quality services can cause further harm. Respect for the clients and the

importance of the work should guide any intervention that takes place.

Maximise opportunities to develop greater understanding of infant mental health across

agencies, bearing in mind the potential for future expansion and integration of the field.

Rather than operate in binaries, consider merging different approaches to develop a nuanced

service that is as complex and sensitive as the issues it addresses.

Ever earlier intervention, working towards prevention, is an opportunity to reduce demand and

so direct resources to all of those who require the service.

The Key Message

During my time at WIN, the key message I received was that in order to improve outcomes for families,

early intervention must always strive to become true prevention. This can be achieved through engaging

families at the earliest possible stage, screening for proven risk factors and looking at families’ needs in a

holistic way - with an awareness of the ways in which poverty, abuse and mental health can interact and

exacerbate one another. WIN achieves this, not through broadening the scope of everyone’s jobs,

expecting one agency or professional to ‘do it all’. Instead WIN’s approach requires and enables workers

to be exceptional in their particular field, making sure strong working relationships exist and that staff

members feel supported to perform their very specific role for families in their journey through services.

As someone who has worked in an increasingly difficult public sector climate, with devastating budget

cuts, and in a role which necessitates a great deal of emotional labour, I found WIN’s approach to

supporting their staff members inspirational. WIN does not hide from the fact that the work they do can

be difficult, frustrating and triggering. The organisation applies its philosophies inward as well as

outward: investing real time ensuring that its workers are nurtured and supported through strong

relationships and structures which do not impose an artificial binary between the personal and the

professional.

‘Strengths-based approach’ is a term that I have encountered frequently in my work both in the public

and third sector. However, having experienced the strengths based work of WIN first hand; I feel we

should strive to more fully embody this approach and be wary of its tokenistic application in some cases.

At WIN, a true understanding of power dynamics has been built into their way of working. There is an

appreciation that as professionals working with underprivileged communities, they are likely to be

viewed by their service users as “experts” or “teachers” and that the implications of this imbalance must

be understood and addressed for service users to be genuinely empowered as parents and individuals.

I feel strongly that reflection on equalities issues should be built into professional structures, not merely

as a box ticking exercise or the responsibility of one particular equalities-informed staff member, but

embedded from top to bottom in organisations - otherwise there is a risk that our work reproduces

oppressive power dynamics. One example of this would be professionals “instructing” service users who

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have experienced abuse in the “correct” way to parent, reproducing the controlling and undermining

approaches of their perpetrators. While we may believe ourselves to be working in a strengths-based

way, routine reflection on these issues would provide an opportunity to discuss what this really means

and looks like in different working situations.

Those who have experienced trauma and abuse often suffer from severe isolation. Those who live in

poverty, are undocumented, live in a huge city, have young children and do not speak the majority

language of the country they live in, even more so. What I was struck by was WIN’s ability to take the

often individualising and stigmatised field of psychotherapy and turn it into a true community

endeavour, building links across the key institutions that families encounter and creating a presence that

is accessible and unintimidating for their marginalised service users.

The example of family night has inspired me to consider the informal ways that families can be brought

together by services to share in sociable, less structured activities with others – sharing food and laughs

with one another, staff members alongside their clients in a spirit of fun and collaboration. In focusing

on the more intensive, individual work, services should not neglect the significant resource that is

community in creating long term resilience.

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Websites of Interest

Winston Churchill Memorial Trust - http://www.wcmt.org.uk/

Westside Infant Family Network - http://www.winla.org/

The CEDAR Project - http://www.cedarnetwork.org.uk/

Scotland’s Early Years Collaborative - http://www.gov.scot/Topics/People/Young-People/early-

years/early-years-collaborative

Centre on the Developing Child, Harvard University - http://developingchild.harvard.edu/

Child Parent Psychotherapy - http://www.cebc4cw.org/program/child-parent-psychotherapy/detailed